Practice Development Clinical Project

Pain Management in the Oncology Unit

Pain has been one of the most distressing symptoms of cancer. It affects the quality of life of patients, their family as well as their caregivers. Being moderate to severe, pain is very common, and its prevalence increases throughout the course of the disease (Kwon, 2014). Although cancer pain is usually adequately controlled through pain management for most patients, however, the problem continues to be undertreated due to several factors(Adam et al., 2017). This essay presents the case encountered during a student clinical placement in the Oncology ward whereby Mia (pseudonym), a 29-year-old female came in for a routine check-up after having had a bilateral mastectomy approximately 2 years ago and from then on she received a combination of external radiation therapy, chemotherapy and hormonal agents. At that time, Mia was referred to the oncology department following a routine breast screening ordered by her General Practitioner due to her strong family history of breast cancer with her mother being diagnosed at the early age of 30. Following her surgery, Mia had chronic pain even though adequate pain management was provided to her. Upon review, she was found to have lymphoedema formation in her axilla. Among women worldwide, cancer is the leading cause of death in high income countries as well as middle income countries. Furthermore, the cancer burden is continually expanding in countries with all type of income level due to the increasing number of the aging population. Throughout the course of cancer, from diagnosis and treatment to the long-term management, patients are faced with multiple factors that impacts their professional, personal, physical and emotional state (Torre, Islami, Siegel, Ward, & Jemal, 2017). This essay will include six criteria which could be used to enhance the learning/information path for newly graduate when dealing with patients having cancer pain post-surgery. The six areas include; Patient empowerment, use of integrative therapies postoperatively, body image post-mastectomy, pain management using physical training, pain assessment, and pain from lymphedema formation.

Breast cancer is the most diagnosed cancer and the leading cause of mortality among women worldwide (Torre et al., 2017). Mia has had quite a few personal issues that had a great impact on her life. Apart from her obesity, Mia is physically inactive, has type 2 diabetes melitus and after the death of her mother, she struggled with alcohol abuse. According to Torre et al. (2017), factors such as, family history of the disease, reproductive factors which influence the endogenous estrogen exposure, physical inactivity, alcohol consumption, excess body weight, high-dose radiation to the chest and exogenous hormones use, have a strong link to breast cancer.

Pain management is a very important aspect in the quality of life of a seriously ill individual. Approximately 60% of women are affected by persistent pain after breast cancer treatment which is often inadequately recognised and hence frequently undertreated. Inadequate pain assessment as well as a lack of knowledge about pain mechanism are among the common barriers for adequate pan management (Schou Bredal, Smeby, Ottesen, Warncke, & Schlichting, 2014). Sensory or motor symptoms and impairments such as weakness, pain, tightness, nerve palsies, poor range of motion, altered movement patterns or swelling in the arm, shoulder and/or breast of the affected side are the issues that may arise from breast cancer (Hayes et al., 2012). The root of the cancer pain is quite complex, and it arises due to issues such as oedema around a tumour, the tumour itself, or metastasis in nerve, tissue or bone or it can even be related to the cancer treatment itself.

Following her surgery, Mia experienced chronic pain which does not seem to subside, even though adequate pain management was given. On a scale of 10, she rated her pain as a 6-7. She states that the pain gets worse on elevation or when holding a certain amount of weight (approximately 5kg). She describes the pain as being worse when she lies down or if she performs repetitive movements. She was reviewed by the pain specialist and the latter concluded that she previously had underlying breast pain which had an increase in intensity following her breast surgery. An analysis conducted by Langford et al. (2015) concluded that women who had preoperative breast pain are at risk of more severe postoperative pain, sensory loss at the breast scar site, impaired shoulder flexion and poorer physical well-being.

A paper by Hayes et al. (2012) studied 7 cohort studies involving population-based samples at 6, 12, 18, 24 and 36 months after breast diagnosis/surgery and the table below shows the results. Cancer pain still lingers around even 36 months after breast cancer diagnosis/surgery with 19% to 54% having at least one symptom.

Poor cancer pain management are associated with decreased quality of life and impaired daily functioning. This frequently leads to increase emergency visits and sometime hospitalization. Furthermore, inadequate pain management can lead to cessation of cancer treatments (Jacobsen & Snyder, 2018). Below is a few information which newly graduate nurses could use when undertaking Mia’s care.

Patients’ Empowerment

Patient empowerment in cancer pain management forms a very important aspect of their care and has been highlighted as playing a key role in pain management. This give the opportunity for the patient to take control of their care without their healthcare provider being judgemental but to understand the needs and do what is in their best interest. An integrative review of several papers conducted by Te Boveldt et al. (2014) suggested that a cyclical model seemed more appropriate in cancer pain management. It highlighted that previous research either focused on pain treatment provided by healthcare providers or the active participation of the patient. Te Boveldt et al. (2014) suggested the following model and recommended that both the active involvement of patients as well as pain treatment induced by healthcare professional should be considered when it comes to pain management.

Use of integrative therapies postoperatively

Breast cancer survivors commonly use integrative therapies for many reasons including, improving quality of life while managing the side effects of cancer therapy. Patients using behavioural therapies, such as mindfulness, meditation, relaxation, and yoga showed a strong mood improvement in the background of anxiety and depression during cancer treatment. Massage and stress management for energy and mood improvement were least recommended. During radiation therapy and chemotherapy, music therapy is recommended to provide short term relief of anxiety. For improving depression and mood during radiation therapy and post treatment, meditation is recommended. Enhancement programs such as energy, sleep and healing touch can be considered when treating pain during chemotherapy. Meditation showed strong link to improving quality of life (Greenlee et al., 2014).

Body Image post-mastectomy

It is a very sensitive issue when dealing with a female’s body image especially after cancer surgery. Patients are very concern about their health but also worry about how their body image will change afterwards. When nurses deal with females (no matter how old), it is sometime quite a delicate topic to discuss. A study conducted by Grogan and Mechan (2017) on 49 women aged between 29-53 years (8 had bilateral surgery and 41 unilateral mastectomy) to examine the positive and negative impact mastectomy has on their body image. The women’s priority was that of survival and at diagnosis, they were more anxious about their health than how their body image might be after. However, for some women, especially that who had unilateral mastectomy, were very displeased because their body was no long symmetric. Mentally, they were not ready to accept that part of their body, which seemed damaged, was removed. They felt lost and out of touch with themselves.

Pain management using physical activity

The prevalence of pain among breast cancer patients is high and is almost inadequately treated as either the intensity of pain is failed to be identified or there is an underestimation of the pain severity. Pain reduces with physical training and this increases cardiorespiratory fitness, strength, flexibility, and quality of life, thus decreases length of hospital stay, fatigue, depression, anxiety, sleep disorders, stress, nausea and vomiting (Reis et al., 2018). A controlled pilot study by Reis et al. (2018) on 28 patient between the age of 30 to 59 years underwent a 12 weeks training, including 60 minutes sessions of resistance training and exercise and two sessions of 3 sets of 20 seconds flexibility training per week. The results showed that combined training decreased total pain intensity, pain points, and pain interference in patients’ daily living as well as an increase in flexibility, oxygen uptake and strength.

Pain assessment

Cancer related pain is difficult to assess and control because of its subjective nature, its magnitude and complexity of cancer. When correct assessment is not undertaken or not properly performed, inadequate pain control result. A comprehensive cancer pain assessment focuses on the location, quality and type of pain, pain history (duration, onset and course), intensity, temporality (intermediate, constant or breakthrough) and pain radiation to other parts of the body. Regular interval comprehensive pain assessment is critical for optimal pain management. This can help in obtaining adequate assessment and thus appropriate treatment can be offered and this can help in improving physical functioning, psychological and emotional status, performance of activities of daily living and improved social interaction. If verbal assessment in not appropriate in some patient, alternative pain assessment tools may be needed (Gallagher, Rogers, & Brant, 2017).

Pain from lymphoedema formation

Lymphoedema is and remains the biggest complication of breast cancer therapy. It is the injury to the axillary lymphatic system which causes accumulation of lymphatic fluid in the interstitial space then causing swelling of the vessels. Fluid can either accumulate in the arm, hand or breast that receives axillary radiation therapy. Although there are no visible changes, lymphoedema causes a feeling of numbness, heaviness or tingling. Chronic lymphoedema may increase in severity and has progressive and irreversible course if not detected and treated early (Dunne & Keenan, 2016).

Below are the risk factors for developing lymphoedema;

* Obesity

* Reduce shoulder mobility

* Positive lymph nodes

* Surgery on axilla

* Post-surgery axillary nodal radiation

* Post-surgery axillary haematoma, infection or seroma.

(Dunne & Keenan, 2016)

In summary, cancer pain, although controlled through pain assessment and management, remains most of the time inadequately controlled. Patients are left with this underlying issue which affects their daily, social, professional as well as personal lives. Being able to recognise and address issues through proper assessment tools and also keeping into consideration the patient’s history, comorbidities, personal life, social environment as well as underlying issues can help in addressing the issue of pain. The above six listed areas are some of the example of how to address a patient’s pain especially if it is post cancer surgery. Patient empowerment help healthcare providers tailor make pain management with the collaboration of the patient and thus better management and adequate control can be achieved. Alternative therapies can help patient confront pain in a much relaxing manner. It helps them relax and feel better about themselves, especially after going through a lot or distress during diagnosis, surgery as well as after. Addressing the issue of body image, especially when the patient is already experiencing pain can be of great importance as patient can have a sense of self confidence and this has a great impact on pain management. Physical activity should be promoted as a few studies have showed improvement in quality of life, oxygen uptake as a great sense of self-appreciation as well as a decrease in pain intensity, pain point and pain interference with daily life. Lymphoedema remains an issue that patient as well as healthcare professional dread as if left untreated may develop into a chronic condition that is irreversible. The changes are invisible to the eyes but sensation such as tingling, numbness and heaviness can disturb a patient’s activity of daily living. There are issues that may not be visible to the eyes but through proper questions and assessment can help treat the problem of pain and prevent it from developing into a chronic condition.