Experiencing pain may increase the odds that cancer survivors will use cigarettes and cannabis, according to a recent study published by Wiley online in CANCER, a peer-reviewed journal of the American Cancer Society. The study also found that cigarette smoking and pain are linked to more treatment-related side effects and worse health among cancer survivors.
Pain and use of cigarettes, e-cigarettes, alcohol, and cannabis commonly occur together in the general population. To characterise pain in relation to such non-opioid substance use specifically among cancer survivors (who often experience pain), investigators analysed data from two national samples of individuals with a past diagnosis of cancer in the United States: 1252 adults from Wave 6 (2021) of the Population Assessment of Tobacco and Health (PATH) Study and 4130 adults from the 2020 National Health Interview Survey.
PATH data indicated that higher past-week pain intensity was associated with a greater likelihood that cancer survivors would use cigarettes, e-cigarettes, and cannabis, and a lower likelihood that they would drink alcohol. National Health Interview Survey data indicated that chronic pain was associated with a greater likelihood of cigarette smoking and a lower likelihood of alcohol use. In both studies, cigarette smoking and pain were linked to fatigue, sleep difficulties, poorer mental/physical health, and lower quality of life.
“These findings show that because pain and substance use are interconnected among cancer survivors, it’s important to focus on treating both together in cancer care. Pain can drive substance use, and substance use can worsen pain, creating a cycle that’s hard to break,” said lead author Jessica M. Powers, PhD, of Northwestern University’s Feinberg School of Medicine. “While cancer survivors might smoke cigarettes or use substances to get immediate relief from their pain and cope with other symptoms, this can be incredibly harmful for their health by reducing the effectiveness of cancer treatments and increasing risk for cancer recurrence.”
Breast cancer is the world’s most prevalent cancer. Although earlier detection and targeted treatment have resulted in high survival rates, many breast cancer survivors experience fear of cancer recurrence. For some survivors this fear is occasional, for others it is persistent and often debilitating.
A new study of breast cancer survivors has found this psychosocial challenge impacts almost every important domain of their lives – the emotional, behavioural, cognitive, relational and professional. A larger number of domains was affected, and they were affected more frequently in those with greater fear of recurrence.
“Study participants were reportedly disease free and trying to rebuild their lives during their post-treatment survivorship,” said senior author Shelley Johns, PsyD, a researcher-clinician with the Regenstrief Institute, the Indiana University School of Medicine and the IU Melvin and Bren Simon Comprehensive Cancer Center. “Our findings provide clarity about how breast cancer survivors are impacted by fear of recurrence and insight into how they cope with this understandable fear.”
The impact of fear of recurrence ranged from mildly to severely disruptive. Women experiencing mild fear reported sporadic occurrences. Those with significant fear described it as persistent and/or easily triggered across multiple life domains.
Disturbed sleep prior to mammograms was reported by survivors with mild fear, while frequent need to absent themselves from social activities, get into bed and pull the blanket over their eyes to avoid thinking about cancer was an example of severe, also known as clinical, fear of recurrence. Approximately 74 percent of study participants were experiencing clinical fear of recurrence.
347 women completed the study’s open-ended survey:
Many reported feelings of stress, irritability and sadness.
Some said fear of recurrence frequently interrupted their train of thought, for example interfering with their job when their disease popped into their mind.
Survivors who thought that they were more worried than they should be compared to other breast cancer survivors reported feelings of embarrassment.
Some indicated it was too hard to be around their family because they were constantly wondering how many more Christmases and birthdays they were going to have with their children.
The paper’s title includes the phrase, “out of a dark place,” a direct quote from a breast cancer survivor who said that she joined the study to support “getting out of a dark place.”
Other survivors noted the specific impact of fear of cancer recurrence on daily life:
“It motivates me to maintain healthy habits. Such as eating five servings of fruits and vegetables, working out and drinking less alcohol. It also motivates me to maintain mental health and physical health.”
“Whenever I feel any kind of pain or discomfort in the area where I had cancer it concerns me and I feel anxious and irritable.”
“Cancer is all around us. Everything is a trigger. Anniversaries, other family/friends’ diagnosis, commercials about drugs, social media, etc. …it’s a daily thought or a daily emotion.”
“Sit for hours doing nothing, do not turn on TV, sleepless, find hours pass by and I am in the same place just thinking, do not participate in activities, get lost driving because I’m deep in thought, compulsive online shopping, collecting things.”
Survivors offered specifics on their coping mechanisms:
“Just trying to be positive, eat healthy, take my meds, get enough sleep, exercise three times a week, and hope for the best.”
“I try to avoid things that make me think about recurrence. For example, unfollowing social media accounts, fast forwarding or leaving the room when commercials about cancer medications are on.”
“I try not to focus on it. I also speak with family members who have lived with cancer longer than myself.”
“Prayer, meditation, staying in the moment, and focusing on making the best of each day.”
While many survivors cited avoidance of thoughts and feelings as their primary coping behaviour, Dr Johns, a health services researcher and clinical health psychologist, observes that research is needed to probe the function of various coping behaviours’ to determine if they are helpful.
In a question seldom posed to participants in a clinical trial, when asked what they hoped to gain by participating in the study, the majority indicated that they sought senses of purpose, belonging, control and connection with others.
The paper concludes, “Fear of cancer recurrence is one of the most common psychological challenges for cancer survivors. Understanding affected life domains, coping strategies employed prior to intervention, and reasons for seeking guidance can inform the development and implementation of evidence-based interventions to effectively address fear of cancer recurrence among persons living with breast cancer.”
A recent analysis of all relevant published studies reveals clear benefits of Cognitive Behavioural Therapy (CBT) for improving mental health and quality of life in cancer survivors. The findings, which are published in Cancer Medicine, extend CBT’s effects beyond what has long been known in the general population.
For the analysis, investigators uncovered 132 clinical trials comparing CBT with controls, including standard therapy, waitlist control, or active/alternative therapy.
Across the trials, CBT moderately improved mental health and quality of life in people with past or current cancer, regardless of cancer type. It seemed to have stronger effects in younger individuals. In-person CBT also appeared more effective than delivering CBT through technology such as web-based videoconference platforms.
“In addition to confirming the general benefit of CBT for individuals with cancer, this study unveiled important nuances of how CBT can be most effective and for which populations. This has major clinical implications for supportive oncology providers,” said corresponding author Anao Zhang, PhD, of the University of Michigan.
