Indian Journal of Palliative Care
Open access journal 
  Print this page Email this page   Small font sizeDefault font sizeIncrease font size Users online: 182  
     Home | About | Feedback | Login 
  Current Issue Back Issues Editorial Board Authors and Reviewers How to Subscribe Advertise with us Contact Us Analgesic Prescription  
  Navigate Here 
 Resource Links
  »  Similar in PUBMED
 »  Search Pubmed for
 »  Search in Google Scholar for
 »Related articles
  »  Article in PDF (455 KB)
  »  Citation Manager
  »  Access Statistics
  »  Reader Comments
  »  Email Alert *
  »  Add to My List *
* Registration required (free)  

  In this Article
 »  Abstract
 » Introduction
 » Methods
 » Results
 »  Results of the I...
 » Discussion
 » Conclusions
 »  References
 »  Article Figures
 »  Article Tables

 Article Access Statistics
    PDF Downloaded6    
    Comments [Add]    

Recommend this journal


Table of Contents 
Year : 2020  |  Volume : 26  |  Issue : 4  |  Page : 444-456

Nonpharmacological interventions for pain management in lung cancer patients: A systematic review

1 Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis, TN 38163, USA
2 Department of Health Behavior and Health Education, Fay W. Boozman College of Public Health, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA

Date of Submission06-Feb-2020
Date of Acceptance25-Mar-2020
Date of Web Publication19-Nov-2020

Correspondence Address:
Jayaprakash Kumar
Department of Preventive Medicine, University of Tennessee Health Science Center, 66 N Pauline St., Memphis, TN 38163
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPC.IJPC_24_20

Rights and Permissions

 » Abstract 

Background: The presence of lung cancer is almost always associated with pain, a symptom that causes severe distress in patients. Although many pharmacological methods are available to manage pain in this oncologic population, the medications often cause undesirable sideeffects and inadequate relief. Nonpharmacological interventions can be used as adjuvants to pharmacological interventions in reducing pain and increasing quality of life. Objectives: The purpose of this review is to compare the efficacy of nonpharmacological interventions in reducing pain in lung cancer patients. Materials and Methods: This is a systematic review study guided by the Preferred Reporting Items of Systematic reviews and Meta-Analysis Protocol. Interventions identified in the present systematic review have been categorized as physical treatment, technologybased, cognitive behavioral, coping, and coaching. Results: Results indicate that the nonpharmacological interventions such as physical treatment interventions, selfmanagement and coaching interventions, cognitive behavioral interventions, and technologybased interventions or coping skills interventions had limited and shortterm effects on alleviating pain among the patients. However, previous studies have provided limited evidence regarding nonpharmacologic therapy due to the lack of a comparison group, small sample sizes, and lack of longterm followup periods to determine whether sustained effects are feasible. Conclusion: Healthcare professionals should consider additional research on the added advantage of utilizing the nonpharmacological interventions as an adjunct option while managing pain in lung cancer patients.

Keywords: Lung cancer, nonpharmacological, pain management

How to cite this article:
Kumar J, Alam MM, Johnson KC. Nonpharmacological interventions for pain management in lung cancer patients: A systematic review. Indian J Palliat Care 2020;26:444-56

How to cite this URL:
Kumar J, Alam MM, Johnson KC. Nonpharmacological interventions for pain management in lung cancer patients: A systematic review. Indian J Palliat Care [serial online] 2020 [cited 2020 Dec 3];26:444-56. Available from:

 » Introduction Top

Lung cancer is the leading cause of death among all types of cancers in the US.[1] New cases of lung cancer in 2016 are estimated to be 13% of all cancers, only second to breast cancer in women and prostate cancer in men.[1] Lung cancer patients report a myriad of physical and psychosocial symptoms varying from pain, fatigue, dyspnea, and coughing to distress, anxiety, and depression.[2] Pain remains one of the most distressful symptoms in cancer patients[3] which affects patients' quality of life and psychosocial functioning.[4],[5],[6],[7] Manifestation of lung cancer pain is multi-faceted due to tumor location, spread of tumors, stage of metastases, existence of other comorbidities, and anti-cancer treatment.[7],[8]

Evidence-based pharmacological interventions indicate that the use of opioid analgesics and surgical interventions are the most common lung cancer pain management methods.[8] However, pharmaceutical pain management methods, especially opioid analgesics often have unreliable pain control and frequently cause adverse effects.[9],[10] To overcome these limitations, nonpharmacological approaches including prophylactic and complementary interventions[11],[12] have been suggested to alleviate pain. A systematic review on nonpharmacological interventions of pain management in cancer patients in general conducted between 2010 and 2013[13] concluded that the effectiveness of those interventions was rather limited with only a short-term effect. To our knowledge, there is no evidence of a systematic review that focuses on the efficacy of nonpharmaceutical pain management interventions conducted among only lung cancer patients. As such, we aim to build on the prior knowledge and systematically review the various nonpharmacological interventions for pain in lung cancer patients over the past 5 years.

 » Methods Top

Study design

Methods and presentation of results for this systematic review were guided by the Preferred Reporting Items of Systematic Reviews and Meta-Analyses Protocol.[14]

Literature search

The literature search involved a systematic search of five journal indexing databases: CINAHL, PubMed, PsycInfo, Scopus, and Web of Science. Each database was searched for relevant articles using the key terms (lung cancer OR lung neoplasms OR thoracic cancer) AND Pain AND (intervention OR program OR management) AND (nonpharmacological). In addition, cross-referencing the articles was performed.

Inclusion/exclusion criteria

Studies were included in this systematic review if interventions were published in English and evaluated the symptom of pain in lung cancer patients (any type and any stage) between January 2010 and December 2015. Interventions that had
Study selection

Two reviewers independently performed the search selection and numbers of references were compared at each step of data extractions. If difference in the numbers were found, the two reviewers discussed the reasons for discrepancies and reached a consensus.

Data extraction

Relevant references were pooled into a database and were reviewed for relevance after elimination of duplicates. Reviewers identified relevant studies and extracted the following information: Authors, year of study, geographic location of study, study design, sample and population setting, measurement tools for outcome, intervention used, and statistical inferences [Table 1]. The overall quality of the methodology of the systematic review was assessed by the assessment multiple systematic reviews[15] criteria and quality of individual interventions with a 27-item quality assessment checklist.[16] Nonrandomized trials scores varied from 23 to 27 and randomized controlled trials' (RCT) scores were in the range of 22–27, indicating the quality of the interventions where a score of 26–28 = excellent; 20–25 = good; 15–19 = fair; and ≤14 = poor.[16]
Table 1: Summary of studies- Interventions in treating pain in patients with lung cancer

Click here to view

 » Results Top

Study selection

The initial search yielded 2288 articles. A total of 1636 references were identified for review after removal of 652 duplicates. On closer inspection, 1619 citations were excluded as they did not meet the full inclusion criteria. Twenty-three studies were selected after data extraction, including six articles obtained through cross referencing. [Figure 1] illustrates the flowchart of literature search process. To be eligible for inclusion, a study must apply at least one pain measurement before and following the intervention or should have measured pain after the intervention, which was our only outcome we considered.
Figure 1: Flowchart of literature search for non-pharmacological interventions for pain management in lung cancer

Click here to view

Characteristics of nonpharmacological interventions


The main characteristics of the reviewed studies are summarized in [Table 1]. The majority of studies were conducted in the US (n = 14), however, other locations included Canada (n = 2), Denmark (n = 1), Germany (n = 3), The Netherlands (n = 1), Spain (n = 1), Taiwan (n = 1), and the UK (n = 1). Out of the 22 studies included in this systematic review,[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40] ten involved only participants with lung cancer [Table 1]. In total, this review included 6315 participants, with sample size per study ranging from 17 to 3133 participants. Gender distribution was reported in all but two studies.[23],[24] The average male percentage cohort was 61%. All studies included adults, with age ranging from 18 to 75 years.

Classification of interventions

In this study, nonpharmacological interventions were broadly classified into five categories:

  1. Physical treatment interventions
  2. Self-management and coaching interventions
  3. Cognitive behavioral interventions
  4. Technology-based interventions
  5. Coping skills interventions.

Of the six studies that emphasized physical treatment, four focused on physical exercise activity and physical therapy,[18],[21],[24],[33] two studies focused on massage,[25],[32] whereas one study focused on acupressure.[40] Five studies were concerned primarily on enhancing cognitive and coping skills.[29],[30],[34],[35],[37] Four studies centered on self-management and coaching.[17],[27],[39],[41] Well-being and mindfulness interventions were the focus of three studies.[23],[31],[38] Three studies centered on the utilization of technology such as telephone or Internet to enhance symptom control.[20],[28],[42]

Nature of interventions

Among physical treatment interventions, exercise treatments were the most examined.[18],[21],[24],[33] Exercise interventions were delivered in either a group format[18] or individual sessions.[21],[24],[33] The comparison groups received individualized sessions of home exercise instructions and postsurgery counseling[18] and conventional physiotherapy including breathing techniques, massage, muscle stretching, and distraction.[24] There were no control groups in two studies.[21],[33] One intervention considered massage therapy[25] consisting of standardized massage and manipulation of soft tissue, whereas one intervention combined massage with exercise.[32] The control group received either social attention[25] or simple hand touch.[32] A second intervention without a control group involved an acupressure intervention which was delivered by Yeh et al.[40] This modality involved sessions where participants received 7 days of brief acupressure treatment for their pain.

In a pretest and posttest one group design, Kwekkeboom et al. evaluated the effect of in-person delivered strategies for relaxation, imagery, and distraction exercises for pain and other symptoms.[29] No control group was used in this intervention. The same cognitive-behavioral intervention was used in a RCT[30] where the control group received usual care. Two interventions evaluated the efficacy of caregiver-assisted coping skills training (CST) and brief pain coping skills training (PCST) interventions delivered via telephone or videoconference.[34],[37] One study provided participants with a combined one-on-one session of narrative therapy and anti-depressant medication,[35] whereas the usual care group received an anti-depressant medication and information about medication.

Four studies involved self-management and coaching interventions.[17],[27],[39],[41] In one study, participants received four educational sessions (“Passport to Comfort”) on minimizing barriers to pain and fatigue, whereas the control received standard care.[17] In another study, a combination of education and coaching sessions aimed to reduce misconceptions about pain and improving self-efficacy in communicating pain to physicians by patients receiving the intervention, whereas those in the control group received enhanced care.[39] The feasibility of Pro-SELF Plus Pain Control Program was evaluated when delivered on a one-on-one basis over 6 1-h sessions.[27] The control group received standard education and care. In the remaining study, Wilkie et al. (2010) evaluated the effects of sensory self-monitoring and reporting coaching of pain in the intervention group, whereas the control group discussed cancer experiences.[39]

Among the technology-based interventions,[20],[28],[42] the first one utilized a telephone-based management care coupled with an automated monitoring of symptoms. The second administered a web-based Internet platform intervention.[28] The remaining two interventions assessed the efficacy of routine screening for distress program to assist patients on physical and psychosocial symptoms including pain, fatigue, anxiety, and depression.[20],[42] Three variants of a routine screening for distress[20] included the minimal screening (usual care and distress level screening), full screening (minimal screening, screening for distress symptoms, and tailored report of patient's concerns), and triage screening (full screening and referral to patient's medical choice as founded appropriate by a member of psychosocial team). Similar to the previous intervention, Carlson et al. compared the impact of a computerized triage intervention that provides participants with a tailored printout summarizing participant's concerns and access instructions to appropriate services to a personalized triage that provides participants with the same printout summary, but participants are contacted to discuss referral options.[42]

Delivery of interventions

A face-to-face approach was the main interventional element of 17 studies.[17],[21],[23],[24],[25],[26],[27],[29],[30],[31],[32],[33],[35],[36],[38],[40],[43] Three interventions were delivered to participants on the computer.[20],[37],[42] A telephone-based intervention was used in three studies.[22],[28],[34] One study used a combination of video, written materials, and in-person, mail or phone delivery intervention elements.[39]


All 23 studies included in this systematic review assessed pain intensity or pain severity. The brief pain inventory (BPI) which assessed pain severity was used in seven studies.[28],[29],[30],[32],[34],[37],[40] A single- or two-item Numeric Rating Scale were used in six interventions.[17],[20],[21],[26],[27],[42] Two studies measured Present Pain Intensity with a Visual Analogy Scale.[25],[39] While Rodríguez et al. used the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ C-30)[35] and van den Hurk et al. used The EORTC QLQ Lung Cancer,[38] Henke et al. used both questionnaires.[24] Other instruments used were Medical Outcomes Studies Short-Form General Health Survey-36;[31] and 36-Item Short Form Health Survey (RAND SF-36);[23],[33] McGill-Pain Questionnaire;[39] and MD Anderson Symptom Inventory.[22] Other outcomes included pain frequency, pain interferences, bodily pain, and pain location [Table 1].

 » Results of the Interventions Top

Exercise interventions yielded mixed results.[18],[21],[24],[33] Brocki et al. (2014) evaluated the effects of a group supervised intervention and reported a moderate, but significant decrease in bodily pain that was short-term (4-month follow-up; mean difference 15.3, 95% confidence interval [CI]: 4–26.6, P = 0.01), but the effect was not sustained long-term (12-month follow-up; P = 0.49).[18] Another program that focused on strength training developed and evaluated a rapid, easy, and strength training exercise program as part of a multidisciplinary intervention.[21] The program did not improve participants' pain scores overtime compared to those in the control group (P = 0.87). Similarly, the supervised resistance exercise training conducted by Peddle-McIntyre et al. found that participants did not decrease their bodily pain levels over 12 weeks (mean difference: 2.9, 95% CI: −0.1–6.4, P = 0.101).[33] Similarly, participants receiving a 7-day strength and endurance training program[24] did not diminish pain levels compared to those in the control group (P > 0.05). However, a differential effect was observed in terms of reported pain location, where participants' pain in their arms or shoulder (P = 0.048) improved significantly, but not for chest and other body parts.[24]

Both interventions that considered massage therapy as an intervention whether entirely or combined with physical exercise yielded significant improvement in the pain level among participants. In one study that evaluated three consecutive massages,[25] participants reported an immediate beneficial effect after each session compared to the control group at each time point (all P < 0.001) and it reached clinical significance over time (F [1, 68) =61.17, P < 0.001). However, mean pain scores between the two groups converged overtime (P = 0.41).[25] In the other study, combined massage therapy with exercise[32] improved participants' pain scores compared to controls for BPI worst pain (mean difference: −1.5, 95% CI: −3.08, −0.008), BPI current pain (mean difference: −2.0, 95% CI: −3.9, −0.1), and total BPI index (mean difference: −2.68, 95% CI: −4.17, −1.18), but not for BPI least pain and BPI pain on average (all P > 0.127). The analgesic effect of acupressure on cancer pain management was shown to yield a short-term reduction in pain intensity, pain average, pain severity, and pain interference of >60% and 50% after the first session (i.e., 3 days from baseline) and at the end of 7 days, respectively (all P < 0.001).[40]

A patient-controlled cognitive behavioral (PC-CB) intervention including strategies for relaxation and imagery exercises[29] yielded significant immediate changes (1-week) in participants' mean pain severity scores (pretest: 4.54 ± 2.27 vs. post-test: 2.77 ± 2.06, P < 0.01), but pain ratings made before and after the 2-week intervention did not differ from each other. One RCT that delivered the same PC-CB intervention but to a larger sample of cancer patients,[30] showed immediate pre- to posttreatment (1 week) changes in pain severity scores (P< 0.001). Moreover, at the 2-week follow-up, pain severity scores in the PC-CB group improved significantly compared to those in the control group (P< 0.006).[30]

The two coping skills interventions had similar results. Porter et al. (2011) assessed the efficacy of a cognitive behavioral intervention in lung cancer patients by comparing a caregiver-assisted CST protocol to an education/support intervention.[34] The results indicated that the participants in both groups improved their worst pain scores over 6 months (P< 0.002).[34] Similarly, a brief PCST intervention[37] (Sommers et al., 2015) was shown to reduce pain after a 1-week intervention (pretreatment: 4.75 ± 1.97; posttreatment: 3.37 ± 1.63; t = 2.92, P = 0.009).

A RCT assessed the combined effect of a psychotherapeutic intervention such as narrative therapy with pharmaceutical treatment (e.g., escitalopram) by comparing it to usual care and escitalopram treatment.[35] A significant pain reduction in the combined therapy group (mean difference: 17.86, 95% CI: 17.86–37.69) compared to the usual care (16.16, 95% CI: 5.35–26.94) was detected at 12 months and 24 months, respectively (combined therapy: 24.24, 95% CI: 13.5–35; usual care: 44.87, 95% CI: 34.9–54.8). Overall, the combined intervention was beneficial in reducing pain overtime compared to the usual care and escitalopram treatment (P = 0.002).

The self-management and coaching interventions saw mixed results. Borneman et al. (2015) evaluated the effectiveness of “Passport to Comfort, ”an educational intervention to improve pain and fatigue management in cancer patients when compared to the control group (i.e., usual care).[17] While an immediate effect in pain change at 1-month follow-up (all P < 0.007) was detected in both groups (intervention and control groups), a sustained effect at 3-month follow-up was detected only in the intervention group (P = 0.001). A tailored education and coaching intervention to minimize misconceptions related to pain and improving self-efficacy of communicating pain to physicians,[27] briefly improved pain-related functional impairment at 2 weeks (P = 0.01), but this effect was not sustained overtime at 6 and 12 weeks (when compared to the control group). In addition, there were no statistically significant changes in pain severity between patients who received the intervention and those in the control group at any time points (all P > 0.27). A pain self-management intervention of skills building, information provision and coaching[26] did not improve the average and worst pain scores of participants at 10 and 22 weeks (all P > 0.48). Similarly, coaching patients to communicate pain to their providers did not improve participants' pain intensity and pain relief scores at 4-week follow-up (all P > 0.37).

Among the mindfulness and well-being interventions, 3 months of choral singing was reported to improve bodily pain of cancer survivors, (pretest: 62.1 ± 28.8; posttest: 72.9 ± 28.2, P = 0.01) where higher scores indicate lesser pain.[23] Similarly, a mindfulness-based stress reduction program that included meditation and yoga sessions,[31] and an intervention that encouraged meditation and a silent day improved patients' pain scores directly after and 3 months after the Mindfulness-Based Stress Reduction training.[38]

Of the three technology-based interventions, telecare management coupled with an automated symptom monitoring system was found to be efficacious in reducing pain.[28] Pain severity decreased significantly in participants receiving the intervention compared to controls at each time point (e.g., 3, 6, and 12 months; all P < 0.01). The largest moderate effect size for between-groups difference was detected immediately after the intervention; however, the effect size remained moderate although slightly attenuated but statistically significant at 6 and 12 months. Other pain-specific outcomes, including pain interference and bodily pain scores improved significantly over 12 months in the intervention group compared to the control group.[28] The remaining two interventions assessed the efficacy of routine screening for distress program to assist patients on physical and psychosocial symptoms including pain, fatigue, anxiety, and depression.[20],[42] Among the three variants of a routine screening distress program [Table 1], patients in the triage group benefited the most by reporting the presence of pain and of clinically elevated pain level (≥4) less frequently (32%) at 3 months compared to those in the minimal screening group (all P < 0.04), but not when compared to full screening group. However, all three groups exhibited similar mean Pain Thermometer levels (P = 0.142). In addition, participants from the triage group were more frequently referred to psychosocial resources than the full screening and minimal screening groups (P = 0.001) and when compared to those nonreferred, they did not improve pain overtime (P = 0.26). Overall, the triage screening and full screening equally decrease the level of pain of participants overtime (P = 0.42). Carlson et al. further explored the efficacy of the triage screening for distress by comparing personalized versus a computerized triage version.[42] While both interventions decreased participants' pain levels over time, there was a significant decline in the rate of change over time for pain along with other clinical symptoms (P< 0.0001). In addition, a moderate change in pain was also observed among patients in the personalized group (0.52 standard deviation [s.d.]) compared to a smaller reduction in pain for the computerized group (0.33 s.d.).

 » Discussion Top

This systematic review was done to compare the efficacy of nonpharmacological interventions in reducing pain in lung cancer patients. Pain is a multifaceted phenomenon and is a result of interactions between biological, affective, cognitive, behavioral, and sociocultural.[44] A pharmacological approach for pain management is considered the standard in clinical settings. Yet, it does not deliver reliable pain control in cancer patients.[13],[45] This is a significant problem as the prevalence of pain in lung cancer patients is estimated to be >45%.[7] Thus, aside from interventions that address the biological aspect of pain, nonpharmacological interventions have been recommended by agencies such as the World Health Organization as adjuvants for pain management.[46]

A systematic review of the effects of such interventions was conducted between 2010 and 2013 in patients exhibiting various types of cancer[13] and the findings indicated the effectiveness of the interventions was rather limited with only a short-term effect. We expanded on this knowledge and examined the effects of nonpharmacological interventions for pain management targeting lung cancer patients. To our knowledge, such a systematic review has not been carried out previously in this oncologic population.

The present systematic review included 23 interventions classified into several categories including physical treatment, technology-based, cognitive behavioral training, coaching, and well-being. While heterogeneity in results was detected among each category of interventions, the majority of them had some short-term pain-relieving effect. There was some evidence of short-term benefit for the relief of cancer pain with almost all interventions, viz a viz., physical exercise activity and physical therapy, massage, cognitive and coping skills, self-management and coaching. Well-being and mindfulness intervention and the utilization of technology to enhance pain control are still in infancy. Thus, due to the heterogeneous nature of the samples and lack of sufficient power and a paucity of rigorous trials, no interventions can be recommended currently.

Exercise interventions were one of the most frequently cited in this systematic review [Table 1], yet they yielded mixed results. In this review, the two interventions that were effective, pain subsided after a short-term exercise regimen,[24],[43] whereas the other two studies did not report any significant effects.[21],[33] This finding is similar to the mixed results that were reported in a systematic review conducted in breast cancer patients to assess the efficacy of exercise in alleviating pain.[47]

Therapeutic massage as a cancer pain intervention appears to be safe and effective and the use of massage in cancer care centers and hospitals is on the rise.[48] This finding is similar to the conclusions of some of the previous studies for other areas of cancer.[49],[50] It is believed that the actual benefits of massage therapy are a combination of many factors such as the communication between the masseuse and the individual, the massage therapists' “personal touch, ”and the patients' attitude about the therapy and the particular technique of massage.[51] Our review also identified the benefit of physical therapy. This intervention can be an effective augment to regular analgesic medication.[52] Literature related to beneficial effects of massage therapy are scanty. The postulated mechanism of the therapy is to relax the muscles and nerves which help to reduce pain associated with contractions or spasms. Massage therapy also are known to benefit neural tissues by reducing compression of the nerves. One study showed that incorporating the massage therapy in regular care of patients with acute conditions helps the patient positively to cope with the physical and mental trauma.[25]

Patient empowerment has been associated with controlling life by adopting the concepts of self-efficacy participating actively and increasing one's own abilities to face challenges.[53] Many models have been tested to enable and empower the individual patients and caregivers in a custom-made way that is preferred by themselves.[54] On the contrary, one study showed that patient empowerment led to an improved quality of care regarding postoperative pain but did not shorten the postoperative pain in old patients who had undergone surgery for cancer.[36] Unfortunately, there is still confusion regarding the operationalization of patient empowerment and issues related to the validity and reliability measures.

Among all cited interventions, there is evidence that cognitive behavioral and coping interventions alleviate pain. The cognitive behavioral approach is useful for modifying the coping skills in varied groups. Another brief review compared patient psycho-education, supportive psychotherapy, and cognitive-behavioral interventions among cancer patients and concluded that a combination of traditional health services and psychosocial support are classic examples of care which is comprehensive and integrated.[55] This conclusion has to be still verified in lung cancer patients exclusively. Similarly, in one of the included studies, the effect detected predominantly was immediate, but it was sustained.[35] Coping strategies for pain due to cancer are still not widely accepted and used due to the lack of sufficient empirical evidence.[56] Nonetheless, coping strategies may be a significant method of alleviating pain among cancer patients and survivors.

Mindfulness-based interventions can be considered as an effective way for functional improvements among cancer survivors.[57] Our review also noted the significant improvements in pain perception by the patients. One meta-analysis concluded that Mindfulness based stress reduction might not only help in reducing pain but also in improving the psychosocial aspects by allowing them to adjust to their status.[58]

Acupressure has also been used with some degree of success. In our review we identified a study which used acupressure therapy for 7 days.[40] Most of the time, this therapy is actually used to prevent nausea and cough caused due to the side effects of other medication for cancer treatment.

Technology-based interventions utilized either the web Internet interface or telephonic reminders. In our review, we found that telecare management was very efficient.[28] New strategies are being developed to use mobile-based interventions in these patients. This will potentially help health-care professionals and providers to maintain and manage the patients remotely.[59]

The above nonpharmacological interventions potentially offer a ray of hope to cancer patients suffering from pain. Providing better access, awareness, and coordinating with different stake holders in health care can be a very effective measure in improving patient experience. Future studies should strive to conduct more stringent RCTs to establish the potential use of these interventions in various settings and ultimately provide timely and appropriate relief to lung cancer patients.

Several limitations should be noted, however. First, the sample size of most of the studies was small and heterogeneous leading to underpowered effect size among the interventions. Fourteen studies had small sample sizes (n = 17–86), and only 8 studies had >200 participants (n = 201–3133). Second, the length of interventions varied from short periods of time (3 days to 2 weeks) to a longer periods of time (e.g., 1–4 months). Only few studies had subsequent follow-ups.[27],[28],[32],[35],[38],[41],[42],[43] Third, some studies lacked a control group which maximizes the threat for potentially confounding variables, thus reducing a study's internal validity.[17],[23],[29],[31],[33],[37],[38],[40] Fourth, a variety of outcome measures were used in these interventions (e.g., pain interference, pain severity, pain frequency, and pain location) thus, making it difficult to compare results between studies and to assess clinical significance of findings even when statistical significance was achieved. Finally, participants varied in their cancer stage and level of pain reported at the entrance in the study which adds to the layer of difficulty of comparing and contrasting results between studies.

 » Conclusions Top

The findings from this systematic review suggest that nonpharmacological interventions may have beneficial effects in alleviating pain in lung cancer patients. However, more research is warranted to explore the long-term effect of such interventions on pain management in this oncologic population. One recommendation involves the use of control groups and larger sample sizes to adequately control for potential confounders of pain which will allow a more robust analyses of the effect of nonpharmacological interventions on pain. Most interventions that exhibited pain alleviating benefits were short-term; however, whether these interventions have sustained benefits could be assessed by extending the follow-up periods.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Siegel RL, Miller KD, Jemal A. Cancer statistics, 2016. CA Cancer J Clin 2016;66:7-30.  Back to cited text no. 1
Tishelman C, Petersson LM, Degner LF, Sprangers MA. Symptom prevalence, intensity, and distress in patients with inoperable lung cancer in relation to time of death. J Clin Oncol 2007;25:5381-9.  Back to cited text no. 2
Cooley ME, Short TH, Moriarty HJ. Symptom prevalence, distress, and change over time in adults receiving treatment for lung cancer. Psychooncology 2003;12:694-708.  Back to cited text no. 3
Di Maio M, Gridelli C, Gallo C, Manzione L, Brancaccio L, Barbera S, et al. Prevalence and management of pain in Italian patients with advanced non-small-cell lung cancer. Br J Cancer 2004;90:2288-96.  Back to cited text no. 4
Iyer S, Taylor-Stokes G, Roughley A. Symptom burden and quality of life in advanced non-small cell lung cancer patients in France and Germany. Lung Cancer 2013;81:288-93.  Back to cited text no. 5
Lin S, Chen Y, Yang L, Zhou J. Pain, fatigue, disturbed sleep and distress comprised a symptom cluster that related to quality of life and functional status of lung cancer surgery patients. J Clin Nurs 2013;22:1281-90.  Back to cited text no. 6
Potter J, Higginson IJ. Pain experienced by lung cancer patients: A review of prevalence, causes and pathophysiology. Lung Cancer 2004;43:247-57.  Back to cited text no. 7
Simmons CP, Macleod N, Laird BJ. Clinical management of pain in advanced lung cancer. Clin Med Insights Oncol 2012;6:331-46.  Back to cited text no. 8
Ripamonti CI, Santini D, Maranzano E, Berti M, Roila F; ESMO Guidelines Working Group. Management of cancer pain: ESMO Clinical Practice Guidelines. Ann Oncol 2012;23 Suppl 7:vii139-54.  Back to cited text no. 9
Baldini A, Von Korff M, Lin EH. A review of potential adverse effects of longterm opioid therapy: A practitioner's guide. PRIM care companion. CNS Disord 2012;14:1-14.  Back to cited text no. 10
Demir Y. Nonpharmacological therapies in pain management. In: Gabor BR, Carl EN, editors. Pain Management-Current Issues and Opinions. Rijeka, Croatia: InTech; 2012. p. 485-502.  Back to cited text no. 11
Pyati S, Gan TJ. Perioperative pain management. CNS Drugs 2007;21:185-211.  Back to cited text no. 12
Hökkä M, Kaakinen P, Pölkki T. A systematic review: Non-pharmacological interventions in treating pain in patients with advanced cancer. J Adv Nurs 2014;70:1954-69.  Back to cited text no. 13
Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1.  Back to cited text no. 14
Shea BJ, Reeves BC, Wells G, Thuku M, Hamel C, Moran J, et al. AMSTAR 2: A critical appraisal tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ 2017;358:j4008.  Back to cited text no. 15
Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 1998;52:377-84.  Back to cited text no. 16
Borneman T, Sun V, Williams AC, Fujinami R, Del Ferraro C, Burhenn PS, et al. Support for patients and family caregivers in lung cancer: Educational components of an interdisciplinary palliative care intervention. J Hosp Palliat Nurs 2015;17:309-18.  Back to cited text no. 17
Brocki BC, Westerdahl E, Andreasen JJ, Souza DS. Improvements in physical performance and health-related quality of life one year after radical operation for lung cancer. Cancer Treat Commun 2015;4:65-74.  Back to cited text no. 18
Carlson LE, Waller A, Groff SL, Bultz BD. Screening for distress, the sixth vital sign, in lung cancer patients: Effects on pain, fatigue, and common problems–secondary outcomes of a randomized controlled trial. Psychooncology 2013;22:1880-8.  Back to cited text no. 19
Carlson LE, Waller A, Groff SL, Zhong L, Bultz BD. Online screening for distress, the 6th vital sign, in newly diagnosed oncology outpatients: Randomised controlled trial of computerised vs personalised triage. Br J Cancer 2012;107:617-25.  Back to cited text no. 20
Cheville AL, Kollasch J, Vandenberg J, Shen T, Grothey A, Gamble G, et al. A home-based exercise program to improve function, fatigue, and sleep quality in patients with Stage IV lung and colorectal cancer: A randomized controlled trial. J Pain Symptom Manage 2013;45:811-21.  Back to cited text no. 21
Cleeland CS, Wang XS, Shi Q, Mendoza TR, Wright SL, Berry MD, et al. Automated symptom alerts reduce postoperative symptom severity after cancer surgery: A randomized controlled clinical trial. J Clin Oncol 2011;29:994-1000.  Back to cited text no. 22
Gale N, Enright S, Reagon C, Lewis I, van Deursen R. A pilot investigation of quality of life and lung function following choral singing in cancer survivors and their carers. Ecancermedicalscience 2012;6:261.  Back to cited text no. 23
Henke CC, Cabri J, Fricke L, Pankow W, Kandilakis G, Feyer PC, et al. Strength and endurance training in the treatment of lung cancer patients in stages IIIA/IIIB/IV. Support Care Cancer 2014;22:95-101.  Back to cited text no. 24
Jane SW, Chen SL, Wilkie DJ, Lin YC, Foreman SW, Beaton RD, et al. Effects of massage on pain, mood status, relaxation, and sleep in Taiwanese patients with metastatic bone pain: A randomized clinical trial. Pain 2011;152:2432-42.  Back to cited text no. 25
Koller A, Miaskowski C, De Geest S, Opitz O, Spichiger E. Results of a randomized controlled pilot study of a self-management intervention for cancer pain. Eur J Oncol Nurs 2013;17:284-91.  Back to cited text no. 26
Kravitz RL, Tancredi DJ, Grennan T, Kalauokalani D, Street RL Jr., Slee CK, et al. Cancer Health Empowerment for Living without Pain (Ca-HELP): Effects of a tailored education and coaching intervention on pain and impairment. Pain 2011;152:1572-82.  Back to cited text no. 27
Kroenke K, Theobald D, Wu J, Loza JK, Carpenter JS, Tu W. The association of depression and pain with health-related quality of life, disability, and health care use in cancer patients. J Pain Symptom Manage 2010;40:327-41.  Back to cited text no. 28
Kwekkeboom KL, Abbott-Anderson K, Wanta B. Feasibility of a patient-controlled cognitive-behavioral intervention for pain, fatigue, and sleep disturbance in cancer. Oncol Nurs Forum 2010;37:E151-9.  Back to cited text no. 29
Kwekkeboom KL, Abbott-Anderson K, Cherwin C, Roiland R, Serlin RC, Ward SE. Pilot randomized controlled trial of a patient-controlled cognitive-behavioral intervention for the pain, fatigue, and sleep disturbance symptom cluster in cancer. J Pain Symptom Manage 2012;44:810-22.  Back to cited text no. 30
Lengacher CA, Reich RR, Post-White J, Moscoso M, Shelton MM, Barta M, et al. Mindfulness based stress reduction in post-treatment breast cancer patients: An examination of symptoms and symptom clusters. J Behav Med 2012;35:86-94.  Back to cited text no. 31
López-Sendín N, Alburquerque-Sendín F, Cleland JA, Fernández-de-las-Peñas C. Effects of physical therapy on pain and mood in patients with terminal cancer: A pilot randomized clinical trial. J Altern Complement Med 2012;18:480-6.  Back to cited text no. 32
Peddle-McIntyre CJ, Bell G, Fenton D, McCargar L, Courneya KS. Feasibility and preliminary efficacy of progressive resistance exercise training in lung cancer survivors. Lung Cancer 2012;75:126-32.  Back to cited text no. 33
Porter LS, Keefe FJ, Garst J, Baucom DH, McBride CM, McKee DC, et al. Caregiver-assisted coping skills training for lung cancer: Results of a randomized clinical trial. J Pain Symptom Manage 2011;41:1-3.  Back to cited text no. 34
Rodríguez Vega B, Palao A, Torres G, Hospital A, Benito G, Pérez E, et al. Combined therapy versus usual care for the treatment of depression in oncologic patients: A randomized controlled trial. Psychooncology 2011;20:943-52.  Back to cited text no. 35
Schmidt M, Eckardt R, Scholtz K, Neuner B, von Dossow-Hanfstingl V, Sehouli J, et al. Patient empowerment improved perioperative quality of care in cancer patients aged ≥65 years – A randomized controlled trial. PLoS One 2015;10:E0137824.  Back to cited text no. 36
Somers TJ, Abernethy AP, Edmond SN, Kelleher SA, Wren AA, Samsa GP, et al. A pilot study of a mobile health pain coping skills training protocol for patients with persistent cancer pain. J Pain Symptom Manage 2015;50:553-8.  Back to cited text no. 37
van den Hurk DG, Schellekens MP, Molema J, Speckens AE, van der Drift MA. Mindfulness-Based Stress Reduction for lung cancer patients and their partners: Results of a mixed methods pilot study. Palliat Med 2015;29:652-60.  Back to cited text no. 38
Wilkie D, Berry D, Cain K, Huang HY, Mekwa J, Lewis F, et al. Effects of coaching patients with lung cancer to report cancer pain. West J Nurs Res 2010;32:23-46.  Back to cited text no. 39
Yeh CH, Chien LC, Chiang YC, Ren D, Suen LK. Auricular point acupressure as an adjunct analgesic treatment for cancer patients: A feasibility study. Pain Manag Nurs 2015;16:285-93.  Back to cited text no. 40
Koller A, Miaskowski C, De Geest S, Opitz O, Spichiger E. A systematic evaluation of content, structure, and efficacy of interventions to improve patients' self-management of cancer pain. J Pain Symptom Manage 2012;44:264-84.  Back to cited text no. 41
Carlson LE, Waller A, Mitchell AJ. Screening for distress and unmet needs in patients with cancer: Review and recommendations. J Clin Oncol 2012;30:1160-77.  Back to cited text no. 42
Brocki BC, Andreasen J, Nielsen LR, Nekrasas V, Gorst-Rasmussen A, Westerdahl E. Short and long-term effects of supervised versus unsupervised exercise training on health-related quality of life and functional outcomes following lung cancer surgery – A randomized controlled trial. Lung Cancer 2014;83:102-8.  Back to cited text no. 43
Roditi D, Robinson ME. The role of psychological interventions in the management of patients with chronic pain. Psychol Res Behav Manag 2011;4:41-9.  Back to cited text no. 44
Santos Salas A, Fuentes Contreras J, Armijo-Olivo S, Saltaji H, Watanabe S, Chambers T, et al. Non-pharmacological cancer pain interventions in populations with social disparities: A systematic review and meta-analysis. Support Care Cancer 2016;24:985-1000.  Back to cited text no. 45
Simon LS, Green A. Individual patient treatment use of unapproved drugs: A new option for the seriously ill. J Pain Palliat Care Pharmacother 2010;24:19-22.  Back to cited text no. 46
Tatham B, Smith J, Cheifetz O, Gillespie J, Snowden K, Temesy J, et al. The efficacy of exercise therapy in reducing shoulder pain related to breast cancer: A systematic review. Physiother Can 2013;65:321-30.  Back to cited text no. 47
Calenda E. Massage therapy for cancer pain. Curr Pain Headache Rep 2006;10:270-4.  Back to cited text no. 48
Hughes D, Ladas E, Rooney D, Kelly K. Massage therapy as a supportive care intervention for children with cancer. Oncol Nurs Forum 2008;35:431-42.  Back to cited text no. 49
Wang HL, Keck JF. Foot and hand massage as an intervention for postoperative pain. Pain Manag Nurs 2004;5:59-65.  Back to cited text no. 50
Sagar SM, Dryden T, Wong RK. Massage therapy for cancer patients: A reciprocal relationship between body and mind. Curr Oncol 2007;14:45-56.  Back to cited text no. 51
Kumar SP. Cancer Pain: A critical review of mechanism-based classification and physical therapy management in palliative care. Indian J Palliat Care 2011;17:116-26.  Back to cited text no. 52
Te Boveldt N, Vernooij-Dassen M, Leppink I, Samwel H, Vissers K, Engels Y. Patient empowerment in cancer pain management: An integrative literature review. Psychooncology 2014;23:1203-11.  Back to cited text no. 53
McCorkle R, Ercolano E, Lazenby M, Schulman-Green D, Schilling LS, Lorig K, et al. Self-management: Enabling and empowering patients living with cancer as a chronic illness. CA Cancer J Clin 2011;61:50-62.  Back to cited text no. 54
Thomas EM, Weiss SM. Nonpharmacological interventions with chronic cancer pain in adults. Cancer Control 2000;7:157-64.  Back to cited text no. 55
Zaza C, Sellick SM, Hillier LM. Coping with cancer: What do patients do? J Psychosoc Onco 2005;23:55-73.  Back to cited text no. 56
Dobos G, Overhamm T, Büssing A, Ostermann T, Langhorst J, Kümmel S, et al. Integrating mindfulness in supportive cancer care: A cohort study on a mindfulness-based day care clinic for cancer survivors. Support Care Cancer 2015;23:2945-55.  Back to cited text no. 57
Ledesma D, Kumano H. Mindfulness-based stress reduction and cancer: A meta-analysis. Psycho-oncology 2009;18:571-9.  Back to cited text no. 58
Hochstenbach LM, Zwakhalen SM, Courtens AM, van Kleef M, de Witte LP. Feasibility of a mobile and web-based intervention to support self-management in outpatients with cancer pain. Eur J Oncol Nurs 2016;23:97-105.  Back to cited text no. 59


  [Figure 1]

  [Table 1]


Print this article  Email this article
Online since 1st October '05
Published by Wolters Kluwer - Medknow