Zi-Xuan Wang, Department of Interventional Radiology, Qingdao Municipal Hospital, Qingdao 266000, Shandong Province, China
Si-Liang Liu, Qian Wang, Department of Gastroenterology, Affiliated Hospital of Medical College, Qingdao University, Qingdao 266000, Shandong Province, China
Chun-Hui Sun, Department of Gastroenterology, Qingdao 3rd People’s Hospital, Qingdao 266000, Shandong Province, China
Author contributions: Wang ZX designed the research; Wang ZX, Liu SL, Sun CH, and Wang Q performed the research; Liu SL, and Sun CH analyzed the data; and Wang ZX wrote the paper.
Correspondence to: Dr. Zi-Xuan Wang, Department of Interventional Radiology, Qingdao Municipal Hospital, 1 Jiaozhou Rd, Qingdao 266000, Shandong Province, China. firstname.lastname@example.org
Telephone: +86-532-82789228 Fax: +86-532-82836421
Received: November 22, 2007 Revised: January 1, 2008
AIM: To assess whether psychological intervention reduces postembolization pain during hepatic arterial chemoembolization therapy.
METHODS: Two hundred and sixty-two patients, who required hepatic arterial chemoembolization for hepatic malignancy and postembolization pain, were randomized into control group (n = 46, receiving medication) and intervention group (n = 216, receiving psychological intervention and medication in turn). The symptom checklist-90 (SCL-90) was used to scale the psychological symptoms of the patients before operation. Pain was scored with a 0 to 10 numeric rating scale (NRS-10) before and after analgesia as well as after psychological intervention (only in intervention group).
psychological symptomatic scores measured with SCL-90 in the
intervention group were higher than the normal range in Chinese (P <
0.05). The somatization, phobia and anxiety symptomatic scores were
associated with pain numerical rating score before analgesia (r = 0.141,
0.157 and 0.192, respectively,
CONCLUSION: Severe psychological distress occurs in patients with hepatic malignancy. Psychological intervention reduces pain scores significantly during hepatic arterial chemoembolization therapy and is thus, highly recommended as a complementary approach to drug analgesia.
© 2008 WJG. All rights reserved.
Key words: Liver neoplasms; Radiology; Psychological intervention; Non-pharmacologica; Pain
Peer reviewer: Toru Ishikawa, MD, Department of Gastroenterology, Saiseikai Niigata Second Hospital, Teraji 280-7, Niigata, Niigata 950-1104, Japan
Wang ZX, Liu SL, Sun CH, Wang Q. Psychological intervention reduces postembolization pain during hepatic arterial chemoembolization therapy: A complementary approach to drug analgesia. World J Gastroenterol 2008; 14(6): 931-935 Available from: URL: http://www.wjgnet.com/1007-9327/14/931.asp DOI: http://dx.doi.org/10.3748/wjg.14.931
Hepatic carcinoma is one of the most common malignant visceral tumors in adults worldwide. Surgical resection remains the major treatment for hepatocellular carcinoma (HCC). However, only 8%-15% of patients meet the criteria for surgical resection[1-3] and the long-term results after resection are still unsatisfactory. The liver is also the most frequent site of metastatic disease from extrahepatic primary tumors. Resection of metastases can prolong the survival time of a small percentage of selected patients. Transarterial chemoembolization (TACE), as a palliative therapy, is recommended for the treatment of unresectable hepatic neoplasms (primary and metastatic)[7,8]. The current routine technique of TACE is to inject iodized oil mixed with a single or a combination of chemotherapeutic agents into the neo-vasculature of hepatic neoplasms. The therapeutic goal is ischemic and cytotoxic insults to the tumor by occluding the feeding and collateral arteries of tumors. Right upper quadrant pain appears to be the most common complaint, followed by fidget, anxiety and noncompliance. Analgesia induced by drugs, such as intraarterial lidocaine and intravenous narcotic analgesics, is required to alleviate the pain[9,10]. However, these medications have side effects and a few patients are not sensitive to sedative and analgesic medications. It is, therefore, necessary to develop non-pharmacologic approaches to improving the patient experience with painful procedures.
Non-pharmacologic practices, such as guided imagery, music therapy, hypnosis, and distraction, can effectively improve patient experiences during painful medical procedures, such as endoscopy. There are few studies analyzing the effect of psychological intervention on pain suffered by hepatic cancer patients undergoing hepatic arterial chemoembolization therapy.
The aim of this investigation was to assess whether psychological intervention reduces postembolization pain during hepatic arterial chemoembolization therapy.
MATERIALS AND METHODS
Between April 2002 and March 2006, 262 patients requiring hepatic arterial chemoembolization for hepatic malignancy (primary or metastatic) and postembolization pain agreed to participate in the study. The group comprised 186 men and 76 women with their age ranged from 13 to 76 years (mean age, 51.96 years). The diagnosis of hepatic tumor was confirmed by pathologic and histologic examination or elevated serum tumor markers. Patient exclusion criteria were as follows: (1) history of interventional diagnosis and/or therapy, (2) bellyache before embolization, (3) treatment with anxiolytic or narcotic analgesics 72 h prior to the therapy, (4) presence of encephalopathy or other significant alterations of mental status or cognitive impairment or visual and auditory deficits, (5) considerable cardiopulmonary morbidity.
Patients were randomized into control group (n = 46, receiving medication) and intervention group (n = 216, receiving psychological intervention and medication in turn). Their baseline characteristics, including demographic information (i.e., age and gender) and tumor type, were collected from the medical records.
The Chinese version of symptom checklist-90 (SCL-90), a psychiatric self-report inventory, was used to scale the psychological symptoms of the patients before operation. All patients were guided to answer 90 items with the uniform advices, and the 90 items in the questionnaire were scored on a five-point scale to reflect the psychological symptom patterns of patients. The items referred to the assessment of index for somatization dimensions, obsessive-compulsive tendencies, depression, anxiety, phobia, interpersonal sensitivity, hostility, paranoid ideations and psychotic states.
During the procedure,
patients in the control group received medication when they experienced
pain, whereas psychological intervention and drug analgesia were
performed in turn on patients who were assigned to the intervention
group for the postembolization pain. Patients in the control group and
those with painful experience after psychotherapy in the intervention
group received medications according to the digital subtraction
angiograms and symptoms, e.g. antispasmodics for arterial spasm,
narcotic analgesics for pain without characteristic signs and symptoms.
The doses of medications were determined by the operator who performing
the procedure according to the condition of patients. Psychological
intervention was performed by two registered nurses with 7- and 10-year
professional experience, respectively. Psychotherapy included
encouragement, verbal suggestion, relaxation training, distraction with
verbal communication on interest of the patients, therapeutic touch on
face of the patients, guided imagery and intra-arterial placebo
The data were analyzed with the Statistical Package for Social Sciences (SPSS 11.0 for Windows). The measure-ment data were expressed as mean ± SD and the enume-ration data as proportions. Statistical tests used in bivariate analysis included c2 test and Student t test. The relationship between mental status and postembolization pain was evaluated with the Pearson correlation coefficient. P < 0.05 was considered statistically significant.
There were slight
differences in baseline characteristics between the control and
intervention groups and none of these differences was statistically
Pearson correlation coefficients showed that the somatization dimensions and phobia were positively correlated with pain numerical rating score before analgesia in intervention group (P < 0.05). In addition, the anxiety level was also positively correlated with the pain numerical rating score before analgesia (P < 0.01) (Table 4).
Patients in both groups experienced pain relief after medication, psychotherapy or combined analgesia during the procedure. The pain scores after analgesic therapy were lower than those before analgesic therapy and the differences were statistically significant (P < 0.01) (Table 5).
Only some patients in the intervention group reported partial or entire pain relief (29.17% and 2.31%, respectively) after psychological intervention (Table 6).
The pain numerical rating scores for the control and intervention groups before analgesia showed no statistical difference, whereas the pain score after analgesia for the intervention group (psychological intervention and medication) was significantly lower than that for the control group (medication) (P < 0.01), indicating that the pain control was better in the intervention group than in the control group during the embolization procedure (Table 7).
TACE is an accepted palliative treatment modality for patients with primary HCC or hepatic metastases. If the tumor is unresectable, the patient is a poor surgical candidate. The clinical yield and survival rate in patients undergoing TACE have been proved[7,8,13]. More studies on TACE or combined methods, such as TACE combined with radiofrequency ablation, radiotherapy or percutaneous ethanol injection, have been reported recently[14-17]. In patients undergoing TACE, postembolization pain appears to be the most common complaint. The pain usually occurs after embolization and peaks within 12-24 h. A large dose of opioid analgesics is often required in most patients when the pain is too severe to endure.
The etiology of pain after TACE is not well under-stood, but several theories have been postulated, including distention of the liver capsule, tumor necrosis, acute ischemia of the liver parenchyma, and gallbladder ischemia secondary to inadvertent embolization of the cystic artery[2,18]. Infusion of iodized oil mixed with chemothera-peutic agents, in particular, results in acute, sharp right hypo-chondrium pain, followed by a deeper visceral pain, most likely due to swelling of the liver and stretching of the capsule that contains the nerve fibers. It is believed that administration of narcotic analgesics can effectively control the pain during the procedure[9,10,19]. In our study, forty-six patients in the control group experienced a significant decrease in abdominal pain after drug analgesia (P < 0.01). However, the pain of most patients was not completely relieved after medication therapy.
In addition to physical suffering, psychiatric syndrome is increasingly recognized as a major component of distress in cancer patients[20-26]. Several factors, including the grief about current and anticipated losses, fear of death, concerns about loved ones and the effect of certain chemotherapeutic drugs on mood, etc[20-23], contribute to psychological distress. Minagawa et al and Godding et al showed that about 30%-60% cancer patients have psychiatric disorders. Our study demonstrated that the SCL-90 factor scores for the intervention group were higher than those for the normal (P < 0.05), indicating that the psychological status is abnormal in patients with severe psychiatric disorders and hepatic carcinoma.
Psychological distress can result in systemic responses. Rorarius et al performed a case-control study to evaluate the stress response and the sensitivity of clinical and biochemical stress markers in patients undergoing laparoscopically assisted vaginal or abdominal hysterectomy and showed that the most sensitive symptoms and markers of the systemic response are pain scores. Passik et al surveyed 1109 cancer patients treated by 12 oncologists with Zung Self-Rating Depression Scale (ZSDS) and numerical rating scale, and found that the untreated psychological distress in cancer patients is associated with amplified pain. In our study, somatization, phobia and anxiety symptoms measured with SCL-90 were correlated with the postembolization pain (P < 0.05), which is consistent with the reported data.
Pariser et al examined the effects of a telephone intervention in adults with arthritis and suggested that minimal intervention may produce positive changes in arthritis self-efficacy (ASE), depression, and pain in some adults. Other psychotherapies, e.g. hypnotic suggestion, relaxation training, distraction therapy, therapeutic touch[33,34], and imagery[35,36], are used in the treatment of disease-related pain. Our results reveal that psychological intervention decreased the pain score significantly (P < 0.01). However, only five patients (2.31%) reported entire pain control and most (68.52%) patients showed a slightly alleviated pain. Drug analgesia was still required by most patients in the intervention group during the procedure.
Several studies reported that psychological intervention during an invasive procedure, e.g. listening to music during endoscopy, could improve tolerance and compliance, alleviate pain and decrease the dose of sedative drugs[38,39]. In our study, pain was well controlled after psychotherapy combined with medication, demonstrating that the pain control is better in the intervention group than in the control group (P < 0.01). The satisfaction of patients was increased accordingly.
In conclusion, patients with hepatic malignancy have severe psychological distress and psychological symptoms (i.e., somatization, phobia and anxiety) associated with the postembolization pain. Psychological intervention reduces pain scores significantly during hepatic arterial chemoembolization therapy and is highly recommended as a complementary approach to drug analgesia.
Postembolization pain is the most common complaint of patients during and after transarterial chemoembolization (TACE) for unresectable hepatic neoplasms. Drug analgesia is often required to decrease pain. However, these medications have side effects and a few patients are not sensitive to sedative and analgesic medications.
Non-pharmacologic practices, such as guided imagery, music therapy, hypnosis, and distraction, can effectively improve patient experiences during painful medical procedures, such as endoscopy.
Innovations and breakthroughs
Psychological intervention can reduce pain significantly during hepatic arterial chemoembolization therapy.
Psychological intervention should be considered during hepatic arterial chemoembolization therapy.
This is an interesting report on a complementary approach to drug analgesia during TAE for hepatic carcinoma.
1 El-Serag HB, Siegel AB, Davila JA, Shaib YH, Cayton-Woody M, McBride R, McGlynn KA. Treatment and outcomes of treating of hepatocellular carcinoma among Medicare recipients in the United States: a population-based study. J Hepatol 2006; 44: 158-166 PubMed
2 Patel NH, Hahn D, Rapp S, Bergan K, Coldwell DM. Hepatic artery embolization: factors predisposing to postembolization pain and nausea. J Vasc Interv Radiol 2000; 11: 453-460 PubMed
3 Sonnenday CJ, Dimick JB, Schulick RD, Choti MA. Racial and geographic disparities in the utilization of surgical therapy for hepatocellular carcinoma. J Gastrointest Surg 2007; 11: 1636-1646 PubMed
4 Zhou XD. Recurrence and metastasis of hepatocellular Zhou XD. Recurrence and metastasis of hepatocellular carcinoma: progress and prospects. Hepatobiliary Pancreat Dis Int 2002; 1: 35-41 PubMed
5 Kuvshinoff B, Fong Y. Surgical therapy of liver metastases. Semin Oncol 2007; 34: 177-185 PubMed
6 Sofocleous CT, Nascimento RG, Gonen M, Theodoulou M, Covey AM, Brody LA, Solomon SM, Thornton R, Fong Y, Getrajdman GI, Brown KT. Radiofrequency ablation in the management of liver metastases from breast cancer. AJR Am J Roentgenol 2007; 189: 883-889 PubMed
7 Llovet JM, Burroughs A, Bruix J. Hepatocellular carcinoma. Lancet 2003; 362: 1907-1917 PubMed
8 Miraglia R, Pietrosi G, Maruzzelli L, Petridis I, Caruso S, Marrone G, Mamone G, Vizzini G, Luca A, Gridelli B. Efficacy of transcatheter embolization/chemoembolization (TAE/TACE) for the treatment of single hepatocellular carcinoma. World J Gastroenterol 2007; 13: 2952-2955 PubMed
9 Lee SH, Hahn ST, Park SH. Intraarterial lidocaine administration for relief of pain resulting from transarterial chemoembolization of hepatocellular carcinoma: its effectiveness and optimal timing of administration. Cardiovasc Intervent Radiol 2001; 24: 368-371 PubMed
10 Romano M, Giojelli A, Tamburrini O, Salvatore M. Chemoembolization for hepatocellular carcinoma: effect of intraarterial lidocaine in peri- and post-procedural pain and hospitalization. Radiol Med (Torino) 2003; 105: 350-355 PubMed
11 Danhauer SC, Marler B, Rutherford CA, Lovato JF, Asbury DY, McQuellon RP, Miller BE. Music or guided imagery for women undergoing colposcopy: a randomized controlled study of effects on anxiety, perceived pain, and patient satisfaction. J Low Genit Tract Dis 2007; 11: 39-45 PubMed
12 Nogueira PA, Leal AC, Pulz C, Nogueira ID, Filho JA. Clinical reliability of the 6 minute corridor walk test performed within a week of a myocardial infarction. Int Heart J 2006; 47: 533-540 PubMed
13 Takayasu K, Arii S, Ikai I, Omata M, Okita K, Ichida T, Matsuyama Y, Nakanuma Y, Kojiro M, Makuuchi M, Yamaoka Y. Prospective cohort study of transarterial chemoembolization for unresectable hepatocellular carcinoma in 8510 patients. Gastroenterology 2006; 131: 461-469 PubMed
14 Ueno K, Miyazono N, Inoue H, Nishida H, Kanetsuki I, Nakajo M. Transcatheter arterial chemoembolization therapy using iodized oil for patients with unresectable hepatocellular carcinoma: evaluation of three kinds of regimens and analysis of prognostic factors. Cancer 2000; 88: 1574-1581 PubMed
15 Zhou ZH, Liu LM, Chen WW, Men ZQ, Lin JH, Chen Z, Zhang XJ, Jiang GL. Combined therapy of transcatheter arterial chemoembolisation and three-dimensional conformal radiotherapy for hepatocellular carcinoma. Br J Radiol 2007; 80: 194-201 PubMed
16 Yamagiwa K, Shiraki K, Yamakado K, Mizuno S, Hori T, Yagi S, Hamada T, Iida T, Nakamura I, Fujii K, Usui M, Isaji S, Ito K, Tagawa S, Takeda K, Yokoi H, Noguchi T. Survival rates according to the Cancer of the Liver Italian Program scores of 345 hepatocellular carcinoma patients after multimodality treatments during a 10-year period in a retrospective study. J Gastroenterol Hepatol 2007 PubMed
17 Jang JW, Park YM, Bae SH, Choi JY, Yoon SK, Chang UI, Nam SW, Kim BS. Therapeutic efficacy of multimodal combination therapy using transcatheter arterial infusion of epirubicin and cisplatin, systemic infusion of 5-fluorouracil, and additional percutaneous ethanol injection for unresectable hepatocellular carcinoma. Cancer Chemother Pharmacol 2004; 54: 415-420 PubMed
18 Fan J, Ten GJ, He SC, Guo JH, Yang DP, Wang GY. Arterial chemoembolization for hepatocellular carcinoma. World J Gastroenterol 1998; 4: 33-37 PubMed
19 Molgaard CP, Teitelbaum GP, Pentecost MJ, Finck EJ, Davis SH, Dziubinski JE, Daniels JR. Intraarterial administration of lidocaine for analgesia in hepatic chemoembolization. J Vasc Interv Radiol 1990; 1: 81-85 PubMed
20 Massie MJ. Prevalence of depression in patients with cancer. J Natl Cancer Inst Monogr 2004: 57-71 PubMed
21 Besisik SK, Kocabey G, Caliskan Y. Major depression and psoriasis activation due to interferon-alpha in a patient with chronic myeloid leukemia; "overlooked and/or misdiagnosed adverse reaction in malignant disease". Am J Hematol 2003; 74: 224 PubMed
22 Ito M, Onose M, Yamada T, Onishi H, Fujisawa S, Kanamori H. Successful lithium carbonate treatment for steroid- induced depression following bone marrow transplantation: a case report. Jpn J Clin Oncol 2003; 33: 538-540 PubMed
23 Geinitz H, Zimmermann FB, Thamm R, Keller M, Busch R, Molls M. Fatigue in patients with adjuvant radiation therapy for breast cancer: long-term follow-up. J Cancer Res Clin Oncol 2004; 130: 327-333 PubMed
24 Block SD. Assessing and managing depression in the terminally ill patient. ACP-ASIM End-of-Life Care Consensus Panel. American College of Physicians - American Society of Internal Medicine. Ann Intern Med 2000; 132: 209-218 PubMed
25 Passik SD, Dugan W, McDonald MV, Rosenfeld B, Theobald DE, Edgerton S. Oncologists' recognition of depression in their patients with cancer. J Clin Oncol 1998; 16: 1594-1600 PubMed
26 Lottick NS, Vanderwerker LC, Block SD, Zhang B, Prigerson HG. Psychiatric disorders and mental health service use in patients with advanced cancer: a report from the coping with cancer study. Cancer 2005; 104: 2872-2881 PubMed
27 Minagawa H, Uchitomi Y, Yamawaki S, Ishitani K. Psychiatric morbidity in terminally ill cancer patients. A prospective study. Cancer 1996; 78: 1131-1137 PubMed
28 Godding PR, McAnulty RD, Wittrock DA, Britt DM, Khansur T. Predictors of depression among male cancer patients. J Nerv Ment Dis 1995; 183: 95-98 PubMed
29 Rorarius MG, Kujansuu E, Baer GA, Suominen P, Teisala K, Miettinen A, Ylitalo P, Laippala P. Laparoscopically assisted vaginal and abdominal hysterectomy: comparison of postoperative pain, fatigue and systemic response. A case-control study. Eur J Anaesthesiol 2001; 18: 530-539 PubMed
30 Pariser D, O'Hanlon A. Effects of telephone intervention on arthritis self-efficacy, depression, pain, and fatigue in older adults with arthritis. J Geriatr Phys Ther 2005; 28: 67-73 PubMed
31 Castel A, Perez M, Sala J, Padrol A, Rull M. Effect of hypnotic suggestion on fibromyalgic pain: comparison between hypnosis and relaxation. Eur J Pain 2007; 11: 463-468 PubMed
32 Diette GB, Lechtzin N, Haponik E, Devrotes A, Rubin HR. Distraction therapy with nature sights and sounds reduces pain during flexible bronchoscopy: a complementary approach to routine analgesia. Chest 2003; 123: 941-948 PubMed
33 Vitale AT, O'Connor PC. The effect of Reiki on pain and anxiety in women with abdominal hysterectomies: a quasi- experimental pilot study. Holist Nurs Pract 2006; 20: 263-272; quiz 273-274 PubMed
34 Vitale A. An integrative review of Reiki touch therapy research. Holist Nurs Pract 2007; 21: 167-179; quiz 180-181 PubMed
35 Reed T. Imagery in the clinical setting: a tool for healing. Nurs Clin North Am 2007; 42: 261-277, vii PubMed
36 Keefe FJ, Abernethy AP, C Campbell L. Psychological approaches to understanding and treating disease-related pain. Annu Rev Psychol 2005; 56: 601-630 PubMed
37 Chlan L, Evans D, Greenleaf M, Walker J. Effects of a single music therapy intervention on anxiety, discomfort, satisfaction, and compliance with screening guidelines in outpatients undergoing flexible sigmoidoscopy. Gastroenterol Nurs 2000; 23: 148-156 PubMed
38 Lee DW, Chan KW, Poon CM, Ko CW, Chan KH, Sin KS, Sze TS, Chan AC. Relaxation music decreases the dose of patient-controlled sedation during colonoscopy: a prospective randomized controlled trial. Gastrointest Endosc 2002; 55: 33-36 PubMed
39 Harikumar R, Raj M, Paul A, Harish K, Kumar SK, Sandesh K, Asharaf S, Thomas V. Listening to music decreases need for sedative medication during colonoscopy: a randomized, controlled trial. Indian J Gastroenterol 2006; 25: 3-5 PubMed
S- Editor Li DL L- Editor Wang XL E- Editor Liu Y