RESEARCH FINDINGS USING GUIDED IMAGERY FOR
Cancer Pain

July, 2006

Definition and Scope of the Problem of Cancer Pain
Pain is among the most common and most feared symptoms of cancer. According to the Cancer Information Network, between 30%-50% of cancer patients experience pain, and approximately 70% experience severe pain at some point during the course of their disease (2006).

National costs of cancer pain management are difficult to estimate. However, in 1990, a single hospital, City of Hope, estimated their costs for hospitalizations for uncontrolled cancer pain at over $5 million. This cost would have risen to $9 million if their patients receiving home parenteral infusions of morphine had been in-patients (Ferrell & Griffith, 1994).


Medical Treatment of Cancer Pain
Various types of drugs are used to control cancer pain: non-steroidal anti-inflammatories (NSAIDS), COX-2 inhibitors, and opioids (such as morphine or Demerol). Non-pain medications can also help: drugs to relieve cramps, stabilize the heart rhythm, seizure medications, sleep aids, and drugs to relieve depression and anxiety. Used correctly, these medications can completely control pain in over 50% of cases, according to cancer specialist Daniel Brookoff, MD (2001a).

For pain that doesn’t respond to oral medications, opiates can be given intravenously (I.V.s) or directly into the spinal canal. In even more severe cases, surgery and radiation are sometimes used effectively. Use of a TENS (Transcutaneous Electrical Nerve Stimulation) device sometimes helps.

Pain specialists estimate that pain could be effectively controlled in nearly all cancers (Brookoff, 2001a). Failure to adequately treat cancer pain can lower quality of life and lead to unnecessary hospital stays. The indirect costs in lost productivity and missed work for patients and caregivers are unknown but must be substantial, as is the burden of unrelieved suffering.


Problems in Cancer Pain Treatment
Some physicians are not adequately informed about the value of non-narcotic medications, particularly anti-depressants (Brookoff, 2001a). Likewise, many patients do not request or use available medications. They may avoid anti-depressants and take less of their narcotics because they are afraid of addiction (Brookoff, 2001b). Depression, insomnia and stress can greatly increase the perception of pain and suffering (Cicala, 2001).


Non-medical Treatments Including Guided Imagery
Various complementary therapies have been found successful to varying degrees in cancer pain. These include acupuncture (Johnstone, Polston et al, 2002), hypnosis (Levitan, 1992; Vickers & Vassileth, 2001), and guided imagery (Syrjala, Cummings & Donaldson, 1992; Syrjala, Donaldson et al, 1995).

Two studies at the Fred Hutchinson Cancer Center demonstrated significant relief of cancer pain with relaxation and self-hypnosis consisting of relaxation and guided imagery (Syrjala, Cummings & Donaldson, 1992; Syrjala, Donaldson et al, 1995).

Researchers at Sloan-Kettering Memorial Cancer Center reported that “randomized trials support the value of hypnosis for cancer pain and nausea; relaxation therapy, music therapy, and massage for anxiety. Such complementary therapies are increasingly provided at mainstream cancer centres” (Vickers & Cassileth, 2001). A University of Minnesota researcher reported significant pain relief from a hypnosis technique called glove anesthesia (Levitan, 1992).

Self-hypnosis, relaxation, and meditation have been significantly effective in many types of pain, including cancer (Sloman, Brown et al, 1994; Sellick & Zaza, 1998). Kabat-Zinn and others reported dramatic improvement in the chronic pain in a group of 90 patients who participated in a 10-week meditation program (Kabat-Zinn, Lipworth & Burney, 1985). These patients had increased comfort and less psychological distress. In some cases, they were able to use less medication. Other researchers’ patients achieved profound relief of arthritis pain with self-hypnosis (guided imagery) (Carni & Gilbert, 1982).

Despite studies that confirm that mind-body approaches such as guided imagery, hypnosis, and relaxation have direct physiological effects in stress levels, the immune system, and pain management (Bakke, Purtzer & Newton, 2002; Gruzelier, 2002), many times, doctors aren’t the first ones to suggest alternative pain approaches. One doctor at the Eastern Virginia School of Medicine found that many cancer patients come to that clinic familiar with hypnosis and request it for their pain (Lynch, 1999).

In a 2003 review of the literature, the authors reviewed complementary and alternative medicine (CAM) use in end-of-life issues such as pain. They found that self-hypnosis was one of the techniques that may provide relief in cancer pain, and that relaxation and imagery specifically could help with the pain of mouth sores (oral musositis) (Pan, Morrison et al, 2000).

Authors of a 2004 review reported evidence of efficacy for hypnosis in cancer pain (Shukla & Pal, 2004). The authors of two dissertations on the effects of guided imagery reported that patients had less anxiety and depression (Caruso, 1999; Henge, 1999). A 2005 review confirmed the efficacy of mind-body techniques for in treating cancer pain, as well as for other anxiety and mood disturbances that are common in oncology patients (Deng & Cassileth, 2005).


Conclusion
When used along with prescribed medications, guided imagery can contribute to controlling pain and anxiety in cancer patients. In some cases, guided imagery can allow reduction of medication usage.


References
Bakke AC, Purtzer MZ, Newton P. The effect of hypnotic-guided imagery on psychological well-being and immune function in patients with prior breast cancer. J Psychosom Res. 2002 Dec;53(6):1131-7.

Brookoff D. (2001a). “Other Medications Used to Treat Cancer Pain,” in The Cancer Pain Sourcebook, R. Cicala, ed. Contemporary Books: Lincolnwood, IL. p.103-125.

Brookoff D. (2001b) “Opioid (Narcotic) Pain Medications,” in The Cancer Pain Sourcebook, R. Cicala, ed. Contemporary Books: Lincolnwood, IL. p. 77-78.

Cancer Information Network.
http://www.cancerlinksusa.com/therapy/cancerpain.asp
Accessed July, 2006.

Caruso P. A comparison of guided imagery techniques with chemotherapy patients. Doctoral Dissertation, California School of Professional Psychology, Alameda, California. 1999.

Cicala R. (2001). “Introduction to Cancer Pain” in The Cancer Pain Sourcebook. R. Cicala, ed. Contemporary Books: Lincolnwood, IL p. 51-74.

Deng G, Cassileth BR. Integrative Oncology: Complementary Therapies for Pain, Anxiety, and Mood Disturbance. CA Cancer J Clin. 2005; 55:109-116.

Devine EC. Meta-analysis of the effect of psychoeducational interventions on pain in adults with cancer. Oncol Nurs Forum. 2003 Jan-Feb;30(1):75-89.

Ferrell BR, Griffith H. Cost issues related to pain management: report from the cancer pain panel of the agency for health care policy and research. J Pain Symptom Manage. 1994 9:221-234.

Gruzelier JH. A review of the impact of hypnosis, relaxation, guided imagery and individual differences on aspects of immunity and health. Stress. 2002 Jun;5(2):147-63.

Helge TD. A comparison of three audio guided imagery tapes on the self efficacy of cancer chemotherapy patients. Doctoral Dissertation, California School of Professional Psychology, Alameda, California. 1999.

Johnstone PA, Polston GR, Niemtzow RC, Martin PJ. Integration of acupuncture into the oncology clinic. Palliat Med. 2002 May;16(3):235-9.

Kabat-Zinn J, Lipworth L, Burney R. The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine. 1985 June; 8(2):163-90.

Levitan AA. The use of hypnosis with cancer patients. Psychiatr Medicine.1992 10(1):119-31.

Lynch DF Jr. Empowering the patient: hypnosis in the management of cancer, surgical disease and chronic pain. Am J Clin Hypn. 1999 Oct;42(2):122-30.

Pan CX, Morrison RS, Ness J, Fugh-Berman A, Leipzig RM. Complementary and alternative medicine in the management of pain, dyspnea, and nausea and vomiting near the end of life. A systematic review. J Pain Symptom Manage. 2000 Nov;20(5):374-87.

Sellick SM, Zaza C. Critical review of 5 nonpharmacologic strategies for managing cancer pain. Cancer Prev Control. 1998; 2: 7-14.

Shulka Y, Pal SK. Complementary and alternative cancer therapies: past, present and the future scenario. Asian Pac J Cancer Prev. 2004 Jan-Mar;5(1):3-14.
Sloman R, Brown P, Aldana E, Chee E. The use of relaxation for the promotion of comfort and pain relief in persons with advanced cancer. Contemp Nurse. 1991; 3: 6-12.

Syrjala KL, Cummings C, Donaldson GW. Hypnosis or cognitive behavioral training for the reduction of pain and nausea during cancer treatment: a controlled clinical trial. Pain. 1992 Feb;48(2):137-46.

Syrjala KL, Donaldson GW, Davis MW, Kippes ME, Carr JE. Relaxation and imagery and cognitive-behavioral training reduce pain during cancer treatment: a controlled clinical trial. Pain. 1995 Nov; 63 (2):189-98.

Varni JW, Gilbert A. Self-regulation of chronic arthritic pain and long-term analgesic dependence in a haemophiliac. Rheumatol Rehabil 1982 Aug;21(3):171-4.

Vickers AJ, Cassileth BR. Unconventional therapies for cancer and cancer-related symptoms. Lancet Onco. 2001 Apr;2(4):226-32.