Pediatric Cancer Pain May Be Misunderstood and Largely Undertreated

A Conversation With Christine T. Chambers, PhD, RPsych


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Cancer pain in children poses certain unique challenges. Over the past decade, insightful research into pediatric cancer pain has focused on pain management that incorporates nonopioid therapies into standard care. To shed light on this important issue, The ASCO Post spoke with Christine T. Chambers, PhD, RPsych, Canada Research Chair in Children’s Pain, Centre for Pediatric Pain Research, and Professor in the Departments of Pediatrics and Psychology & Neuroscience (with cross appointments in Anesthesia, Pain Management & Perioperative Medicine, and Psychiatry) at Dalhousie University in Halifax, Nova Scotia, Canada. 

Impact of Early Experiences

Please describe how pediatric cancer pain differs from adult pain.

Naturally, children with cancer experience the same types of pain that adult cancer patients do, from the cancer burden itself and the treatments. However, children are more emotionally vulnerable, and therefore, their early life experiences can influence the trajectory of their lives. For instance, there’s evidence that poorly managed pain in children changes the way they process pain later on in life. Naturally, there is still a lot we don’t know about pediatric pain and its subtle effects on survivorship. 

Pediatric vs Adult Pain Management

How does pain management in pediatric patients differ from that in adults?

Essentially the same pharmacologic interventions are used, but they are personalized to the needs of a child. There are also psychological interventions and cognitive behavior treatments tailored for the pediatric patient. I think one of the main differences between adult and pediatric patients has to do with the role of the parents. 

As would be expected, children with cancer are almost always accompanied by their parents during assessment and treatment, and over the past 20 years, much of my work has been studying the role parents play in the oncology setting. My current study, “It Doesn’t Have to Hurt” (http://itdoesnthavetohurt.ca), is centered on providing parents with research evidence that they can incorporate into the care of their children. 

Currently, children are not receiving the evidence-based care they deserve. It can take 17 years for research findings to translate into improvements in clinical care, and we aim to change that. 

Pain Assessment

What pain assessment techniques are used in pediatric patients?

Pain assessment is a cornerstone of effective pain care, and there are developmentally appropriate ways to assess pain in the pediatric setting. For instance, we have several good self-report tools such as the Faces Pain Scale, which caregivers can use to rate pain. 


When working with children [with cancer pain], we have to make sure that the parent is supported and coached in an effective way.
— Christine T. Chambers, PhD, RPsych

My colleague Jennifer Stinson, PhD, RN-EN, CPNP, of The Hospital for Sick Children (“SickKids”) in Toronto, created an incredible assessment tool called the Pain Squad app that’s been tested in published studies1,2 and is available for free through the iTunes Store. Young patients (and their parents) can download the app to their smart phone. It’s an engaging way for children with cancer to track their pain, and the app has a report that can be shared with the health-care team, so the information can be used to inform treatment (see box). Some Canadian TV stars appear on the app, so it’s a fun but evidence-based tool. And as part of our research study, we had children from around the world download the app and provide us with feedback. 

Parent-Child Issues

Please talk about the parent-child relationship issues in this setting.

No parent wants to see his or her child in pain, especially with a life-threatening disease like cancer. Naturally, parents in these settings are under tremendous stress. Our research and the research of others have shown that what parents say and do has a major impact on the child’s pain experience. In fact, there’s a counterintuitive finding in the literature that when parents reassure their child—for instance, before a procedure, saying that everything’s going to be okay—that kind of behavior is actually related to an increase in pain and stress. 

We’ve tried to disentangle that phenomenon in my lab, and what we’ve learned is that when parents reassure their children during pain, the child perceives the parent as being anxious, which exacerbates the pain. When working with children, we have to make sure the parent is supported and coached in an effective way. 

Novel Approaches

Are there any novel nondrug approaches in pediatric cancer pain?

One effective nonmedication intervention that is backed by the most evidence is hypnosis. That surprises people because many don’t truly understand what hypnosis is in the cancer setting. It’s essentially a form of deep relaxation through suggestion, and we try to educate parents and promote the use of hypnosis. 

Pain Squad App

  • The Pain Squad app, developed by a research team at The Hospital for Sick Children in Toronto, helps children with cancer track their pain, including the following information:
  • Location, severity, and timing of pain and how much it interferes with daily activities.
  • Cause of pain (eg, treatment or cancer itself).
  • What makes the pain better or worse and how it can be reduced or eliminated. 

For more information, visit http://www.sickkids.ca/Research/I-OUCH/Pain-Squad-App/index.html.

 

Also, we have a lot of evidence-based information about effective novel strategies that are not being employed, and so my recent focus has been an online cancer knowledge campaign called “Making Cancer Less Painful for Kids” (#KidsCancerPain). We’re working with a team of scientists, clinicians, parents, and other stakeholders to take the evidence we have and create digital content, via blogs, videos, and Instagram images, to educate parents about all the existing tools that can help them manage their child’s pain needs. 

Nobody is a more motivated advocate than a parent. We’re using social media to increase access to valuable resources and support for parents of children with cancer. ■

Disclosure: Dr. Chambers reported no conflicts of interest.

References

1. Stinson JN, Jibb LA, Nguyen C, et al: Development and testing of a multidimensional iPhone pain assessment application of adolescents with cancer. J Med Internet Res 15:e51, 2013.

2. Stinson JN, Jibb LA, Nguyen C, et al: Construct validity and reliability of a real-time multidimensional smartphone app to assess pain in children and adolescents with cancer. Pain 156:2607-2615, 2015.



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