The Growing Pains of Cancer Survivors: A Call for a Paradigm of Interdisciplinary Care

As improved cancer surveillance, more accurate diagnosis, and more efficacious treatment begin to extend life expectancy for numerous patients, the number of cancer survivors will predictably continue to grow into the future1. And as the survivor population increases, new and unique challenges become more apparent. For example, more than 40% of cancer survivors experience pain after their initial diagnosis2. For those survivors, physical pain is not the only hardship to be faced. They also encounter numerous psychological, social, spiritual, and financial challenges after diagnosis and treatment3. The entire spectrum of pain is now recognized to be more prevalent than earlier thought and unique to each person who has undergone cancer treatment. Particular factors acting in conjunction with the physical causes of pain and contributing to total pain include loss of appetite, loneliness, fatigue, social isolation, existential distress, and family disharmony. Communication is a vital ingredient for the adequate assessment and treatment of patients and their pain. The level of communication about pain can vary for team members, both with each other and with their patients. Patients may also feel lost within an oncologic setting because of the vast variety of professionals they encounter, each speaking different jargon and rarely communicating with one another. As a result, patients and their families are often left to decipher the overall message and to try to make sense of what is being relayed to them. Thus, many patients might not recognize—or might even understate—the degree of their pain. The interdisciplinary team approach implies integration of several disciplines to develop solutions open-mindedly. The team focuses on common goals and shared development of treatment processes4. This approach allows aspects of care that might remain unaddressed by some medical professionals to be picked up and addressed by others. In addition, increased communication within the team can further the ability of various team members to be more effective within their own treatment processes. The patient can also take advantage of a much larger toolbox to describe pain symptoms and to mitigate mal-communication5. Interdisciplinary teams allow for a continuing dialogue between physicians; nurses; physical, occupational, and vocational therapists; dieticians; social workers; psychologists; and the patient. The philosophies of cancer treatment have been transformed in recent years, and health care professionals have reached a point at which integration of pharmacologic and nonpharmacologic treatment for the relief of pain is the order of the day. With this transformation in mind, the ultimate goals of oncologic health care include eradication or control of the disease, minimization of treatment side effects, optimization of function and overall quality of life, and for survivors, empowerment. Even given this knowledge, management of chronic pain for cancer survivors is still not optimal. For the patient, pain management is achieved through a variety of measures: revision of the pain source, alteration of pain perception, and inhibition of the transmission of pain messages to the central nervous system. Among pharmacologic treatments, agents such as opioids have been used as the foundation of analgesic therapy. Morphine is currently the most widely used opioid, but little research has been conducted to attempt to distinguish whether some opioids might be more effective than others. Tricyclic antidepressants promise to play a role in future for the treatment of neurologic pain. Anti-inflammatory agents—more commonly known as nsaids (nonsteroidal anti-inflammatory drugs)—and steroids are used in combination with opioids to treat several pain symptom types for cancer survivors. The next step is to provide patients with nonpharmacologic approaches that offer holistic treatment. These sorts of approaches allow for the patient’s other pain symptoms to be addressed through roundtable discussion with the interdisciplinary team and with spiritual or religious counsel; through training to encourage the stamina and endurance needed to counter the effects of treatment; and through a powerful ability to recognize stressful situations and to apply effective and learned coping skills. Already, use of a team approach has shown great efficacy in the treatment of chronic pain in the general population. One third of individuals so managed are able to return to work, and a decrease in pain intensity of 70% and an improvement in mood of 90% have been noted6. Those results show much promise for application within the treatment of cancer survivors. As the lives of cancer survivors continue to be prolonged, every type of pain that they might experience must be cared for. The interdisciplinary team reaches far beyond the basic paradigms of clinical treatment to both understand and manage pain. Cancer survivors will continue to experience chronic pain, but once this holistic form of treatment is fully realized, the team will be able to provide the patient with one of the most powerful tools of all: a return to a sense of meaning in life, as Victor Frankl so aptly described it7.