Routine Pain Screenings Important for Childhood Cancer Survivors

Childhood cancer survivors are at a higher risk of pain and associated functional impairments later in life, study results show. These results, according to experts, highlight the need for routine pain screening in survivors.

Childhood cancer survivors are 3.4 times more likely to report pain with daily interference compared to those without a history of childhood cancer, according to data published in Cancer. Because of this, the study authors wrote, it is important that childhood cancer survivors be screened routinely for pain and receive interventions targeting pain interference.

“Advances in treatment and supportive care have dramatically improved childhood cancer survival such that approximately 84% of children and adolescents diagnosed today survive more than five years from diagnosis,” study authors wrote. “However, approximately 95% of survivors develop physical, neurocognitive and/or psychosocial impairments by age 45 years.”

Moreover, previous studies have demonstrated that up to 59% of adults who survived childhood cancers report experiencing pain. Among survivors, 9% experienced persistent pain over a five-year period, 9% worsened pain, 8% persistent pain interference and 11% worsened pain interference. According to the authors, this suggested the potential persistence of pain within this population.

Overall, the authors sought to gain a better understanding of pain in childhood cancer survivors, as well as identify cancer-related factors associated with the pain and examine the associations between pain and neurocognition, physical performance, social functioning and health-related quality of life.

To find conclusive evidence, the authors examined data from 2,836 survivors (mean age, 32.2 years) with a mean time of 23.7 years since diagnosis. All participants were enrolled in the St. Jude Lifetime Cohort (SJLIFE), and were survivors of leukemia (36%), central nervous system tumors (9%), lymphoma (21%), Ewing sarcoma or osteosarcoma (7%) and other solid tumors (25%). Sixty-two percent of the survivors were treated with surgery, 85% with chemotherapy, 32% with cranial radiotherapy and 25% with noncranial radiotherapy. The data derived from the survivors were compared with 343 people (mean age, 35.5 years) who had no history of childhood cancer.

“Because survivors of childhood cancer are at risk of neurocognitive deficits, physical performance impairments and reduced social attainment secondary to their primary cancer diagnosis and its treatment,pain may exacerbate the underlying risk of impairment, thereby further compromising functional outcomes and (quality of life) in adulthood,” the authors wrote. “However, to our knowledge, less is known regarding the impact of pain on clinically assessed neurocognitive functioning, measured physical performance abilities or social functioning among survivors.”

Both groups were assessed using a short form survey with two questions: how much bodily pain have you had during the past four weeks? And have you ever been told by a doctor or other health care professional that you have or have had migraines and other severe headaches? Three answers were given as options for each: “no,” “yes, and the condition is still present” and “yes, but the condition is no longer present.” Study authors explained, “survivors were considered to have pain if they reported either moderate-to-very severe bodily pain or headaches and/or migraines with the condition still present.”

To examine relative risks (measure of risk of an event happening in one group compared to same event happening in another group) between pain and neurocognition, participants were assessed across four domains of attention, memory, executive function and processing speed. For physical function, there were tests in aerobic capacity, flexibility, strength, balance, mobility and adaptive physical function. Social functioning was examined via self-report in education (unable to attend school because of a health condition), employment (unable to hold a job because of a health condition), marital status, independent living and assistance with personal care or routine needs. Finally, study authors assessed health-related quality of life using the results from physical functioning, social functioning and general health as well as vitality and limitations due to emotional and mental health.

Who Experiences Pain the Most

The survey and assessment results showed that 27% of survivors reported moderate-to-very severe bodily pain, 24% reported migraines or other severe headaches and 65% reported pain with or without pain interference. “We observed a greater prevalence of pain in survivors compared with community controls (those without a history of childhood cancer), with approximately 39% of survivors reporting moderate-to-very severe pain within the past month, with (18%) or without (21%) moderate-to-extreme daily interference,” the study authors wrote.

In more detail, bodily pain and pain interference was significantly higher among survivors younger than 30 years, with the exception of women aged younger than 50. Survivors of soft-tissue sarcoma, non-Hodgkin lymphoma and Ewing sarcoma and/or osteosarcoma had the highest odds of pain with daily interference, as well as those with histories of amputation or limb-sparing surgeries.

Those who reported pain with daily interference on the survey were also found to have a 4.5 times increased risk of not being able to hold a job or attend school, plus a 5.6 times increased risk of needing assistance with personal care or routine needs. They also had a 65%-to-90% increased risk of impaired attention and a 90% increased risk of executive function and processing speed. Pain with daily interference was associated with impaired physical performance on nearly all measures of physical function.

The study authors added that survivors with grade 3 or 4 (severe or serious) chronic health conditions have 2-times increased odds of pain with daily interference, and 1.6-times increased odds of pain without daily interference compared to survivors without severe-to-life threatening chronic health conditions. Survivors who were overweight or obese also had an increased risk of pain with daily interference, along with those with neurologic, gastrointestinal, cardiovascular and pulmonary conditions. “These associations are not particularly surprising but highlight the importance of considering survivors’ current health status, in addition to distal treatment exposures when anticipating their risk of developing pain,” the authors wrote.

“The current study results have demonstrated that a substantial percentage of adult survivors of childhood cancer experience pain that adversely impacts multiple aspects of daily functioning,” they concluded. “These results also highlighted the need for the routine assessment of pain and related factors within the context of survivorship care.”

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