Cancer Survivorship: Managing Pain

By Barrie Cassileth, MS, PhD

Cancer patients almost always contend with pain in some form— whether from the tumor itself or as a side effect of treatment. Complementary therapies such as acupuncture, massage therapy, mind-body techniques, and music therapy can help reduce this pain safely and without toxicity or side effects. These therapies can be particularly effective in conjunction with conventional pain medications, boosting the results and potentially decreasing the amount of prescription drugs required to keep you comfortable. They may also be helpful on their own, in cases where medication either isn’t effective or causes intolerable side effects. Patients who require longterm pain management may also develop a tolerance to pain medications, making complementary therapies an attractive alternative for getting relief without side effects or drug dependence. For these reasons patients with chronic pain tend to be heavy users of complementary therapies.

Managing Pain with Acupuncture

Acupuncture is widely used for pain by the general population— both acute pain, such as that associated with a dental procedure, and chronic pain, such as a headache. Increasingly, acupuncture is used for cancer-related pain too, as a growing number of studies find it to be effective. Acupuncture appears to work by stimulating the nervous system, causing the release in the brain of certain chemicals that control pain. Brain imaging studies suggest that it can deactivate areas of the brain involved in pain perception.

One of the first well-designed trials of acupuncture for chronic cancer pain was conducted in 2003. It tested auricular acupuncture—in which needles are placed at acupoints on the ear—for patients whose pain remained despite ongoing treatment with pain medication. Patients were needled either at the correct acupressure points or at non-acupressure points on their ears. A third group had pressure (as opposed to needles) applied at non-acupuncture points. After two months of these treatments, pain intensity had decreased by 36 percent in the patients who received correct acupuncture. Little difference was observed in the two control groups, showing not only that acupuncture was effective but also that the specific points mattered. Needling random points did not have the same effect as proper acupuncture.1

Another study, conducted at Memorial Sloan Kettering Cancer Center, tested acupuncture specifically in patients with cancer of the head or neck who had received neck dissection surgery. Patients either received acupuncture weekly for four weeks or usual care from their physician. Those in the acupuncture group reported significant reductions in pain compared with their usual-care counterparts.2

Yet another high-quality study found acupuncture to be effective at reducing joint pain in breast cancer patients taking aromatase inhibitor drugs. Joint pain is a common and unpleasant side effect of such medication, which blocks the production of estrogen. This randomized trial compared true versus sham acupuncture at multiple points on the ears and elsewhere on the body. Women in the acupuncture group had significantly less pain at six weeks.3

Not all studies are this unequivocal, but acupuncture is clearly promising as a complementary therapy for alleviating cancer-related pain. Given its safety record, acupuncture is a good option for pain control without any major downsides. Insertion of acupuncture needles is virtually painless, and most patients actually find the treatments relaxing. It is important, however, that you choose an acupuncturist who is trained and certified to work with cancer patients.

Managing Pain with Massage Therapy 

Massage therapy may be very beneficial for chronic pain and is widely available in hospital programs. This modality comes in many forms—Swedish massage, foot reflexology, Reiki, and other very gentle-touch massage therapies— and its effects go beyond relieving sore muscles. Among other benefits, it is calming and relaxing, improves blood and lymph circulation, reduces stress, and helps with sleep. All of this factors into its ability to reduce pain.

Clinical trials show that massage can diminish pain, anxiety, and other symptoms related to cancer treatment. Although the number of high-quality studies is limited, results confirm that body or foot massage can decrease pain in cancer patients. One study of nearly 1,300 patients showed that massage improved patients’ pain scores by 40 percent.4 In general, most patients feel better after massage therapy, reporting substantial relief of symptoms for hours or sometimes days after treatment.

Furthermore, massage therapy is very safe. The antiquated belief that massage might spread cancer around the body has long since been proven incorrect. Neverthelessif you seek massage outside the hospital setting, it is important that you find a therapist trained to work with cancer patients.

Managing Pain with Mind-Body Therapies

Mind-body techniques—such asmeditation, self-hypnosis, guided imagery, and yoga—are particularly useful for those who want to take an active role in their own well-being. These approaches essentially teach you how to control your mind and, in turn, your body, to reduce the sense of pain, anxiety, and stress. The idea that pain perception can be influenced by a person’s attitudes and beliefs, which can be altered with the help of mind-body therapies, has become increasingly mainstream in recent years. The fact that placebos work—that belief can affect biology—is essentially proof of concept.

Randomized controlled trials show that self-hypnosis, which essentially helps reprogram the brain’s responses to signals from the body, can significantly reduce pain. In one study patients who received hypnosis training prior to undergoing bone marrow transplant reported significantly less pain than those who did not receive the training.5

Similarly, another study found that metastatic breast cancer patients who attended group therapy with hypnosis weekly for one year reported significantly less pain and moodiness than patients who attended weekly group therapy without hypnosis.6 A National Institutes of Health panel strongly recommends the use of hypnosis for cancer-related pain. Mind-body techniques such as self-hypnosis, guided imagery, and relaxation are easy to learn and can be very beneficial when practiced before and during painful or stressful procedures such as chemotherapy and radiation therapy and in preparation for surgery.

Music therapy too can often reduce pain and anxiety. One large clinical trial found that music therapy after surgery reduced both patients’ pain levels and the amount of morphine they needed to remain comfortable.7

Some herbs and supplements used topically also have painreducing properties. Among the more promising are capsaicin, a compound found in chili pepper, and an herb called boswellia. Capsaicin cream is applied to painful areas of the skin and is believed to diminish pain by desensitizing nerve endings. It first causes heat, pain, or a burning sensation when applied but ultimately brings relief. One study found that the use of capsaicin cream over 16 weeks significantly reduced the perception of pain in cancer patients after surgery.8

Because capsaicin can be extremely irritating to the mucous membranes and the eyes, avoid contact with eyes and do not apply to irritated or broken skin. Wear gloves when applying to the affected area. Do not use if you are on ACE inhibitors, as capsaicin can increase the incidence of cough that is associated with ACE inhibitors. Also, if you are taking sedatives, capsaicin may increase sedation; if you are taking theophylline or antihypertensives, capsaicin may affect their actions or increase absorption. The problems and precautions associated with capsaicin would not make it a first or even a second choice for pain relief.

References

  1. Alimi D, Rubino C, Pichard-Léandri E, Fermand- Brulé S, Dubreuil-Lemaire ML, Hill C. Analgesic effect of auricular acupuncture for cancer pain: A randomized, blinded, controlled trial. Journal of Clinical Oncology. 2003;21(22):4120- 26. doi: 10.1200/JCO.2003.09.011.
  2. Pfister DG, Cassileth BR, Deng GE, et al. Acupuncture for pain and dysfunction after neck dissection: Results of a randomized controlled trial. Journal of Clinical Oncology. 2010;28(15):2565- 70. doi: 10.1200/JCO.2009.26.9860.
  3. Oh B, Kimble B, Costa DS, et al. Acupuncture for treatment of arthralgia secondary to aromatase inhibitor therapy in women with early breast cancer: Pilot study. Acupuncture in Medicine. 2013;31(3):264-71. doi: 10.1136/ acupmed-2012-010309.
  4. Cassileth BR, Vickers AJ. Massage therapy for symptom control: Outcome study at a major cancer center. Journal of Pain and Symptom Management. 2004;28(3):244-49. doi: 10.1016/j. jpainsymman.2003.12.016.
  5. Syrjala KL, Cummings C, Donaldson GW. Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: A controlled clinical trial. Pain. 1992;48(2):137-46.
  6. Nash MR, Tasso A. The effectiveness of hypnosis in reducing pain and suffering among women with metastatic breast cancer and among women with temporomandibular disorder. International Journal of Clinical and Experimental Hypnosis. 2010;58(4):497-504. doi: 10.1080/00207144.2010.499353.
  7. Good M, Anderson GC, Stanton-Hicks M, Grass JA, Makii M. Relaxation and music reduce pain after gynecologic surgery. Pain Management Nursing. 2002;3(2):61-70.
  8. Ellison N, Loprinzi CL, Kugler J, et al. Phase III placebo-controlled trial of capsaicin cream in the management of surgical neuropathic pain in cancer patients. Journal of Clinical Oncology. 1997;15(8):2974-80.

Excerpted with permission from Survivorship: Living Well during and after Cancer (Spry Publishing, 2014; $16.95) by Barrie Cassileth, PhD. © Copyright 2014 Spry Publishing. Available for purchase everywhere books are sold.

Barrie R.Cassileth, MS, PhD, is  Laurance S. Rockefellerchair and  chief of the Integrative Medicine Department at Memorial Sloan Kettering Cancer Center (MSKCC) in New York City. She has an extensive medical leadership career and is a recognized authority on complementary therapies and integrative medicine in oncology. Her work includes more than 170 publications in medical literature, more than 40 medical textbook chapters, and 22 books for physicians, patients, and families. She was a founding member of the Advisory Council to the US National Institutes of Health Office of Alternative Medicine, now the National Center for Complementary and Alternative Medicine; she previously served on the National and NY-NJ Regional Boards of the American Cancer Society and on multiple national and international committees. She is a staunch opponent of cancer quackery. She is founding president of the Society for Integrative Oncology. Since joining MSKCC in 1999, Dr. Cassileth has established prototypic research, education, and clinical programs in integrative medicine. Her most recent book, The Complete Guide to Complementary Therapies in Cancer Care: Essential Information for Patients, Survivors and Health Professionals, was published in 2011by World Scientific. Survivorship:  Living Well during and after Cancer, an evidence-based guide for patients and families, was published in April 2014 by Spry. 

Prescribed Reading

In Survivorship: Living Well during and after Cancer (Spry, 2014; $16.95), Barrie Cassileth, MS, PhD, offers a comprehensive overview of evidence-based integrative cancer treatment, providing a welcome resource for patients and their loved ones. Dr. Cassileth provides background on complementary therapies, describing various options and their potential to alleviate symptoms of cancer treatment and including important information about current research related to each topic. Written in a clear, accessible style, the book provides insight throughout to differentiate effective, evidence based treatments from dangerous “alternative” therapies. The result of Dr. Cassileth’s work is a book that is at once easy to understand and backed by considerable research—a valuable resource for anyone facing a cancer diagnosis.

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