Skip to main content
NCBI home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2011 Nov 1.
Published in final edited form as: Cancer Nurs. 2010 Nov;33(6):436–444. doi: 10.1097/NCC.0b013e3181e212b4

Pain, Neuropathic Symptoms, and Physical and Mental Well-Being in Persons with Cancer

Cindy S Tofthagen 1, Susan C McMillan 1
PMCID: PMC3070947  NIHMSID: NIHMS221855  PMID: 21479139

Abstract

Background

Neuropathic pain is present in at least 25-40% of people with cancer pain and is thought to be more difficult to control than other types of cancer related pain.

Objective

The purpose of this study was to explore differences in the experience of cancer patients who describe their pain using neuropathic descriptors compared to those who do not.

Methods

A secondary analysis of data from 234 outpatients from a large NCI designated cancer center in west, central Florida was conducted to identify differences in pain, pain interference, symptoms, health related quality of life, and depression between the two groups.

Results

Patients with numbness, tingling, or electric-like sensations reported higher levels of current pain (p= .001), pain at its worst (p= .001), pain on average (p= .019), pain at its least (p= .008), and pain interference (p< .001). They reported problems with dizziness/lightheadedness significantly more often (p=.004) and also reported more severe problems with concentration (p=.047), poorer physical (p=.019) and mental health (p=.024), although no differences in depressive symptoms were found.

Conclusions

The results of this study indicate that cancer patients with numbness, tingling, or electric-like sensations have significantly higher levels of pain and pain interference, and lower health related quality of life than do patients without these symptoms.

Implications for Practice

These results highlight the ongoing need for research evaluating methods of treating neuropathic pain; education regarding assessment and management of neuropathic pain; and aggressive efforts to relieve neuropathic pain in oncology settings.

Despite the vast resources spent on pain management, many patients with cancer continue to have severe, unrelieved pain 1, 2. Cancer pain is associated with a variety of physical and emotional symptoms including disability, loss of sleep, and depression 3-7. Neuropathic pain is present in at least 25-40% of people with cancer pain and is thought to be more difficult to control than other types of cancer related pain 8, 9.

Relationships between neuropathic pain and diminished physical and psychological well-being have been well documented in non-oncology patients 10-14. Studies indicate that people with neuropathic pain experience a significant burden of illness. This includes poor general health and reduced physical performance which can result in significant emotional distress10, 14-16. Coexisting symptoms (insomnia, disequilibrium, etc.) can also affect the health and well being of persons with neuropathic pain 17, 18. Similar relationships may exist in cancer patients with neuropathic pain, however these relationships have been understudied and warrant further investigation 19-21. In addition, little is known about how neuropathic pain differs from non-neuropathic pain with respect to pain severity and physical and emotional performance in persons with cancer. Important differences may exist that if recognized, could lead to better pain management for all patients.

The purpose of this study was to explore differences in the experience of cancer patients who describe their pain using neuropathic descriptors (numbness, tingling, or electric like sensations) compared to those who do not use these descriptors. The following research question guided this study: How does the experience of cancer patients with numbness, tingling, and electric-like sensations differ from the experience of other cancer patients with respect to pain, physical symptoms, health- related quality of life and depressive symptoms?

Symptoms of neuropathic pain vary greatly from person to person. Numbness, tingling, and electric-like pain are descriptions repeatedly used within the literature to describe neuropathic pain and are thought to be unique to neuropathic pain because their presence indicates neuronal dysfunction 22. Numbness, tingling, or electric-like are unlikely to be used to describe pain of non-neuropathic origin. Therefore, this study looks at numbness, tingling, and electric-like as indicators of neuropathic pain.

Muscle weakness, problems with concentration, and dizziness/lightheadedness represent potential motor and autonomic symptoms that may co-occur with neuropathic pain and interfere with physical and emotional well-being. Because these symptoms may share an underlying neuropathic etiology, more information regarding the prevalence of these symptoms in persons with cancer is needed. Sleep has also been identified as a significant problem in persons with cancer as well as persons with peripheral neuropathy 15, 23.

Study Methods

The data for this study were extracted from data collected for a National Institute of Nursing Research (NINR) funded study entitled Coping with Pain: a Problem–Solving Approach for Caregivers of Cancer Patients (R01 NR008270-04). The purpose of the parent study was to evaluate a psycho-educational intervention for caregivers of cancer patients with pain.

The focus of the parent study was to support family caregivers of patients experiencing cancer pain. The authors of the current study sought to learn more about the experiences of patients experiencing pain, particularly those with pain with a neuropathic component. Only data from the first set of patient questionnaires, collected upon agreement to participate in the study, were included in this secondary analysis.

Sample and Setting

The sample of 234 outpatients with cancer was accrued at Moffitt Cancer Center, a large National Cancer Institute (NCI) designated comprehensive cancer center in Tampa, Florida. Participants were recruited from all outpatient clinics at the cancer center. Inclusion criteria included a diagnosis of cancer and pain severity level of at least 3 on a 0 to 10 scale. Patients had to be adults at least 18 years old, have at least a sixth grade education, and have no documented neurological or psychiatric disorders. Patients were excluded if they were unable to read and understand English or were receiving hospice or home health care services. A sample of 345 participants was sought for the parent study however, accrual was limited by time and patient and caregiver refusals.

Instruments

The instruments used for this study included the Memorial Symptom Assessment Scale, Medical Outcomes Study Short-Form, and the Center for Epidemiologic Studies Scale-Depression and a revised version of the Brief Pain Inventory. Demographic data including age, gender, race and ethnicity, marital status, religious preference, income, employment status, type of cancer, and stage of cancer was collected.

Brief Pain Inventory-Revised

Pain Severity and Pain Interference were assessed using a revised version of the Brief Pain Inventory (BPI-R). BPI-R assesses pain severity with 4 items that ask about present pain, pain at its worst, least, and on average using a 0-10 scale24, 25. A seven-item Interference Subscale assesses pain's interference with daily functioning. Participants are asked to rate on a scale of 0-10 how much in the past week pain has interfered with general activity, mood, walking ability, normal work, relationships with other people, sleep, and enjoyment of life. Subscale scores range from 0 to 70. Significant correlations of the Interference subscale with functional impairment and mood disturbance items from the Profile of Mood States. Cronbach's alphas from ranged from .86 to .91. Test-retest reliability was strong in previous studies26. The pain severity items and interference items in the BPI-R are identical to the same items on both the long and short forms of the original BPI27, 28.

The long version of the BPI contains a list of 15 pain descriptors that patients may use to describe pain28. Three descriptors were added (tingling, electric-like, and dull) for the parent study to allow differentiation of pain into nociceptive and neuropathic. The BPI-R asked patients to circle as many of the following words as needed to fully describe their pain: aching; throbbing; shooting; stabbing; gnawing; tingling; sharp; tender; burning; exhausting; tiring; electric-like; penetrating; nagging; numb; miserable; unbearable; and dull. Patients were also asked if pain was continuous or intermittent and how long (in months) had they had this pain.

Memorial Symptom Assessment Scale

The Memorial Symptom Assessment Scale (MSAS) was used to assess select physical symptoms that have been previously identified in persons with neuropathic pain; muscle weakness; sleep problems; problems with concentration; and dizziness/lightheadedness 29. The MSAS was designed to assess symptoms commonly associated with cancer in 3 dimensions: (1) severity of the symptom; (2) frequency with which it occurs; and (3) the distress it produces. For this study, only data regarding the presence, severity, and distress of selected items were used in the analysis. Scores for severity and distress range from 0-3 with higher scores indicating higher severity or distress29, 30.

Validity and reliability data for the original MSAS have been strong in persons undergoing cancer treatment29. Factor analysis confirmed two factors that distinguished three major groups of symptoms. The three confirmed groups of symptoms were Psychological, High Prevalence and Low Prevalence Physical Symptoms. Reliability coefficients indicated strong internal consistency for the subscales (alpha=.83-.92).

Medical Outcomes Study Short- Form

Health related quality of life was measured using the Medical Outcomes Study Short Form (SF-36), a 36 item self report measure that assesses eight health–related concepts 31. Four of the eight subscales assess physical well-being and four assess emotional well-being. Physical subscales include physical functioning, role limitations due to physical health problems, bodily pain, and general health. These four subscales combine to form a physical component score. Emotional subscales include vitality, social functioning, role limitations due to emotional problems, and mental health 32. These four subscales combine to form a mental component score. Higher scores indicate higher levels of functioning. The SF-36 has undergone extensive psychometric testing and has been widely used in studies involving individuals with cancer. Test retest reliability coefficients for the subscales range from .68-.93, and internal consistency reliability results range from .52 to .78.

Center for Epidemiologic Studies Scale-Depression

The Center for Epidemiological Studies Scale-Depression (CES-D) is a 20-item self-report scale that assesses current depressive symptoms. Scores range from 0-60 with higher scores indicating more depressive symptoms. Scores above 16 on the CES-D are associated with high levels of psychological distress 33. The CES-D is a widely used scale that has proven useful in measuring the symptoms of depression. The CES-D has been translated into multiple languages, and has impressive reliability and validity. Factor analysis confirmed the structure of the scale. Cronbach alphas were .85 for the general public and .85-.91 in persons with cancer, indicating strong reliability 34-36.

Procedures

The study was approved by the Protocol Research Monitoring Committee at the Cancer Center and the Institutional Review Board of the University of South Florida. For the parent study, potential participants with a scheduled appointment were identified for eligibility through clinician referral and review of the medical record. Participants who were determined to be eligible were invited to participate, and then consented and randomized into an intervention group or a control group who received usual care. The intervention consisted of three one-hour sessions and two brief follow up calls with caregivers over a 12 week period. Topics included pain assessment, managing side effects of pain medications, communication with health care providers, coping techniques, and stress management. Patients and caregivers were asked to individually complete separate questionnaire packets at three time intervals; one upon consent to participate, one six weeks after the beginning of the study and one twelve weeks after the beginning of the study. Participants were reimbursed $25 per questionnaire packet completed.

Data Analysis

The intervention and control groups were combined and baseline data from both groups were analyzed. Data from the first set of patient questionnaires were included. The sample was divided into two groups using pain descriptors reported on the Brief Pain Inventory-Revised. Patients who reported one or more of the following pain descriptors; numbness, tingling, or electric-like, were grouped together and compared with a group of patients who did not use any of those three descriptors to describe their pain. This approach to grouping participants was based upon the current literature that consistently identifies numbness, tingling, and electric-like sensations as terminology consistent with a neuropathic pain component and provided a logical method for the researchers to examine neuropathic pain within the context of the parent study.

Demographic data were analyzed using descriptive statistics including frequencies, percentages, means, and standard deviations. Differences between means were analyzed to determine differences between patients with numbness, tingling, or electric-like sensations and patients who did not report these symptoms. A series of independent t-tests were used to determine differences in pain levels, pain interference, length of pain, health-related quality of life, severity and distress levels of muscle weakness, sleep problems, problems with concentration, and dizziness/lightheadedness. Bonferroni adjustments were used because multiple comparisons were made. A series of chi-square tests were analyzed to determine differences in number of participants in each group reporting muscle weakness, sleep problems, problems with concentration, and dizziness/lightheadedness, disability, and continuous vs. intermittent pain. A power analysis was conducted prior to this analysis to determine adequacy of the existing sample size. Estimating a medium estimated effect size, a total of 128 patients (64 patients in each group) were needed to achieve 80% power with two-sided 5% significance level.

Results

Sample

Data describing the demographic characteristics of the sample were analyzed. The sample was almost equally divided between men and women who were predominantly white and married (Table 1). A majority was Christian, either non-Catholic or Catholic, and were retired or disabled. Annual family incomes ranged from less than $10,000 to more than $100,000. Patients had a mean age of about 56 (SD=12.8) years and ranged in age from 24 to 84 years of age. They reported an average of 13 years (SD=2.3) of formal education and had a variety of cancer diagnoses including solid tumors and hematologic malignancies, Most had stage three or four disease and were receiving chemotherapy or radiation therapy (Table 2).

Table 1.

Frequency and Percent of Patients by Gender, Race and Ethnicity, Marital Status, Income, and Religious Preference (n=234).

Variable Frequency Percent
Gender
 Male 121 51.7
 Female 113 48.3
Race and Ethnicity
 White, non-hispanic 199 85.0
 Black, non-hispanic 14 6.0
 Hispanic 14 6.0
 Asian 1 .4
 Other 6 2.6
Marital Status
 Married/Cohabiting 195 83.4
 Divorced/Separated 26 11.1
 Single, never married 9 3.8
 Widowed 4 1.7
Religious Preference
 Non-Catholic Christian 98 41.9
 Catholic 63 26.9
 Jewish 6 2.6
 Islam 1 0.4
 Other 41 17.5
 None 24 10.3
 Missing 1 0.4
Family Income
 <$10,000 16 6.8
 $10,001-19,999 30 12.8
 $20,000-39,999 53 22.6
 $40,000-59,000 38 16.2
 $60-000-100,000 40 17.1
 >$100,000 18 7.7
 Prefer not to answer 39 16.7
Employment
 Working 30 12.8
 On leave 33 14.1
 Disabled 88 37.6
 Retired 77 32.9
 Homemaker 18 7.7
 Student 3 1.3
Open in a new tab

Table 2.

Frequency and percentage of patients by cancer type.

Frequency Percentage
Cancer Type
Lung 53 22.6
Solid tumors-miscellaneous 30 12.8
Hematologic malignancies 26 11.1
GI malignancies 25 10.7
Breast 23 9.8
Gynecologic malignancies 18 7.7
Head & Neck 17 7.3
Prostate 12 5.1
Pancreatic 12 5.1
Sarcoma 8 3.4
Malignant Melanoma 5 2.1
Renal 3 1.3
Cancer Stage
Stage 1 12 5.1
Stage 2 14 6.0
Stage 3 53 22.6
Stage 4 77 32.9
undocumented 58 24.8
other 17 7.3
missing 3 1.3
Treatment stage
Newly diagnosed, not under treatment 6 2.7
Receiving radiation 50 21.6
Receiving chemotherapy or biotherapy 175 74.8
Receiving hormonal therapy 29 12.4
Palliative care alone 52 22.2
Open in a new tab

Eighty five participants (36%) were in the group that reported numbness, tingling, or electric- like pain and 149 (64%) participants were in the comparison group. In the group reporting numbness, tingling, or electric-like pain, 54% (n=46), used one of the three included descriptors, 34% (n=29) used two of the three descriptors, and 12% (n=10) used all three of the included descriptors. Patients in both groups had similar ethnicity, income, education, religion, and marital status. Patients with numbness, tingling, or electric-like sensations (M=54, SD=13.8) were an average of 4 years younger than patients who did not report these pain characteristics (M=58, SD=11.91), (t (192) = 2.12, p = .034).

Analysis of data from the demographics questionnaire revealed that patients who reported numbness, tingling, and electric-like sensations were more likely to be disabled. Disability was reported in 51% of patients with numbness, tingling, or electric like-sensations compared with 30% of patients without these symptoms χ2 (1, N = 234) = 9.6, p = .003.

Pain

Pain and pain interference was assessed using data from the BPI-R to identify differences in severity and interference with performance. Patients with numbness, tingling, or electric-like sensations reported significantly higher levels of current pain severity (p=.001), pain at its worst (p=.001), pain on average (p=.019), and pain at its least (p=.008) (Table 3). Patients with numbness, tingling, or electric-like sensations were more likely to report continuous instead of occasional pain χ2 (1, N = 234) = 8.6, p = .004. Pain duration in months was almost twice as long for patients with numbness, tingling, or electric-like sensations (M= 36.7, SD=66.3) than for patients who did not report these pain characteristics (M=17.4, SD=42.2). Patients with numbness, tingling, or electric-like sensations reported greater pain interference with general activity, walking ability, normal work, sleep, mood, relationships with other people and total pain interference (Table 4). Differences in pain interference with enjoyment of life were non-significant.

Table 3.

Pain Differences in Patients With and Without Numbness, Tingling, and Electric-Like Sensations.

Variable Range Characteristicsa N Mean SD t p
current pain 0-10 without 149 3.91 2.52 -3.39 .001
with 85 5.02 2.19
pain at its worst 1-10 without 149 7.69 2.17 -3.468 .001
with 85 8.53 1.51
pain at its least 0-10 without 149 2.48 2.10 -2.687 .008
with 85 3.21 1.97
pain on average 0-10 without 149 4.79 1.91 -2.372 .019
with 85 5.41 1.95
Pain duration in months .25-420 without 149 19.4 42.18 -2.203 .029
with 85 36.7 66.29
Open in a new tab
a

numbness, tingling, or electric- like sensations

Table 4.

Possible Ranges, Means, and Standard Deviations for Pain Interference.

Variable Possible Range Characteristicsa N Mean SD t p
General activity 0-10 without 149 5.2 2.98 -4.51 <.001
with 85 6.7 2.24
Walking ability 0-10 without 149 4.9 3.2 -4.47 <.001
with 85 6.8 3.0
Normal work 0-10 without 149 5.5 3.5 -3.52 .001
with 85 7.0 2.5
Sleep 0-10 without 149 4.8 3.1 -3.58 <.001
with 85 6.4 2.4
Mood 0-10 without 149 4.7 2.9 -3.89 <.001
with 85 6.1 2.6
Relationships with other people 0-10 without 149 4.1 2.9 -3.23 .001
with 85 5.4 2.8
Enjoyment of life 0-10 without 149 6.3 3.2 -1.66 .077
with 85 6.9 2.5
Total Pain Interference 0-70 without 149 35.5 17.8 -4.45 <.001
with 85 45.6 14.0
Open in a new tab
a

numbness, tingling, or electric- like sensations

Symptoms

Muscle weakness, dizziness/lightheadedness, problems with concentration, and problems with sleep were assessed using individual items from the MSAS to determine differences in the symptom experience between the two groups. Patients with numbness, tingling, and electric-like sensations reported problems with dizziness/lightheadedness significantly (p=.004) more often than did patients who did not report these pain characteristics (Table 5) and also reported more severe problems with concentration (p=.047). No significant differences in occurrence of muscle weakness, sleep problems, or problems with concentration were found. No significant differences in severity or distress of muscle weakness, dizziness/lightheadedness, or problems with sleep were found among those who reported the symptoms in each group.

Table 5.

MSAS Symptom Differences in Patients With and Without Numbness, Tingling, and Electric-Like Sensations.

Variable Without With Total Chi Square p
Muscle weakness
no 57 26 83
yes 80 57 147 1.28 .160
total 147 83 230
Sleep problems
no 61 26 87
yes 86 58 144 2.53 .073
total 147 84 231
Problems with concentration
no 88 41 129
yes 59 42 101 2.36 .081
total 147 83 230
Dizziness/lightheadedness
no 97 39 136
yes 51 45 96 8.07 .004
total 148 84 232
Open in a new tab

Health Related Quality of Life

Differences in health related quality of life were assessed using data from the SF-36. Patients with numbness, tingling, or electric-like pain had significantly (p=.003) more bodily pain and perceived their general health as poorer (p=.009), had more role limitations due to physical health problems (p=.001), and lower scores for vitality (p=.008). Differences in emotional role functioning indicate that patients with numbness, tingling, or electric-like sensations have more difficulty (p=.003) performing regular daily activities as a result of emotional distress (Table 6). Physical (p=.019) and mental (p=.024) component scores were significantly lower in patients with numbness, tingling, or electric-like pain.

Table 6.

Ranges, Means, and Standard Deviations for Standardized Subscales of the SF-36 in Cancer Patients with Numbness, Tingling, or Electric-Like Sensations.

Variable Characteristicsa N Mean SD t p
Physical Functioning without 149 30.03 9.98 1.86 .064
with 85 27.54 9.61
Role Limitations-Physical without 149 33.82 9.45 3.31 .001
with 85 30.11 4.93
Bodily Pain without 149 38.03 10.14 2.97 .003
with 85 34.18 8.33
General Health without 149 34.75 7.63 2.62 .009
with 85 32.01 7.88
Vitality without 149 38.23 9.66 2.69 .008
with 85 34.85 8.38
Social Functioning without 149 35.61 11.96 1.63 .105
with 85 32.98 11.68
Role Limitations-Emotional without 149 41.34 13.89 3.01 .003
with 85 35.56 13.99
Mental Health without 149 44.64 11.57 1.63 .104
with 85 41.90 13.57
Physical Component Score without 149 30.93 8.34 2.35 .019
with 85 28.31 7.57
Mental Component Score without 149 44.86 12.12 2.27 .024
with 85 40.91 13.39
Open in a new tab
a

numbness, tingling, or electric-like sensations

Depressive Symptoms

Differences in depressive symptoms were assessed using data from the CES-D. This study found no significant differences in depressive symptoms. Both groups reported high levels of depressive symptoms. The mean CES-D score for patients without numbness, tingling, or electric-like sensations was 18.96 while the mean score for patients with these characteristics was 20.38. CES-D scores were negatively correlated with SF-36 mental component scores (r= .404, p<.001) indicating that as depressive symptoms increase, mental health decreases.

Discussion

Sample

In this sample, 36% of patients reported numbness, tingling, or electric like pain, which are characteristics typically associated with neuropathic pain. This high incidence of neuropathic pain characteristics among outpatients with moderate to severe pain, suggests that control of neuropathic pain continues to be problematic, even in facilities whose entire mission is to care for the needs of cancer patients. Literature supports the use of algorithms and treatment guidelines as effective in alleviating neuropathic pain but requires close communication between clinicians and patients as well as ongoing assessment 8, 37.

The higher incidence of disability among the patients with numbness, tingling, or electric-like sensations, along with the findings that these patients report more interference and poorer health related quality of life, indicate that neuropathic pain has a strong influence on patients' ability to maintain their usual life style and activity level. Patients with neuropathic pain may have co-existing neurological symptomatology such as loss of balance, muscle weakness, loss of manual dexterity, and loss of fine motor coordination that contributed to the high incidence of disability and functional deficits in this study17, 19, 20, 38. Such symptoms limit physical performance and may also prevent people from being able to perform essential job responsibilities.

This study did not thoroughly evaluate non-painful symptoms of a neuropathic origin but future studies should focus on evaluation of both painful and non-painful neuropathies. In our study, disability was measured by a single item on the demographic questionnaire but the findings from the SF-36 physical and emotional role limitations subscales and the BPI-R interference scale also indicate that patients with neuropathic pain have significantly more difficulty performing in their usual roles. These findings support the results of earlier literature documenting relationships between neuropathy and physical disability 15, 20, 39, 40.

Pain

The study confirms that patients in our sample with numbness, tingling, or electric-like sensations report more intense current pain, least pain, average pain, and worst pain and report continuous pain more often. They also had more pain interference with general activity, walking ability, normal work, sleep, relationships with people and mood. Insignificant differences in enjoyment of life probably reflect the myriad of issues that cancer patients face, including pain, that impact their enjoyment of life.

Similar findings have been demonstrated in persons with chronic pain from a variety of causes, where pain that was considered predominantly neuropathic in origin was found to be significantly more severe and debilitating than non-neuropathic pain14. Previous studies of patients with peripheral neuropathy have also demonstrated high levels of pain severity that interfere with both physical and mental functioning 15. These findings again highlight the need for aggressive pain management in cancer treatment, including differentiating the source of the pain so that individuals with neuropathic pain can be reliably identified and treated more appropriately. More research evaluating treatment approaches for neuropathic pain is needed and health-care professionals need ongoing education focusing on assessment and treatment of neuropathic pain.

One limitation of the study is the lack of clinical assessment of pain. Future studies should include evaluation by a clinician trained to properly differentiate between non-neuropathic and neuropathic pain or verify mixed pain syndromes. A second limitation of the study was that the BPI-R had not previously been validated to differentiate between neuropathic and non-neuropathic pain as was done in this study. However, results show significant differences between the two groups, which offer beginning support for the validity of this use. Further research in this area is needed.

Symptoms

Analysis of selected symptoms including muscle weakness, sleep problems, problems with concentration, and dizziness/lightheadedness showed that dizziness/lightheadedness was more prevalent and severity of problems with concentration more severe in patients with numbness, tingling, or electric-like sensations. Dizziness/lightheadedness, and problems with concentration may also reflect symptoms of neuropathy41. Previous studies have identified relationships between neuropathic pain and sleep in non-cancer populations15, 23 and muscle weakness in cancer patients42, 43 but no differences in these symptoms were demonstrated in this study. Patients with documented neurological disorders were excluded from the study, which may have affected these results, because patients with previously diagnosed neurologic disorders may have been more likely to experience these symptoms.

Dizziness and lightheadedness may contribute to falls, and problems with concentration may also compromise patients' ability to maintain safety within the home. Interventions aimed at promoting safety and minimizing fall risk should be initiated and reevaluated at regular intervals since symptoms may worsen quickly41. Instruments are available to help evaluate neuropathic symptoms19, 22, 44-48. These instruments should be widely utilized along with physical assessment, in clinical practice, to gain a better understanding of how neuropathic pain is influencing patients' lives and make appropriate recommendations and referrals.

Health Related Quality of Life

Results of this study indicate that patients with neuropathic symptoms (numbness, tingling, and electric-like sensations) have poorer health related quality of life than those without these characteristics. Patients with numbness, tingling, or electric-like sensations had significantly greater physical and role limitations and reduced vitality. They also had more bodily pain and perceived their general health as poorer. These findings indicate that patients with neuropathic pain have less energy, are more socially isolated, and experience more physical and psychological distress. Again, these results support the findings of earlier studies which demonstrate that patients with chronic neuropathic pain have poorer health related quality of life than patients with non-neuropathic pain 14. These results also further support the use of the BPI-R to group patients into neuropathic and non-neuropathic pain groups.

Nurses should be cognizant of the profound impact that neuropathic pain can have on health-related quality of life, including physical and mental functioning. Nursing interventions should focus on relieving pain and improving functional status. Maintaining independence, improving physical and emotional well-being are important goals that patients and clinicians can work toward together.

Depressive Symptoms

Mean scores for depressive symptoms were higher in patients with numbness, tingling, or electric-like sensations, although differences were not statistically significant. Measurement of depression may be confounded by the physical symptoms that cancer patients experience. This may have occurred in our study as scores are higher than in previous studies involving persons with cancer. Higher scores in this study may also have been related to the fact that all the patients had at least moderately severe pain 34, 49. The results support previous findings of high levels of depressive symptoms in persons with chronic pain 15, 23. Negative correlations between CES-D scores and SF-36 mental component scores support validity of the CES-D in this study.

In addition to chronic pain and cancer related symptoms; loss of independence, financial pressures and strained relationships all contribute to depressive symptoms in cancer patients 50. It is important for healthcare professionals to assess for psychological distress and depressive symptoms, take time to listen to concerns, and provide emotional support. Nurses may be the first to recognize depressive symptoms and initiate appropriate referrals to mental health professionals.

Limitations

Several limitations in the sample were found. The sample was not large, there was a very small sample of minority patients, all had to be able to read and understand English, which eliminated several minority patients, and all came from one cancer center in a single geographic location. Future studies should include more ethnically and geographically diverse samples. Because the larger study from which this data was taken required patients to have a family caregiver, patients with no spouse were less likely to be included. The presence of an available family caregiver might have biased the results in some unknown ways.

Previous researchers differentiated between neuropathic pain and non-neuropathic pain using pain descriptors from the McGill Pain Questionnaire with mixed results9, 51, 52. Further research using the descriptors included in this study are needed. Although numbness, tingling and electric-like are believed to reflect neuropathic pain, and the literature confirms the use of these terms, it is possible that there were patients with neuropathic pain who did not report numbness, tingling, or electric-like sensations. Pain description should be combined with clinical assessment to identify underlying pain mechanisms. It is not uncommon for patients to simultaneously experience two or more types of pain53. Because only the presence of specific characteristics were examined as indicators of neuropathic pain, it is likely that the percentage of patients with neuropathic pain was under-estimated in this study.

Conclusions

The results of this study indicate that cancer patients with numbness, tingling, or electric-like sensations have significantly higher levels of pain and pain interference, and lower health related quality of life than do patients without these symptoms. No significant differences in depressive symptoms were detected although relatively high levels of depressive symptoms were identified in both groups. When evaluating patients with severe pain, the possibility of a neuropathic component should be considered, since neuropathic pain requires a different approach to treatment37, 54, 55. These results highlight the ongoing need for research evaluating methods of treating neuropathic pain; education regarding assessment and management of neuropathic pain; and aggressive efforts to relieve neuropathic pain in oncology settings. Better control of neuropathic pain may positively influence quality of life and improve physical and emotional well-being in persons with cancer.

Acknowledgments

Funded by a grant from the National Institutes of Health (R01 NR008270-04) and an American Cancer Society Doctoral Scholarship in Cancer Nursing (DSCN-08-205-01)

References

  • 1.Green CR, Anderson KO, Baker TA, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Medicine. 2003 Sep;4(3):277–294. doi: 10.1046/j.1526-4637.2003.03034.x. [DOI] [PubMed] [Google Scholar]
  • 2.Shaiova L. Difficult pain syndromes: bone pain, visceral pain, and neuropathic pain. Cancer Journal. 2006 Sep-Oct;12(5):330–340. doi: 10.1097/00130404-200609000-00002. [DOI] [PubMed] [Google Scholar]
  • 3.Hauser K, Rybicki L, Walsh D. Do pain, depression and fatigue cluster in advanced cancer?. 2006 ASCO Annual Meeting Proceedings Part I; 2006; p. 8522. [Google Scholar]; Journal of Clinical Oncology. 2006 [Google Scholar]
  • 4.Kurtz ME, Kurtz JC, Stommel M, Given CW, Given B. Predictors of depressive symptomatology of geriatric patients with lung cancer-a longitudinal analysis. Psychooncology. 2002 Jan-Feb;11(1):12–22. doi: 10.1002/pon.545. [DOI] [PubMed] [Google Scholar]
  • 5.Mystakidou K, Parpa E, Tsilika E, et al. The relationship of subjective sleep quality, pain, and quality of life in advanced cancer patients. Sleep. 2007 Jun 1;30(6):737–742. doi: 10.1093/sleep/30.6.737. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Mystakidou K, Tsilika E, Parpa E, Katsouda E, Galanos A, Vlahos L. Psychological distress of patients with advanced cancer: influence and contribution of pain severity and pain interference. Cancer Nursing. 2006 Sep-Oct;29(5):400–405. doi: 10.1097/00002820-200609000-00009. [DOI] [PubMed] [Google Scholar]
  • 7.Vallerand AH, Templin T, Hasenau SM, Riley-Doucet C. Factors that affect functional status in patients with cancer-related pain. Pain. 2007 Nov;132(1-2):82–90. doi: 10.1016/j.pain.2007.01.029. [DOI] [PubMed] [Google Scholar]
  • 8.Grond S, Radbruch L, Meuser T, Sabatowski R, Loick G, Lehmann KA. Assessment and treatment of neuropathic cancer pain following WHO guidelines. Pain. 1999 Jan;79(1):15–20. doi: 10.1016/S0304-3959(98)00138-9. [DOI] [PubMed] [Google Scholar]
  • 9.Wilkie DJ, Huang HY, Reilly N, Cain KC. Nociceptive and neuropathic pain in patients with lung cancer: a comparison of pain quality descriptors. Journal of Pain and Symptom Management. 2001 Nov;22(5):899–910. doi: 10.1016/s0885-3924(01)00351-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 10.Galvez R, Marsal C, Vidal J, Ruiz M, Rejas J. Cross-sectional evaluation of patient functioning and health-related quality of life in patients with neuropathic pain under standard care conditions. European Journal of Pain. 2007 Apr;11(3):244–255. doi: 10.1016/j.ejpain.2006.02.002. [DOI] [PubMed] [Google Scholar]
  • 11.Gore M, Brandenburg NA, Hoffman DL, Tai KS, Stacey B. Burden of illness in painful diabetic peripheral neuropathy: the patients' perspectives. Journal of Pain. 2006 Dec;7(12):892–900. doi: 10.1016/j.jpain.2006.04.013. [DOI] [PubMed] [Google Scholar]
  • 12.Povedano M, Gascon J, Galvez R, Ruiz M, Rejas J. Cognitive function impairment in patients with neuropathic pain under standard conditions of care. Journal of Pain and Symptom Management. 2007 Jan;33(1):78–89. doi: 10.1016/j.jpainsymman.2006.07.012. [DOI] [PubMed] [Google Scholar]
  • 13.Rasmussen PV, Sindrup SH, Jensen TS, Bach FW. Symptoms and signs in patients with suspected neuropathic pain. Pain. 2004 Jul;110(1-2):461–469. doi: 10.1016/j.pain.2004.04.034. [DOI] [PubMed] [Google Scholar]
  • 14.Smith BH, Torrance N, Bennett MI, Lee AJ. Health and quality of life associated with chronic pain of predominantly neuropathic origin in the community. Clinical Journal of Pain. 2007 Feb;23(2):143–149. doi: 10.1097/01.ajp.0000210956.31997.89. [DOI] [PubMed] [Google Scholar]
  • 15.Gore M, Brandenburg NA, Dukes E, Hoffman DL, Tai KS, Stacey B. Pain severity in diabetic peripheral neuropathy is associated with patient functioning, symptom levels of anxiety and depression, and sleep. Journal of Pain and Symptom Management. 2005 Oct;30(4):374–385. doi: 10.1016/j.jpainsymman.2005.04.009. [DOI] [PubMed] [Google Scholar]
  • 16.Jensen MP, Chodroff MJ, Dworkin RH. The impact of neuropathic pain on health-related quality of life: review and implications. Neurology. 2007 Apr 10;68(15):1178–1182. doi: 10.1212/01.wnl.0000259085.61898.9e. [DOI] [PubMed] [Google Scholar]
  • 17.Visovsky C. Chemotherapy-induced peripheral neuropathy. Cancer Investigation. 2003 Jun;21(3):439–451. doi: 10.1081/cnv-120018236. [DOI] [PubMed] [Google Scholar]
  • 18.Wilkes G. Peripheral neuropathy related to chemotherapy. Seminars in Oncology Nursing. 2007 Aug;23(3):162–173. doi: 10.1016/j.soncn.2007.05.001. [DOI] [PubMed] [Google Scholar]
  • 19.Almadrones L, McGuire DB, Walczak JR, Florio CM, Tian C. Psychometric evaluation of two scales assessing functional status and peripheral neuropathy associated with chemotherapy for ovarian cancer: a gynecologic oncology group study. Oncology Nursing Forum. 2004 May;31(3):615–623. doi: 10.1188/04.ONF.615-623. [DOI] [PubMed] [Google Scholar]
  • 20.Bakitas MA. Background Noise: The Experience of Chemotherapy-Induced Peripheral Neuropathy. Nursing Research. 2007 September/October;56(5):323–331. doi: 10.1097/01.NNR.0000289503.22414.79. [DOI] [PubMed] [Google Scholar]
  • 21.Calhoun EA, Welshman EE, Chang CH, et al. Psychometric evaluation of the Functional Assessment of Cancer Therapy/Gynecologic Oncology Group-Neurotoxicity (Fact/GOG-Ntx) questionnaire for patients receiving systemic chemotherapy. International Journal of Gynecological Cancer. 2003 Nov-Dec;13(6):741–748. doi: 10.1111/j.1525-1438.2003.13603.x. [DOI] [PubMed] [Google Scholar]
  • 22.Bouhassira D, Attal N, Fermanian J, et al. Development and validation of the Neuropathic Pain Symptom Inventory. Pain. 2004 Apr;108(3):248–257. doi: 10.1016/j.pain.2003.12.024. [DOI] [PubMed] [Google Scholar]
  • 23.Zelman DC, Brandenburg NA, Gore M. Sleep impairment in patients with painful diabetic peripheral neuropathy. Clinical Journal of Pain. 2006 Oct;22(8):681–685. doi: 10.1097/01.ajp.0000210910.49923.09. [DOI] [PubMed] [Google Scholar]
  • 24.Daut RL, Cleeland CS, Flanery RC. Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain. 1983 Oct;17(2):197–210. doi: 10.1016/0304-3959(83)90143-4. [DOI] [PubMed] [Google Scholar]
  • 25.McCormack JP, Li R, Zarowny D, Singer J. Inadequate treatment of pain in ambulatory HIV patients. Clin J Pain. 1993 Dec;9(4):279–283. doi: 10.1097/00002508-199312000-00010. [DOI] [PubMed] [Google Scholar]
  • 26.Serlin RC, Mendoza TR, Nakamura Y, Edwards KR, Cleeland CS. When is cancer pain mild, moderate or severe? Grading pain severity by its interference with function. Pain. 1995 May;61(2):277–284. doi: 10.1016/0304-3959(94)00178-H. [DOI] [PubMed] [Google Scholar]
  • 27.Cleeland CS. Pain Research Group; The Brief Pain Inventory-Short Form. Available at: http://prc.coh.org/pdf/BPI%20Short%20Version.pdf. [Google Scholar]
  • 28.Cleeland CS. Pain Research Group; The Brief Pain Inventory-Long Form. Available at: http://www.mdanderson.org/education-and-research/departments-programs-and-labs/departments-and-divisions/symptom-research/symptom-assessment-tools/bpilong.pdf. [Google Scholar]
  • 29.Portenoy RK, Thaler HT, Kornblith AB, et al. The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress. European Journal of Cancer. 1994;30A(9):1326–1336. doi: 10.1016/0959-8049(94)90182-1. [DOI] [PubMed] [Google Scholar]
  • 30.McMillan SC, Small B. Symptom distress and quality of life in patients with cancer and newly admitted to hospice home care. Oncology Nursing Forum. 2002;29(10):1421–1426. doi: 10.1188/02.ONF.1421-1428. [DOI] [PubMed] [Google Scholar]
  • 31.Ware JE, Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Medical Care Jun. 1992;30(6):473–483. [PubMed] [Google Scholar]
  • 32.McHorney CA, Ware JE, Jr, Raczek AE. The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Medical Care Mar. 1993;31(3):247–263. doi: 10.1097/00005650-199303000-00006. [DOI] [PubMed] [Google Scholar]
  • 33.Radloff LS. The CES-D scale: A self report depression scale for research in the general population. Applied Psychological Measurements. 1977;1(385-401) [Google Scholar]
  • 34.Hann D, Winter K, Jacobsen P. Measurement of depressive symptoms in cancer patients: evaluation of the Center for Epidemiological Studies Depression Scale (CES-D) J Psychosomatic Research. 1999 May;46(5):437–443. doi: 10.1016/s0022-3999(99)00004-5. [DOI] [PubMed] [Google Scholar]
  • 35.Schroevers MJ, Sanderman R, van Sonderen E, Ranchor AV. The evaluation of the Center for Epidemiologic Studies Depression (CES-D) scale: Depressed and Positive Affect in cancer patients and healthy reference subjects. Quality of Life Research. 2000;9(9):1015–1029. doi: 10.1023/a:1016673003237. [DOI] [PubMed] [Google Scholar]
  • 36.Lewinsohn PM, Seeley JR, Roberts RE, Allen NB. Center for Epidemiologic Studies Depression Scale (CES-D) as a screening instrument for depression among community-residing older adults. Psychology and Aging. 1997 Jun;12(2):277–287. doi: 10.1037//0882-7974.12.2.277. [DOI] [PubMed] [Google Scholar]
  • 37.Smith EL, Whedon MB, Bookbinder M. Quality improvement of painful peripheral neuropathy. Seminars in Oncology Nursing. 2002 Feb;18(1):36–43. doi: 10.1053/sonu.2002.30043. [DOI] [PubMed] [Google Scholar]
  • 38.Visovsky C, Collins M, Abbott L, Aschenbrenner J, Hart C. Putting evidence into practice: evidence-based interventions for chemotherapy-induced peripheral neuropathy. Clinical Journal of Oncology Nursing. 2007 Dec;11(6):901–913. doi: 10.1188/07.CJON.901-913. [DOI] [PubMed] [Google Scholar]
  • 39.Chaudhry V, Chaudhry M, Crawford TO, Simmons-O'Brien E, Griffin JW. Toxic neuropathy in patients with pre-existing neuropathy. Neurology. 2003 Jan 28;60(2):337–340. doi: 10.1212/01.wnl.0000043691.53710.53. [DOI] [PubMed] [Google Scholar]
  • 40.Strumberg D, Brugge S, Korn MW, et al. Evaluation of long-term toxicity in patients after cisplatin-based chemotherapy for non-seminomatous testicular cancer. Annals of Oncology. 2002 Feb;13(2):229–236. doi: 10.1093/annonc/mdf058. [DOI] [PubMed] [Google Scholar]
  • 41.Wickham R. Chemotherapy-induced peripheral neuropathy: a review and implications for oncology nursing practice. Clinical Journal of Oncology Nursing. 2007 Jun;11(3):361–376. doi: 10.1188/07.CJON.361-376. [DOI] [PubMed] [Google Scholar]
  • 42.Wampler MA, Hamolsky D, Hamel K, Melisko M, Topp KS. Case report: painful peripheral neuropathy following treatment with docetaxel for breast cancer. Clinical Journal of Oncology Nursing. 2005 Apr;9(2):189–193. doi: 10.1188/05.CJON.189-193. [DOI] [PubMed] [Google Scholar]
  • 43.Hilkens PH, Verweij J, Vecht CJ, Stoter G, van den Bent MJ. Clinical characteristics of severe peripheral neuropathy induced by docetaxel (Taxotere) Annals of Oncology. 1997 Feb;8(2):187–190. doi: 10.1023/a:1008245400251. [DOI] [PubMed] [Google Scholar]
  • 44.Backonja MM, Krause SJ. Neuropathic pain questionnaire--short form. Clinical Journal of Pain. 2003 Sep-Oct;19(5):315–316. doi: 10.1097/00002508-200309000-00005. [DOI] [PubMed] [Google Scholar]
  • 45.Cavaletti G, Frigeni B, Lanzani F, et al. The Total Neuropathy Score as an assessment tool for grading the course of chemotherapy-induced peripheral neurotoxicity: comparison with the National Cancer Institute-Common Toxicity Scale. Journal of the Peripheral Nervous System. 2007 Sep;12(3):210–215. doi: 10.1111/j.1529-8027.2007.00141.x. [DOI] [PubMed] [Google Scholar]
  • 46.Huang HQ, Brady MF, Cella D, Fleming G. Validation and reduction of FACT/GOG-Ntx subscale for platinum/paclitaxel-induced neurologic symptoms: a gynecologic oncology group study. International Journal of Gynecological Cancer. 2007 Mar-Apr;17(2):387–393. doi: 10.1111/j.1525-1438.2007.00794.x. [DOI] [PubMed] [Google Scholar]
  • 47.Krause SJ, Backonja MM. Development of a neuropathic pain questionnaire. Clinical Journal of Pain. 2003 Sep-Oct;19(5):306–314. doi: 10.1097/00002508-200309000-00004. [DOI] [PubMed] [Google Scholar]
  • 48.Wampler MA, Miaskowski C, Hamel K, Byl N, Rugo H, Topp KS. The modified Total Neuropathy Score: a clinically feasible and valid measure of taxane induced peripheral neuropathy in women with breast cancer. Journal of Supportive Oncology. 2006;4(8):W9–W16. [Google Scholar]
  • 49.Butler LD, Koopman C, Cordova MJ, Garlan RW, DiMiceli S, Spiegel D. Psychological distress and pain significantly increase before death in metastatic breast cancer patients. Psychosomatic Medicine. 2003 May-Jun;65(3):416–426. doi: 10.1097/01.psy.0000041472.77692.c6. [DOI] [PubMed] [Google Scholar]
  • 50.Albright A, Valente S. Depression and suicide. In: Carroll-Johnson R, Gorman L, Bush N, editors. Psychosocial Nursing Care along the Cancer Continuum. 2. Pittsburgh: Oncology Nursing Society; 2006. pp. 241–260. [Google Scholar]
  • 51.Mystakidou K, Parpa E, Tsilika E, Pathiaki M, Galanos A, Vlahos L. Comparison of pain quality descriptors in cancer patients with nociceptive and neuropathic pain. In Vivo. 2007 Jan-Feb;21(1):93–97. [PubMed] [Google Scholar]
  • 52.Holtan A, Kongsgaard UE. The use of pain descriptors in cancer patients. Journal of Pain and Symptom Management. 2009 Aug;38(2):208–215. doi: 10.1016/j.jpainsymman.2008.08.008. [DOI] [PubMed] [Google Scholar]
  • 53.Bennett MI, Smith BH, Torrance N, Lee AJ. Can pain can be more or less neuropathic? Comparison of symptom assessment tools with ratings of certainty by clinicians. Pain. 2006 Jun;122(3):289–294. doi: 10.1016/j.pain.2006.02.002. [DOI] [PubMed] [Google Scholar]
  • 54.Baron R. Mechanisms of disease: neuropathic pain--a clinical perspective. Nature Clinical Practice Neurology. 2006 Feb;2(2):95–106. doi: 10.1038/ncpneuro0113. [DOI] [PubMed] [Google Scholar]
  • 55.Xiao WH, Bennett GJ. Chemotherapy-evoked neuropathic pain: Abnormal spontaneous discharge in A-fiber and C-fiber primary afferent neurons and its suppression by acetyl-l-carnitine. Pain. 2007 Jul 27; doi: 10.1016/j.pain.2007.06.001. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES