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NON-PHARMACOLOGICAL MEASURES FOR CANCER PAIN

An Overview of Non-pharmacological Measures Used In Patients With Cancer Pain

Emerson R. Fletcher, George C. Koulianos, Madison M. Schrock, and Delaney R. Early

Centofanti School of Nursing, Youngstown State University

NURS 3749: Nursing Research

Ms. Heasley

April 6, 2022
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NON-PHARMACOLOGICAL MEASURES FOR CANCER PAIN

Literature Review Paper

Intro

Throughout the research conducted, it was discovered that a lot of new techniques for

cancer pain relief are on the rise. The topic of cancer pain patients who experience pain or severe

side effects that use holistic or non-pharmacological care compared to chemotherapy to increase

the patient’s outcomes was extensive throughout the research found using multiple reliable

sources. The remedies of neuromodulation, folk remedies, reflexology, visual reality,

acupuncture, cognitive-behavioral interventions, and hypnosis were explored throughout the

research, and findings including their effectiveness, their betterness compared to others, the need

for more research, etc. Out of the thousands of articles that popped up when we searched non-

pharmacological measures for cancer pain we found eight very good ones to support our thesis

statement. The articles that we used were located in the following journals and websites: Journal

of Clinical Oncology, A Cancer Journal for Clinicians, F1000Research (PUBMED), Journal of

Osteopathic Medicine, Supportive Care in Cancer, Integrative Cancer Therapies, Complementary

Therapies in Clinical Practice and Cancer control. The key works that we searched were, Cancer

AND (Pain OR Discomfort) AND (meditation OR yoga OR exercise OR acupuncture), with pain

being our main search word used.

Cognitive-Behavioral Interventions

According to the Journal of Clinical Oncology, the cause of cancer patients'

psychological pain and adverse effects is due to the malignancy itself or the adverse effects of

opioids, chemotherapy, or radiation. It is no secret that cancer patients not only go through pain

physically, but also psychologically. According to Cancer Control, the subjective portion of pain
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is thought to be influenced by distorted or irrational thoughts that create exaggerated feelings and

an increase in the perception of pain. Literature shows that asking patients to track their pain,

thoughts, and the emotions they experience, prescribed by their physician for specific times, or

after pain flare-ups, has been proven to be useful for cancer pain patients (Menefee et al., 2005).

Cognitive-behavioral therapy has been proven to be effective not only in chronic pain, but also

beneficial cost-wise (Maindet et al., 2019). Two studies on online interventions of acceptance

and commitment therapy discovered that lower physiological distress led to greater outcomes in

pain-related interference and found no association between baseline depression diagnosis and

outcomes (Maindet et al., 2019). However, it has also been shown that using mindfulness-based

interventions with patients with higher psychological distress or a history of depression tends to

obtain the greatest improvements in chronic pain (Maindet et al., 2019).

Although there are some studies that show cognitive-behavioral interventions are used to

improve the psychological status of cancer pain patients, there is also a cognitive-behavioral

intervention known as catastrophizing that has been shown to negatively affect cancer pain

patients. According to the Journal of Osteopathic Medicine, catastrophizing is a maladaptive

cognitive coping strategy that involves cancer pain patients to make negative cognitive and

emotional evaluations of their pain or the circumstances they are under. On top of this,

catastrophizing has been shown to be associated with depression and increased pain intensity. As

if cancer pain patients do not deal with enough life-altering obstacles with pain, catastrophizing

can also interfere with life activities secondary to pain and anxiety. Due to the amounts of

different research and findings, it is clear that cognitive-behavioral therapy has a lot of room for

development and research in the cancer pain field.

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NON-PHARMACOLOGICAL MEASURES FOR CANCER PAIN

Acupuncture

Acupuncture has been an up-and-coming technique over the years. Acupuncture is a treatment

that involves needles being planted into pressure points or areas of pain on the body (Bardia et

al., 2006, p. 5458). Research studies have been done to test the effectiveness of acupuncture on

cancer patients' pain. Multiple studies have shown benefits to many of the symptoms most cancer

patients face. According to the Journal of Clinical Oncology, Alimi et al reported the

effectiveness of acupuncture when it is being used for cancer pain. This study had participants go

through two sessions that were 1 month apart from each other. This research study showed the

possibility of a nonpharmacological treatment that can be greatly beneficial to cancer patients'

pain. Journal of Clinical Oncology also commented on the need for more studies on acupuncture

to learn more about the effectiveness of cancer patients' pain and further side effects of treatment.

The Journal of Osteopathic Medicine included information about chronic cancer pain and the

benefit of acupuncture. According to the Journal of Osteopathic Medicine,

Chronic pain in cancer survivors is often not alleviated by conventional treatments and is

the most common reason acupuncture treatment is sought (Menefee et al., 2005). A

recent meta-analysis reported that 9 out of 11 clinical trials showed decreases in

survivors’ perceived pain after acupuncture treatment.

Chronic cancer pain cannot always be managed by opioids due to the possibility of becoming

dependent on them. Acupuncture gives cancer patients with chronic pain a nonpharmacological

way to deal with their pain. Cancer Control analyzed other research studies on acupuncture and
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found that acupuncture therapy, when used alone, is not as effective as conventional drug

therapy. In their literature review, they did comment on acupuncture still giving cancer patients

less pain and a better quality of life without the adverse effects that pain-relieving medications

have. Overall, Elizabeth Thomas’s article in Cancer Control came to the conclusion that

acupuncture is more beneficial when used in multimodal therapies for cancer pain. Acupuncture

has been proven to have a beneficial effect on cancer patients' pain. Chronic cancer pain patients

may benefit from this therapy due to the downsides to them using certain pain medications. Even

if pain medication is used by a cancer patient, acupuncture can help alleviate more of the pain

using multimodal therapies. Acupuncture still needs to go through more research to find further

evidence to support this therapy in treating cancer pain, but this nonpharmacological treatment is

very promising according to the studies that have been completed and reviewed.

Visual Reality

Visual reality is a technology that is used for entertainment which has now been used in

the treatment for cancer pain. Visual reality is when technology goggles are used to create a

simulated experience. This simulated experience can be anything such as a beach or a forest.

According to Caroline Maindet’s article (Maindet et al., 2019), visual reality has been used for

cancer patients going through painful procedures such as chemotherapy and port access. These

procedures can be very painful for the patient and many times, certain pain medications cannot

be administered when having chemotherapy done. This nonpharmacological treatment provides

patients with an easy way to treat the pain. This therapy is not only convenient but also has been

proven to be effective in treating pain. Caroline Maindet states,

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VR has been used with success in rehabilitation systems to treat cancer survivors coping

with upper body chronic pain . . . Participants immersed in a VR experience reported

reduced pain levels, general distress/ unpleasantness, and a desire to use VR again during

painful medical procedures.

Patients with acute and chronic cancer pain are able to use this therapy to help relieve their pain

during and after painful procedures. Patients not only felt less pain after but wanted to use this

therapy again when having painful procedures done. This therapy is very promising and effective

in treating cancer pain in studies that have been done.

Hypnosis

Hypnosis is usually seen as a form of magic trick or entertainment. In current times,

hypnosis has been studied to decrease pain in cancer patients. The definition of hypnosis is,

“ . . . a complex process of attentive, receptive concentration characterized by a modified

sensorium, altered psychological state, and minimal motor functioning”(Menefee, Lynette A. and

Monti, Daniel A., 2005, p. 19). This nonpharmacological treatment, according to Caroline

Maindet, has shown benefits to using hypnosis in cancer-related pain from treatments and

concomitant disease. Supportive Care in Cancer also discusses hypnosis as the only non-

invasive CIT technique that is recommended by France. This recommendation by France is due

to the many studies that have all shown the effectiveness of hypnosis related to cancer pain. In

Supportive Care in Cancer, a study by Syrajala showed significant effectiveness in hypnosis

therapy. In this study, there were 4 groups. The study was set up as follows: group one had

routine treatment, group two had therapist attentional control, group three participated in

hypnosis, and group four had a cognitive-behavioral skills package. Results of the study by
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Syrjala show that the hypnosis group had significantly less posttransplant pain than any of the

other therapies tested. This shows a significant benefit to cancer patients and pain relief.

According to The Journal of Osteopathic Medicine, the NIH Technology Assessment Panel

found, “strong evidence for use of hypnosis in reducing pain, including that associated with

cancer” (Menefee, Lynette A. and Monti, Daniel A., 2005, p. 19). Hypnosis was found by this

pannel to have successfully relive not only pain but the side effects such as nausea and vomiting

that are associated with the use of chemotherapy. Hypnosis has had multiple credible studies and

literature reviews that have proven the effectiveness of this nonpharmacological treatment on

cancer-related pain. Hypnosis was found to have a better effect on pain than cognitive behavioral

skills and therapist attentional control.

Understanding and Managing Cancer Pain

Cancer has been a prevalent topic for many years now and is only becoming more

significant due to all the research being done on it. According to the Department of Hematology

and Medical Oncology, “more than 14 million cases of cancer were diagnosed worldwide in

2012 and by 2025 the number is expected to reach more than 20 million” (2017, para. 1).

Unfortunately what comes along with cancer is cancer pain. Cancer pain has continued to evolve

bringing more awareness when patients come to the hospital for their treatments. It is one of the

patients’ biggest fears when they are first diagnosed with cancer because everyone has a different

pain tolerance and most patients don’t know how much they can take.

Pharmacological treatments have been Doctors' first mechanism of action when treating

any pain, especially cancer pain. Opioids have been the main treatment of cancer pain but, “their

role in treatment has been evolving largely due to a growing understanding of their adverse
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effects associated with chronic use. This is especially important in the context of longer survival

in cancer and improving survival rates'' (Chwistek, 2017, para. 35). Just because it is

pharmacological does not mean it is always the best thing to do, so researchers have found

healthier and more beneficial ways to treat cancer pain without using medication. One of the

most effective ways is known as Neuromodulation. “Neuromodulation is described as electrical

or chemical alteration of signal transmission within the nervous system by using implanted

devices or- increasingly- non-invasive techniques, which result in modulation of pain signals

leading to analgesia” (Chwistek, 2017, para. 64,67,68). This study was focused on the different

categories of neuromodulation and why they are so beneficial.

The first category of neuromodulation is spinal cord stimulation. “Spinal cord stimulation

is a minimally invasive outpatient technique that involves the placement of electrodes in the

epidural space” (Chwistek, 2017, para. 69,70). At the beginning of the study, they connect the

electrodes to a pulse generator that is placed under the buttocks area. The main goal of the

treatment is based on the electrical stimulation of the dorsal root ganglion which will suppress

the transmission of stimuli from the nociceptive nerve fibers, overall decreasing pain. Spinal

cord stimulation is also very beneficial because it goes hand in hand with peripheral nerve

stimulation which is rapidly evolving in the oncology field. Upon reviewing these findings, “

The case and observational studies of the clinical use of PNS present it as an attractive modality

for treatment of neuropathic pain states due to peripheral nerve injuries, nerve entrapments, or

damage to nerve plexuses. These are common complications of cancer- or cancer-related

therapies” (Chwistek, 2017, para. 65,84). Spinal cord stimulation allows the stimulation to reach

the majority of the patient's body allowing it to take the edge off the pain the cancer is causing

without having to receive medication.

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Evaluating Complementary and Alternative Therapies For Cancer Patients

CAM therapy or alternative medicine is starting to become more prevalent in patients'

day-to-day lives. According to the study done by the American Cancer Society, “ A recent

systematic review of relevant published data located 26 surveys of cancer patients from 13

countries including five from the US. The average prevalence of CAM use across all studies was

31%” (Cassileth, 1999). This shows the prevalence of this therapy and how the whole world is

using it to treat the different effects of pain, not just the United States. Another effective CAM

therapy is Herbal remedies. This category consists of homeopathy, acupuncture, and folk

remedies to help ease the patient’s pain. According to The American Cancer Society, “Herb sales

in drugstores and food stores increased 35% from 1993 to 1994 totaling $106.7 million for the

year” (Cassileth, 1999). The even better thing with CAM therapies is that health insurance covers

it. “ More than 30 major insurers, half of them Blue plans, cover more than one alternative

therapeutic method” (Cassileth, 1999). These numbers are very good compared to other medical

therapies and give cancer patients more reassurance to do this type of therapy. When (you) give

patients another option besides traditional pills it allows them to explore the different therapies

and see that there is more out there than traditional medicine. Herbal medicine and spinal cord

stimulation are all effective ways to treat cancer pain with many benefits to them.

Reflexology

Reflexology has been used as a complementary and alternative therapy for many years.

They have used this methodology to decrease levels of anxiety, depression, pain, and overall

improving the quality of life of patients undergoing reflexology therapy. Reflexology is utilizing

various pressure points in the foot to stimulate a brain response. Reflexology is described to
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work by “increasing neural stimulation and blood flow. It is also assumed that it increases the

release of dopamine and endorphin hormones by stimulating the immune system, endocrine

system, and neuropeptides. These hormones are likely to prevent pain transmission, provide

relaxation, reduce stress, and increase peace.” (Turkcu & Ozkan 2021)

A recent study was performed by Sinem Goral Turkcu and Sevgi Ozkan on the effects of

reflexology on women undergoing chemotherapy for gynecological cancers. The study consisted

of sixty-four patients undergoing chemotherapy, and they were divided into two groups of thirty-

four. One group was the intervention group and received reflexology treatment, compared to the

non-intervention group which did not receive any additional treatment. The intervention group

received reflexology treatments three times a week for two weeks with thirty to thirty-five-

minute sessions. All sixty-eight participants of the study took a personal information form during

the first two weeks of the trial along with the fourth week of the trial. The personal information

form scored each participant's level of anxiety, depression, and quality of life and additionally

separated them into subdivisions.

Turkcu and Ozkan stated the results were as followed:

● “ Anxiety levels of the intervention group significantly decreased at the end of the

reflexology sessions (on the second week) and two weeks after the intervention (on the

fourth week) compared to their anxiety levels before the reflexology intervention”.

(Turkcu & Ozkan 2021)

● “Depression levels of the intervention group also significantly decreased at the end of the

reflexology session (on the second week) and two weeks after the sessions (on the fourth

week) compared to their depression levels before reflexology. However, there was a
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significant increase in the depression levels of the intervention group in the fourth week

compared to the second week”. (Turkcu & Ozkan 2021)

● “The global quality of life of the intervention group significantly increased at the end of

the end of reflexology sessions (on the second week) and two weeks after the session (on

the fourth week) compared to the global quality of their life before reflexology sessions.

Overall even though some of the benefits of reflexology are not long-lasting, there are positive

effects for the patient receiving reflexology as treatment.

Conclusion

Overall, the non-pharmacological measures that could be used for patients receiving

cancer treatments are endless. Patients undergo a variety of horrific symptoms following cancer

treatment with the most common being pain and discomfort. We found in our research that pain

isn't always physical but could also be mental. From our research, it's evident that

neuromodulation, folk remedies, reflexology, visual reality, acupuncture, cognitive-behavioral

interventions, and hypnosis all positively affected patients undergoing cancer treatment. The

effects of these therapies included a decrease in pain mentally and physically, and also gave the

patient a better quality of life overall.

Reference Page

Bardia, A., Barton, D. L., Prokop, L. J., Bauer, B. A., & Moynihan, T. J. (2006). Efficacy of

complementary and alternative medicine therapies in relieving cancer pain: A systematic

review. Journal of Clinical Oncology, 24(34), 5457–5464.

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https://doi.org/10.1200/jco.2006.08.3725

Cassileth, B. R. (1999). Evaluating complementary and alternative therapies for cancer

patients.

CA: A Cancer Journal for Clinicians, 49(6), 362–375.

https://doi.org/10.3322/canjclin.49.6.362

Chwistek, M. (2017). Recent advances in understanding and managing cancer pain.

F1000Research, 6, 945. https://doi.org/10.12688/f1000research.10817.1

Göral Türkcü, S., & Özkan, S. (2021). The effects of reflexology on anxiety, depression and

quality of life in patients with gynecological cancers with reference to Watson's theory of

human caring. Complementary Therapies in Clinical Practice, 44, 101428.

https://doi.org/10.1016/j.ctcp.2021.101428

Maindet, C., Burnod, A., Minello, C., George, B., Allano, G., & Lemaire, A. (2019). Strategies

of complementary and integrative therapies in cancer-related pain—attaining exhaustive

cancer pain management. Supportive Care in Cancer, 27(8), 3119–3132.

https://doi.org/10.1007/s00520-019-04829-7

Menefee, L. & Monti, D. (2005). Nonpharmacologic and Complementary Approaches to

Cancer Pain Management. Journal of Osteopathic Medicine, 105(s5), 15-20.

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https://doi.org/10.7556/jaoa.2005.20023

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https://doi.org/10.1177/107327480000700206
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