Elizabeth M.Thomas, PsyD, PhD, and Sharlene M.Weiss, RN, PhD, Sylvester Comprehensive Cancer Center at the Universityof Miami School of Medicine, Miami, Fla.

Abstract and Introduction
Abstract
Background:Pain is often poorly controlled in cancer patients. Chronic pain affects adult patients at all stages of cancer management. Optimal pain management may require attention to psychosocial variables and the inclusion of nonpharmacological techniques.
Methods:Three nonpharmacological strategies that are effective in reducing pain caused by cancer — patientpsychoeducation, supportive psychotherapy, and cognitive-behavioral interventions — are reviewed. Recommendations for physicians to facilitate a mental health referral are also discussed.
Results: Effective treatment of cancer pain begins with assessing the severity, characteristics, and impact of pain. Emotional distress (especially anxiety, depression, and beliefs about pain) has emerged as predictive of patient pain levels. Appropriate pain management may require a multidisciplinary approach.
Conclusions: Patient psychoeducation has empowered patients to actively participate in pain control strategies. Supportive psychotherapy can assist patients in managing the stressors associated with cancer, and cognitive-behavioral therapy helps patients to recognize and modify the factors that contribute to physical and emotional distress.

Introduction
Physical pain is perhaps one of the most fearedconsequences for patients with cancer. Available estimates suggest that chronic pain affects 60% of adultpatients with newly diagnosed or intermediate-stagecancer and up to 95% of patients with advanced disease.^[1,2] Indeed, the magnitude of the problem is sogreat that some reports indicate that 25% of individualsmay actually die in significant pain.^[3]

Ninety percent of cancer patients are believed tobe manageable with relatively simple medical interventions.^[2] However, in practice, less than 50% experienceeffective pain relief.^[3] To account for this discrepancy inpain management, a number of psychosocial factorshave been implicated in the literature. While someresearchers have focused on inadequacies related tohealth care providers or health care systems (eg, anemphasis on prolonging life or achieving cure ratherthan alleviating suffering),^[2,4] others have identifiedissues involving the patients themselves.^[5-9] That is,patients experience difficulty assessing and communicatingabout pain, are reluctant to report pain, have limitedexpectations for relief, and generally lack knowledgeabout current therapeutic approaches. Even whenpain is addressed medically, patients may be noncompliantwith treatment due to concerns about drug tolerance,addiction, side effects, or respiratory depression.

Of all of the psychosocial factors, emotional distress(particularly anxiety, depression, and beliefs aboutpain) has consistently emerged as predictive of patientpain levels. Spiegel and Bloom^[10] found that the site ofmetastases in women with advanced breast cancer wasnot reliably associated with pain; rather, emotional distressand the belief that pain signaled a worsening oftheir condition predicted the reporting of pain. Similarly,Daut and Cleeland^[11] found that cancer patientswho attributed their pain to a cause other than cancerreported the least interference with activities of dailyliving and pleasure. Further, Ahles et al^[12] comparedcancer patients with and without pain and demonstratedthat patients with pain scored higher on measures ofdepression, anxiety, hostility, and somatization. Thus,attention to the psychosocial variables of the cancerpatient through nonpharmacological interventionseemingly provides an additional and viable avenue forthe treatment of cancer-related pain.

This article focuses on three of the most commonapproaches employed by mental health professionals:patient psychoeducation, supportive psychotherapy,and cognitive-behavioral therapy. The basic principlesbehind these methods are explained and relevantresearch studies are discussed. Only those studies thathave methodically strong designs are included in orderto critically examine the efficacy of these approaches.

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Cancer Control 7(2):157-164, 2000. © 2000 H. Lee Moffitt Cancer Center and Research Institute, Inc