Review Article
Pain Prevalence During Cancer Treatment: A Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.jpainsymman.2021.09.011Get rights and content

Abstract

Context

Pain is one of the most complex and prevalent symptoms in the cancer population. Despite the protective role of acute cancer-related pain, it is also an important predictor for the likelihood of developing chronic pain after cancer treatment.

Objectives

Since the last systematic review on pain prevalence rates during cancer treatment dates already from 2016, the aim of the present systematic review was to provide an overview of pain prevalence rates during cancer treatment since this previous review.

Methods

A systematic search of the literature, including studies between 2014 and 2020, was conducted using the databases Pubmed, Embase, Scopus, Web of Science and Cochrane. Studies reporting pain prevalence rates during or within three months after curative cancer treatment was included. Title/abstract and full-text was screened double-blinded, followed by independent evaluation of the risk of bias. All prevalence rates were pooled within meta-analyses and a meta-regression was performed to clarify the amount of heterogeneity.

Results

Of the 9052 studies, 12 studies were included in the meta-analysis of which 10 included breast cancer and two lung cancer patients. The pooled pain prevalence rate was 40% (95%CI 0.29–0.51), with a heterogeneity of 96%. Out of the meta-regression, only the covariate “method of pain measurement” significantly clarified the heterogeneity (P < 0.05), resulting in a residual heterogeneity of 94.88%.

Conclusion

Five years after the last systematic review published on this topic, pain is still very prevalent during cancer treatment. However, the pain prevalence rates were also very heterogeneous. These two findings emphasize the need for further research on the development of adequate pain assessment and pain management approaches during cancer treatment.

Introduction

Of the 10 million patients diagnosed with cancer worldwide, pain is one of the most common, complex and persisting symptoms during and after cancer treatment.1 Pain during cancer treatment, equalized as acute pain in this systematic review, is defined as pain up to three months after treatment and chronic pain as the pain persistent for more than three months.2

Pain during cancer treatment can be caused by the cancer itself or by the different available treatment modalities.3 The most common treatment modalities are surgery, radiotherapy and chemotherapy.4 Acute postsurgical pain commonly exists after cancer surgery. This pain can either be neuropathic or nociceptive or a combination of both.5,6 The predictors of an increased severity of acute pain are, among other things, an increased duration of surgery and higher rates of pain catastrophizing before surgery.7 Furthermore, 90% of the oncological patients treated with neurotoxic chemotherapy develop chemotherapy-induced peripheral neuropathic pain and radiotherapy can also result in radiation-induced peripheral neuropathic pain and radiation-induced fibrosis.8, 9, 10

Despite the protective role of acute pain after these treatment modalities, acute pain can lead to a reduced general functioning in daily life.11 Furthermore, it also has an important impact on quality of life.12 The experience of pain may have an enormous impact on someone's mood, resulting in feelings of depression, an increase in anxiety and even cognitive dysfunctions.13 Moreover, acute cancer-related pain is also an important predictor for chronic pain after cancer treatment, which can lead to neuroplastic changes.7 Therefore, it is important to already be attentive of pain during cancer treatment, to improve daily functioning, quality of life and to prevent becoming chronic after treatment.

In 2016, a systematic review was published about the prevalence rates of pain during and after cancer treatment in all cancer stages.14 They included patients with head and neck, lung, breast, gastrointestinal, prostate, gynecological, and other cancer types and patients receiving anticancer treatment with curative or palliative intention.14 They concluded that pain is a prevalent and persistent symptom, with prevalence rates up to 55% during cancer treatment, even though the increased efforts to assess and manage pain related to cancer treatment.14

Several studies indicate that there are still some barriers for an effective pain management approach.15,16 Some important reasons for an undertreatment of pain are the fear of clinicians for addiction and side effects of the pain medication, limited knowledge of the use of pain education and even cultural beliefs of the clinician themselves.15 Furthermore, pain assessment is often not a priority for the health care professional and they often have limited knowledge of the several pain assessment methods.16

However, during the last five years, the awareness of acute pain during cancer treatment as a real health problem has increased through the availability of more officially endorsed guidelines on assessment and management of cancer-related pain.17, 18, 19 For example, the European Society for Medical Oncology clinical practice guidelines published in 2018 some important rules for an adequate pain assessment.17 In one way, increased attention and thus assessment of pain can result into an increase in pain prevalence rates. However, this can as well lead to an improvement in cancer-related pain management, which can in turn result in a decrease in pain prevalence rates. Therefore, the aim of this review was to provide a new overview of the pain prevalence rates during cancer treatment. Moreover, this overview will give more insight in the increasing need for an adequate pain assessment and pain management approach.

Section snippets

Methods

This systematic review was registered within the International Prospective Register of Systematic Reviews (PROSPERO reference CRD42016038870) on 11 November 2020 and adhered to the PRISMA statement recommendations.20

Study Search

The initial search resulted in 9052 studies (see Fig. 1). After removing duplicates, 7300 studies were screened on title/abstract. After title/abstract screening, 1740 studies were screened on full-text. Some of the authors (n = 93) were mailed to obtain essential information, whereof 81 studies were excluded because not receiving a response within a reasonable timeframe of two weeks or did not meet the predefined eligibility criteria. We contacted our third reviewer (A. D. G.) about 19 studies

Discussion

The aim of this systematic review was to give an overview of the pain prevalence rate during cancer treatment, five years after the last systematic review published on this topic.14 The overall pain prevalence rate was 40% (95%CI 0.29–0.51) during and up to three months after curative cancer treatment.

The previous systematic review of van den Beuken-van Everdingen et al. (2016) reported a higher pooled pain prevalence rate of 55% (95% CI 0.46–0.64) during cancer treatment, compared to our

Conclusion

This systematic review shows that, despite the development of new guidelines for pain assessment and pain management, there is still a high prevalence rate of pain during and up to three months after curative cancer treatment. Furthermore, there is a high heterogeneity in the reported pain prevalence rates between the different studies. These two findings emphasize the need for further investigations on adequate pain assessment and pain management approaches, during and within three months

Disclosures and Acknowledgments

This work was supported by the University of Antwerp [grant number 41776, 2020]. The authors declare no conflicts of interest.

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