1. DiGiulio, Sarah

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A new study of how best to understand the impact of adjuvant chemotherapy-induced pain on the daily lives of women with breast cancer found that using multiple methods to evaluate patients' pain allowed nurses to better understand the severity of pain. The findings highlight the limitations of using just one measure of chemotherapy-induced pain and imply nurses need to better understand and treat such pain (Cancer Nursing 2015;38:31-39).


The key finding from the study was understanding pain's impact on the women's daily lives, study coauthor Susanne Hellerstedt-Borjesson, RN, a PhD candidate at Uppsala University in the Department of Public Health and Caring Science, explained via email. "The pain made some of the women feel isolated and alone; and others became consumed by thoughts of death and dying."


Though the association between pain and breast cancer treatment is known, Hellerstedt-Borjesson said that the results from this study suggest that women being treated in the adjuvant setting were more surprised by the pain associated with their treatment than they expected and the women did not get information about pain from their health care providers.


Study Details

The study included 16 women with newly diagnosed breast cancer undergoing adjuvant treatment who had received sequences of chemotherapy in doses of 75 mg/m2 or greater of epirubicin/docetaxel, and reported having chemotherapy-induced pain with a visual analogue score of at least four at one or more courses of treatment.


The researchers assessed chemotherapy-induced pain for the women using three methods: (1) by interviews to investigate perception, intensity, distribution, and impact of pain on daily life (see box); (2) by having the women indicate the location and intensity of pain on a body image to capture pain distribution (levels of pain were either none, acceptable, interruptive, and unbearable or excruciating); and (3) by the visual analogue score registrations to assess pain intensity.


Based on the researchers' qualitative analysis of all three methods of pain analysis, the pain was categorized into three groups: manageable, beyond imagination, and crippling. Manageability of pain, pain's impact on social life and self-care, pain quality, emotions associated with pain, pain distribution, and patients' perceived confidence in the future worsened for each category.


Six women fell into the manageable pain category based on all three measures; four women fell into the pain beyond imagination category; and six women fell into the crippling pain category.


The researchers found that across all categories, pain was described as most intense three to seven days after treatment, and the worst pain developed after the first course of treatment. For nearly all of the women in the study, pain had a major impact on daily life. And most of the women claimed they lacked information about how long the pain was expected to persist, the researchers noted in the study.


Key Takeaways

A key finding from the study was that the estimation of the worst perceived pain on the visual analogue score did not fully agree with the interviews and the body image assessments-and that none of the methods alone fully captured the extent of patients' pain.


Measuring pain in only one way risks clearly seeing all the dimensions of the patient's pain, Hellerstedt-Borjesson said. "But by using three methods we could see a clearer picture of the pain's effect quality, location, and intensity that the women experienced."


The findings imply, she added, that there is a need for better and more frequent use of available instruments to assess pain, as well as to develop protocols allowing better treatment of pain assessed using these instruments.


Other key implications of the research were the need for pain to be communicated, visualized, and treated properly. The data showed, the study notes, that pain prevented patients from engaging in physical activity, caused social isolation, and could cause the patient to be consumed by thoughts of death and dying.


"Nurses caring for patients undergoing adjuvant chemotherapy for breast cancer need to inform patients and be open about the side effects of pain," Hellerstedt-Borjesson said. "Nurses need to develop their ability to communicate, interpret, evaluate, and treat chemotherapy induced pain."


Real Responses

The study authors included these examples of responses women shared during in-person interviews in the study:


From a woman in the "manageable pain" category:


"Heavy symptoms like my body doesn't want to do anything, the best I can compare it to is when you have a real flu-like weakness from fever."


"My back ached much like bad menstrual cramps, in my large leg muscles and feet."


From a woman in the "pain beyond imagination" category:


"How bad will it be? Will it always be like this? The uncertainty was tough; I was tense which perhaps made it even more evil."


"I couldn't even walk the dog. Later we took a very short walk, but I moved so slowly that the dog turned around and looked at me."


From a woman in the "crippling pain" category:


"I cried on and off, even though I'm not someone to get scared, thinking that this just as well might be the end, because I could not take it anymore, and that's so unlike me."


"It felt like I'd been thrown into a dryer and I was being tossed back and forth; it pulled and ripped me apart."