Topical Review

Pain in Survivors of Pediatric Cancer: Applying a Prevention Framework

Amanda L. Stone, PHD; Cynthia W. Karlson, PHD; Lauren C. Heathcote, DPhil; Abby R. Rosenberg, MD, MS; Tonya M. Palermo, PHD


J Pediatr Psychol. 2018;43(3):237-242. 

In This Article

Abstract and Introduction


Objective To apply a biopsychosocial framework to understand factors influencing pain in survivors of pediatric cancer to inform pain prevention efforts and highlight the need for interdisciplinary care.

Method This topical review draws from both pediatric cancer survivorship research and chronic noncancer pain research to illustrate how components of a preventative model can be applied to pain in survivorship.

Results Pain is a common experience among long-term survivors of pediatric cancer. The pain experience in survivorship can be conceptualized in terms of biological disease and treatment factors, cognitive and affective factors, and social and contextual factors. We review literature pertinent to each of these biopsychosocial factors and tailor an existing public health prevention framework for pain in survivors of pediatric cancer.

Conclusions Classifying survivors of pediatric cancer into pain risk categories based on their daily experiences of pain, pain-related functional impairment, and distress could help guide the implementation of pain-related prevention and intervention strategies in this population. Future research is needed to establish the efficacy of screening measures to identify patients in need of psychosocial pain and pain-related fear management services, and interdisciplinary pediatric chronic pain management programs in survivors of pediatric cancer.


With continuing improvements in pediatric cancer treatment, increasing numbers of children are surviving cancer each year. In fact, 80% of children diagnosed with cancer survive >5–10 years (Phillips et al., 2015). Pain is a common experience among long-term survivors of pediatric cancer. Studies demonstrate up to 58.7% of survivors report pain and are four times more likely to experience pain compared with their siblings (Huang et al., 2013; Lu et al., 2011). Pain experienced by survivors can be acute (i.e., short-lasting pain occurring from a medical procedure or acute illness), episodic (i.e., recurrent experiences of pain separated by pain-free periods), or chronic (i.e., pain daily or almost every day for at least 3 months). One third to one half of survivors of pediatric cancer report experiencing at least mild pain-related impairment, and pain has been associated with elevated suicidal ideation and distress (Alessi et al., 2007; Recklitis et al., 2010). In addition to the emotional distress that can occur in response to a painful experience, pain symptoms may be additionally distressing for survivors because they raise concerns of recurrent disease or serious treatment-related medical complications (Zebrack et al., 2002). Although some survivors will experience pain, given the nature of their disease and treatment course, prevention efforts targeting pain-related distress and impairment in this population could improve overall quality of life.

This topical review aims to apply a biopsychosocial framework to first understand factors influencing pain in survivors of pediatric cancer. We then apply a public health prevention model (Kazak, 2006) to demonstrate how assessment and interdisciplinary intervention could be aimed at preventing and reducing pain, functional impairment, and pain-related distress within the broader context of interdisciplinary survivorship care to address physical late effects, psychological, social, and educational needs. Owing to Because of the limited empirical attention directed at episodic and chronic pain in survivors of pediatric cancer, we also draw on chronic noncancer pain research to illustrate components of a pain prevention model.