What Does CATS Have to Do With Cancer? The Cognitive Activation Theory of Stress (CATS) Forms the SURGE Model of Chronic Post-surgical Pain in Women With Breast Cancer.
Open accessAbstract
Chronic post-surgical pain (CPSP) represents a highly prevalent and significant clinical problem. Both major and minor surgeries entail risks of developing CPSP, and cancer-related surgery is no exception. As an example, more than 40% of women undergoing breast cancer surgery struggle with CPSP years after surgery. While we do not fully understand the pathophysiology of CPSP, we know it is multifaceted with biological, social, and psychological factors contributing. The aim of this review is to advocate for the role of response outcome expectancies in the development of CPSP following breast cancer surgery. We propose the Cognitive Activation Theory of Stress (CATS) as an applicable theoretical framework detailing the potential role of cortisol regulation, inflammation, and inflammatory-induced sickness behavior in CPSP. Drawing on learning theory and activation theory, CATS offers psychobiological explanations for the relationship between stress and health, where acquired expectancies are crucial in determining the stress response and health outcomes. Based on existing knowledge about risk factors for CPSP, and in line with the CATS position, we propose the SURGEry outcome expectancy (SURGE) model of CPSP. According to SURGE, expectancies impact stress physiology, inflammation, and fear-based learning influencing the development and persistence of CPSP. SURGE further proposes that generalized response outcome expectancies drive adaptive or maladaptive stress responses in the time around surgery, where coping dampens the stress response, while helplessness and hopelessness sustains it. A sustained stress response may contribute to central sensitization, alterations in functional brain networks and excessive fear-based learning. This sets the stage for a prolonged state of inflammatory-induced sickness behavior - potentially driving and maintaining CPSP. Finally, as psychological factors are modifiable, robust and potent predictors of CPSP, we suggest hypnosis as an effective intervention strategy targeting response outcome expectancies. We here argue that presurgical clinical hypnosis has the potential of preventing CPSP in women with breast cancer.
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Negative response outcome expectancies sustain activation of the physiological stress response and increase risk of CPSP through pathophysiological mechanisms such as central sensitization, cortisol dysfunction, impairment of corticolimbic connectivity and inflammatory induced sickness behavior.
“Negative response outcome expectancies sustain the activation of the physiological stress response and increase the risk of CPSP through pathophysiological mechanisms such as central sensitization, cortisol dysfunction, impairment of corticolimbic connectivity and inflammatory induced sickness behavior.”
From Pre- and post-operative psychological interventions to prevent pain and fatigue after breast cancer surgery (PREVENT): Protocol for a randomized controlled trial (2022) · cites this paper as [19]
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Experimental — accuracy not yet measuredThe SURGE model proposes that pain and stress in response to surgery are appraised through learned patterns of responses and response outcome expectancies.
“The SURGE proposes that pain and stress in response to surgery are appraised through learned patterns of responses and what these responses will accomplish, response outcome expectancies.”
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Vedvarende smerter efter kræftbehandling
Johannsen, M., Jensen, A. B., Jespersen, T. W., & Zachariae, B. (2020) · Cited by 1 · see citing works
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Brief Outpatient Rehabilitation Program for Post–COVID-19 Condition
Nerli, T. F., Selvakumar, J. P., Cvejic, E., Heier, I., Pedersen, M., Johnsen, T. L., & Wyller, V. B. (2024) · JAMA Network Open · doi:10.1001/jamanetworkopen.2024.50744 · Cited by 42 · see citing works
Reme, S. E., Munk, A., Holter, M. T. S., Falk, R. S., & Jacobsen, H. B. (2022) · PLoS ONE · doi:10.1371/journal.pone.0268606 · Cited by 21 · see citing works
“It is thus assumed that the distinct pathophysiology reflects both peripheral and central sensitization as well as humoral factors contributing to pain [19], and CPSP is now grounded in the bio-psycho-social model, where psychological and social factors contribute to biological factors in the development of chronic pa…”
Self-citationRosenberger, D. C., Segelcke, D., & Pogatzki-Zahn, E. M. (2023) · Current Opinion in Supportive and Palliative Care · doi:10.1097/spc.0000000000000673 · Cited by 12 · see citing works
Can perioperative psychological interventions reduce chronic pain after surgery?
Peters, M. L. (2023) · British Journal of Hospital Medicine · doi:10.12968/hmed.2022.0400 · Cited by 8 · see citing works
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Munk, A., Jacobsen, H. B., Schnur, J. B., Montgomery, G. H., & Rème, S. E. (2023) · PAIN Reports · doi:10.1097/pr9.0000000000001058 · Cited by 9 · see citing works
Self-citationMunk, A., Jacobsen, H. B., & Rème, S. E. (2022) · European Journal of Pain · doi:10.1002/ejp.1979 · Cited by 6 · see citing works
Self-citationEide, L. S., Rike, P.-O., Rème, S. E., Snekkevik, H., Rössner, S., Rosén, G., Lindeløv, J. K., & Løvstad, M. (2024) · Trials · doi:10.1186/s13063-023-07867-z · Cited by 2 · see citing works
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Self-citationSchjödt, B., Agdal, M. L., & Vika, M. E. (2022) · Textbooks in contemporary dentistry · doi:10.1007/978-3-031-04248-5_3 · Cited by 1 · see citing works
Sallam, M., Al-Mahzoum, K., Alenezi, M. A., Alsaeed, M., Alsaeed, F., Albayati, N., Alkhaldi, S., Obeidat, R. J., & Barakat, M. M. (2024) · COVID · doi:10.3390/covid4090102 · Cited by 1 · see citing works
Research Progress on the Effect of Body Mass Index on Perioperative Pain
吴, 锦. (2024) · Advances in Clinical Medicine · doi:10.12677/acm.2024.14112877
Rème, S. E., Munk, A., Montgomery, G. H., Schnur, J. B., Falk, R. S., Smits, M., & Jacobsen, H. B. (2025) · Anesthesiology · doi:10.1097/aln.0000000000005821
Self-citationEide, L. S., Rike, P.-O., Reme, S. E., Snekkevik, H., Rössner, S., Rosén, G., Lindeløv, J. K., & Løvstad, M. (2024) · Figshare · doi:10.6084/m9.figshare.24934183
Self-citationKenner, F., Abshire, L., & Davin, S. A. (2026) · Springer eBooks · doi:10.1007/978-3-032-11484-6_22
Jacobsen, H. B., & Rème, S. E. (2026) · Frontiers in Psychology · doi:10.3389/fpsyg.2026.1881081
Self-citation
- Authors
- Munk, A., Reme, S. E., & Jacobsen, H. B.
- Affiliations
- University of Oslo (NO)
- Oslo University Hospital (NO)
- Corresponding author
- Jacobsen, Henrik Børsting
- Venue
- Frontiers in Psychology
- Publisher
- Frontiers Media SA
- Published
- 2021-03-23
- Volume
- 12
- Pages
- 630422-630422
- ISSN
- 1664-1078 (ISSN-L)
- PMC
- PMC8023326
- OpenAlex
- W3139430252
- Cited by
- 16
- References
- 153
- Citations by year
- 2026: 2 · 2025: 3 · 2024: 5 · 2023: 3 · 2022: 3
- FWCI
- 0.49
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- Frontiers in Psychology (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- University of Oslo eBooks (submittedVersion, other-oa)
- NORA - Norwegian Open Research Archives (submittedVersion, other-oa)
- Funders
- Norwegian Cancer Society
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Cancer, Stress, Anesthesia, and Immune Response
- Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
- Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Treatment
- Keywords
- chronic postoperative pain, breast cancer surgery, cognitive activation theory of stress, cortisol regulation, inflammation, sickness behavior, central sensitization, coping, helplessness, hypnosis, psychobiological stress response
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