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Refereed/Peer-reviewed Purpose: Here, we describe the development and pilot study of a personalized eHealth intervention containing a pain science education program and self-management support strategies regarding pain and pain-related functioning in female survivors of breast cancer. First, we aimed to evaluate the eHealth intervention’s acceptability, comprehensibility, and satisfaction; second, we aimed to assess its preliminary efficacy. Methods: A mixed-method study design was used. Breast cancer survivors with persistent pain were recruited. After 6 weeks of engagement with the eHealth intervention, acceptability, comprehensibility, and satisfaction were measured quantitatively with a self-constructed questionnaire and described qualitatively using focus groups. A joint display was used to present the meta-interferences between data. Efficacy was assessed via mixed effects models with repeated measures (outcomes assessed at baseline, 6 weeks, and 12 weeks). Results: Twenty-nine women with persistent pain after breast cancer surgery participated. Overall, the eHealth program was well received and experienced as easy to use and helpful. The eHealth intervention seems useful as an adjunct to comprehensive cancer aftercare. Efficacy estimates suggested a significant improvement in pain-related functioning, physical functioning, and quality of life. Conclusion: A personalized eHealth intervention appears valuable for persistent pain management after breast cancer surgery. A large controlled clinical trial to determine effectiveness, and a full process evaluation, seems warranted.

This paper discusses the growing problem of persisting pain after successful treatment of breast cancer and presents recommendations for improving pain-related outcomes for this group. We discuss the dominant treatment approach for persisting pain post-breast cancer treatment and draw contrasts with contemporary treatment approaches to persistent pain in non-cancer-related populations. We discuss modern application of the biopsychosocial model of pain and the notion of variable sensitivity within the pain system, moment by moment and over time. We present the implications of increasing sensitivity over time for treatment selection and implementation. By drawing on transformative changes in treatment approaches to persistent non-cancer-related pain, we describe the potentially powerful role that an intervention called pain science education, which is now recommended in clinical guidelines for musculoskeletal pain, may play in improving pain and disability outcomes after successful breast cancer treatment. Finally, we present several research recommendations that centre around adaptation of the content and delivery models of contemporary pain science education, to the post-breast cancer context. ispartof: JOURNAL OF CANCER SURVIVORSHIP ispartof: location:United States status: Published online

The Belgian Cancer Registry reported 10,905 new female breast cancer patients in 2018. Although successful screening, early intervention and enhanced treatment options have improved breast cancer survival, 90% of survivors suffer lifelong sequelae, which substantially impair daily life functioning and quality of life. One of the most frequently reported side effects of breast cancer treatments is pain, possibly affecting all aspects of functioning, including physical activity, upper limb use and return to work. As a result, adequate pain management during the early stages of breast cancer treatment is essential for resolving and preventing these issues, both in the short and long term. Over the last few decades, there has been a greater understanding of the important role of educational interventions in the management of pain. However, they mainly focus on tissue injury as the source of pain and are often restricted to biomedical pain management instructions. Only recently, increased knowledge on pain mechanisms has resulted in a more modern educational approach, also known as pain science education (PSE). During the sessions, the patient is explained that pain is not always a true representation of the actual state of the tissues, but that it is the brain’s interpretation of the threat of the injury, which is influenced by a variety of psychosocial factors. By zooming out of the purely biomedical vision on pain, PSE aims for a reconceptualization from a biomedical or structural model to an actual biopsychosocial one. Patients who understand that tissue damage is not the only cause of pain, but that stress, sleep, social interactions and physical activity, among other things, can all influence the pain experience, may be more likely to engage in activities they previously avoided due to pain. This, in turn, may lead to improved functioning. The existing evidence for the potential benefits of PSE in non-cancer pain populations, along with the lack in methodologically strong studies in breast cancer patients, led us to the main research objective of this PhD research project, which was to investigate the effectiveness of PSE in improving functioning after breast cancer surgery. In conclusion, this work provides deeper insights into the follow-up of pain-related disability after breast cancer surgery, as well as the clinical application of PSE in this population and recommendations for further research. At first glance, our findings suggest that PSE does not ensure more favorable outcomes compared to biomedical pain education. However, several concerns were raised about the PSE intervention’s cookie-cutter approach, leading to the conclusion that the question should not be whether educational interventions are necessary, but rather how the delivery method, timing and other factors could be refined to achieve a change in behavior and, as a result, improved functioning. The complexity of educational interventions combined with a health care system that is entirely biomedical in nature will require years of efforts to optimize these interventions through a variety of mechanisms.

Eline Coppens, The role of childhood adversities in fibromyalgia: prevalence and relationship to stress reactivity Supervisors: prof. dr. Patrick Luyten, prof. dr. Lukas Van Oudenhove, Co-supervisor: prof. dr. Bart Morlion Dissertation submitted to obtain the degree of Ph.D. in Psychology Patients with fibromyalgia syndrome (FM) suffer from chronic widespread pain (CWP). A history of childhood adversities (ECA) has been shown to elevate the risk to develop FM. The prevalence of ECA in FM typically ranges between 16% and 60%. However, it is not clear whether the prevalence of ECA in FM is different compared to other functional somatic disorders (FSS), and whether and how ECA may play a role in the pathogenesis of these disorders. FSS has been associated with dysfunction of the stress response system. The hypothalamic-pituitary-adrenal (HPA) axis, which plays a central role in stress regulation, in particular might be influenced by psychosocial factors such as ECA, and associated insecure adult attachment strategies and impairments in embodied mentalizing. Therefore, in Chapter 1, we investigated the prevalence of different types of (ECA) and posttraumatic stress disorder (PTSD) features in female FM/CWP patients compared with patients with Functional Dyspepsia (FD), another FSS, and achalasia, a somatic disease. The second aim of this study was to investigate the relationship between ECA and pain severity as well as the possible role of PTSD symptom severity in this relationship. As expected, we found that about half of all FM/CWP patients reported at least one type of ECA. Furthermore, the odds of reporting at least one type of ECA did not differ from the odds in FD patients, but was four times higher compared to achalasia patients. However, the presence or severity of ECA was not related to pain severity. Yet, FM/CWP patients were about 6 times more likely to meet PTSD criteria compared to those with functional dyspepsia (FD) and achalasia. PTSD severity also mediated the relationship between ECA severity and pain severity, despite the lack of a direct relationship between both. In chapter 2, in the same sample of FM/CWP women, we explored possible relationships between both ECA and PTSD symptom severity on the one hand and various indices of psychosocial and physical functioning, on the other. We found that ECA was only associated with depression severity. PTSD symptom severity, by contrast, was highly significantly associated with all indices of physical and psychosocial functioning. Furthermore, relationships among PTSD severity and these indices were mediated by problems with embodied mentalizing, with problems with describing emotions being particularly important. From Chapter 3 onwards, we focused on the neurobiology of FM in relation to psychosocial features typical of these patients. We found a, blunted cortisol responsivity of FM to the Trier Social Stress Test (TSST) compared with healthy controls (HC) without ECA. FM patients had, however, higher subjective stress levels compared with HCs, particularly at baseline and during recovery from the TSST. In FM patients, ECA was not associated with cortisol or subjective stress levels, nor with responsivity to the TSST. These results reflect a dissociation between subjective and cortisol responses to stress in FM. In chapter 4 we found significantly more difficulties with identifying feelings (DIF), but not difficulties with describing feelings (DDF), in FM patients compared to HCs. We did not find any significant differences, however, in adult attachment strategies or emotion processing between FM and HC. Yet, insecure attachment was related to both the cortisol response and subjective distress in the TSST in HC, but not in FM. These latter findings may be related to the observed hypoactivity of the cortisol stress system in FM and high baseline levels of subjective distress in these patients. In conclusion, high levels of ECA in FM/CWP in combination with PTSD features, but not ECA as such, were related to pain severity. This suggests that the impact, rather than the mere presence, of ECA is of crucial importance in determining the influence of ECA on pain severity in FM/CWP. Indeed, PTSD features were associated with all physical and psychosocial functioning indices. Moreover, these relationships were mediated by problems with embodied mentalizing. Finally, we observed a "crash" of the stress system or attenuated resilience in FM compared with HC. Prospective research is needed in this context to further replicate these findings. status: published