Quality of Life Research

, Volume 22, Issue 6, pp 1273–1280 | Cite as

Pain and other symptoms and their relationship to quality of life in cancer patients on opioids

  • Sigridur ZoëgaEmail author
  • Nanna Fridriksdottir
  • Valgerdur Sigurdardottir
  • Sigridur Gunnarsdottir



The purpose of this study was to assess pain, other symptoms and QOL, and the relationship between these variables, among cancer patients on strong opioids.


The study was cross-sectional, descriptive, and correlational. A convenience sample of 150 cancer patients, ≥18 years, all on strong opioids for ≥3 days was recruited.


The mean (SD) age was 64.7 (12.7) years, and 59 % were women. Mean (SD) time from cancer diagnosis was 36.3 (55.1) months. The median number of symptoms was 9, range 1–16 and the mean (SD) severity was 1.9 (0.5) on a 1–4 scale. Pain was one of the most prevalent (90 %) and severe symptoms with a mean (SD) of 2.56 (0.9). Number of symptoms explained 25.8 % of the variance in QOL, adjusted for age and sex. Another model, also adjusted for age and sex, showed that pain, fatigue, insomnia and depression, explained 33.6 % of the variance in QOL.


The symptomatology in this study was similar to studies on patients with advanced cancer. QOL was associated with the number of symptoms patients experience and individual symptoms, notably fatigue and pain. Despite the use of strong opioids, pain was both common and severe, suggesting under-treatment. Pain and other symptoms need to be assessed and managed in order to improve patients’ QOL. Special attention needs to be paid to multisymptom management in patients on opioids.


Cancer Pain Symptoms Quality of life Opioids EORTC QLQ-C30 



We owe our gratitude to Gudbjorg Jona Gudlaugsdottir, research nurse, for her impressive work during data collection. The study received grants from the following institutions/funds: 1. The Icelandic Research Fund for Graduate Students. 2. University of Iceland Research Fund. 3. Landspitali University Hospital Research Fund. 4. The Icelandic Nurses Association Research Fund. 5. The Icelandic Cancer Society Research Fund. 6. Bergþóra Magnúsdóttir and Jakob J. Bjarnason Memorial Fund. 7. The Memorial Fund of the Palliative Unit at the Landspitali University Hospital. 8. The Scientific Fund of the Oncology Unit of the Landspitali University Hospital.

Conflict of interest

The authors declare that they have nothing to disclose. The study sponsors had no role in the study design, data collection, or in the writing or decision to submit the manuscript for publication.


  1. 1.
    Icelandic Cancer Registry. (2012). Cancer in Iceland. Accessed 15 Dec 2011.
  2. 2.
    Statistics Iceland. (2009). Deaths by main categories of the European shortlist by sex 1986–2008. Reykjavík: Statistical Iceland.Google Scholar
  3. 3.
    Chang, V. T., Hwang, S. S., Feuerman, M., & Kasimis, B. S. (2000). Symptom and quality of life survey of medical oncology patients at a veterans affairs medical center: A role for symptom assessment. Cancer, 88(5), 1175–1183.PubMedCrossRefGoogle Scholar
  4. 4.
    Portenoy, R. K., Thaler, H. T., Kornblith, A. B., Lepore, J. M., Friedlander-Klar, H., Coyle, N., et al. (1994). Symptom prevalence, characteristics and distress in a cancer population. Quality of Life Research, 3(3), 183–189.PubMedCrossRefGoogle Scholar
  5. 5.
    Teunissen, S. C., Wesker, W., Kruitwagen, C., de Haes, H. C., Voest, E. E., & de Graeff, A. (2007). Symptom prevalence in patients with incurable cancer: A systematic review. Journal of Pain and Symptom Management, 34(1), 94–104.PubMedCrossRefGoogle Scholar
  6. 6.
    Saevarsdottir, T., Fridriksdottir, N., & Gunnarsdottir, S. (2010). Quality of life and symptoms of anxiety and depression of Icelandic patients receiving cancer chemotherapy at two time points. Cancer Nursing, 33(1), E1–E10.PubMedCrossRefGoogle Scholar
  7. 7.
    Holtan, A., Aass, N., Nordoy, T., Haugen, D. F., Kaasa, S., Mohr, W., et al. (2007). Prevalence of pain in hospitalised cancer patients in Norway: A national survey. Palliative Medicine, 21(1), 7–13.PubMedCrossRefGoogle Scholar
  8. 8.
    van den Beuken-van Everdingen, M. H., de Rijke, J. M., Kessels, A. G., Schouten, H. C., van Kleef, M., & Patijn, J. (2007). Prevalence of pain in patients with cancer: A systematic review of the past 40 years. Annals of Oncology, 18(9), 1437–1449.PubMedCrossRefGoogle Scholar
  9. 9.
    Wells, N., Murphy, B., Wujcik, D., & Johnson, R. (2003). Pain-related distress and interference with daily life of ambulatory patients with cancer with pain. Oncology Nursing Forum, 30(6), 977–986.PubMedCrossRefGoogle Scholar
  10. 10.
    Mercadante, S., & Fulfaro, F. (2005). World Health Organization guidelines for cancer pain: A reappraisal. Annals of Oncology, 16(Suppl 4), 132–135.Google Scholar
  11. 11.
    World Health Organization. (1996). Cancer pain relief: With a guide to opioid availability. Geneva: World Health Organization.Google Scholar
  12. 12.
    Grond, S., Zech, D., Diefenbach, C., & Bischoff, A. (1994). Prevalence and pattern of symptoms in patients with cancer pain: A prospective evaluation of 1635 cancer patients referred to a pain clinic. Journal of Pain and Symptom Management, 9(6), 372–382.PubMedCrossRefGoogle Scholar
  13. 13.
    Lidstone, V., Butters, E., Seed, P. T., Sinnott, C., Beynon, T., & Richards, M. (2003). Symptoms and concerns amongst cancer outpatients: Identifying the need for specialist palliative care. Palliative Medicine, 17(7), 588–595.PubMedCrossRefGoogle Scholar
  14. 14.
    Walsh, D., Donnelly, S., & Rybicki, L. (2000). The symptoms of advanced cancer: Relationship to age, gender, and performance status in 1,000 patients. Supportive Care in Cancer, 8(3), 175–179.PubMedCrossRefGoogle Scholar
  15. 15.
    Meuser, T., Pietruck, C., Radbruch, L., Stute, P., Lehmann, K. A., & Grond, S. (2001). Symptoms during cancer pain treatment following WHO-guidelines: A longitudinal follow-up study of symptom prevalence, severity and etiology. Pain, 93(3), 247–257.PubMedCrossRefGoogle Scholar
  16. 16.
    Esther Kim, J. E., Dodd, M. J., Aouizerat, B. E., Jahan, T., & Miaskowski, C. (2009). A review of the prevalence and impact of multiple symptoms in oncology patients. Journal of Pain and Symptom Management, 37(4), 715–736.PubMedCrossRefGoogle Scholar
  17. 17.
    Hoekstra, J., de Vos, R., van Duijn, N. P., Schade, E., & Bindels, P. J. (2006). Using the symptom monitor in a randomized controlled trial: The effect on symptom prevalence and severity. Journal of Pain and Symptom Management, 31(1), 22–30.PubMedCrossRefGoogle Scholar
  18. 18.
    Ferrans, C. E. (2005). Quality of life as an outcome of cancer care. In C. H. Yarbro, M. H. Frogge, & M. Goodman (Eds.), Cancer nursing principles and practice (pp. 183–200). Massachusetts: Jones and Bartlett Publishers.Google Scholar
  19. 19.
    Ferrans, C. E., Zerwic, J. J., Wilbur, J. E., & Larson, J. L. (2005). Conceptual model of health-related quality of life. Journal of Nursing Scholarship, 37(4), 336–342.PubMedCrossRefGoogle Scholar
  20. 20.
    Hjermstad, M. J., Fayers, P. M., Bjordal, K., & Kaasa, S. (1998). Health-related quality of life in the general Norwegian population assessed by the European Organization for Research and Treatment of Cancer Core Quality-of-Life Questionnaire: The QLQ = C30 (+3). Journal of Clinical Oncology, 16(3), 1188–1196.PubMedGoogle Scholar
  21. 21.
    Parker, P. A., Baile, W. F., de Moor, C., & Cohen, L. (2003). Psychosocial and demographic predictors of quality of life in a large sample of cancer patients. Psycho-Oncology, 12(2), 183–193.PubMedCrossRefGoogle Scholar
  22. 22.
    Miaskowski, C., Cooper, B. A., Paul, S. M., Dodd, M., Lee, K., Aouizerat, B. E., et al. (2006). Subgroups of patients with cancer with different symptom experiences and quality-of-life outcomes: A cluster analysis. Oncology Nursing Forum, 33(5), E79–E89.PubMedCrossRefGoogle Scholar
  23. 23.
    McMillan, S. C., & Small, B. J. (2002). Symptom distress and quality of life in patients with cancer newly admitted to hospice home care. Oncology Nursing Forum, 29(10), 1421–1428.PubMedCrossRefGoogle Scholar
  24. 24.
    Skevington, S. M. (1998). Investigating the relationship between pain and discomfort and quality of life, using the WHOQOL. Pain, 76(3), 395–406.PubMedCrossRefGoogle Scholar
  25. 25.
    Redeker, N. S., Lev, E. L., & Ruggiero, J. (2000). Insomnia, fatigue, anxiety, depression, and quality of life of cancer patients undergoing chemotherapy. Scholarly Inquiry for Nursing Practice, 14(4), 275–290.PubMedGoogle Scholar
  26. 26.
    Honea, N., Brant, J., & Beck, S. L. (2007). Treatment-related symptom clusters. Seminars in Oncology Nursing, 23(2), 142–151.PubMedCrossRefGoogle Scholar
  27. 27.
    Laugsand, E. A., Sprangers, M. A., Bjordal, K., Skorpen, F., Kaasa, S., & Klepstad, P. (2010). Health care providers underestimate symptom intensities of cancer patients: A multicenter European study. Health and Quality of Life Outcomes, 8, 104.PubMedCrossRefGoogle Scholar
  28. 28.
    Aaronson, N. K., Ahmedzai, S., Bergman, B., Bullinger, M., Cull, A., Duez, N. J., et al. (1993). The European Organization for Research and Treatment of Cancer QLQ-C30: A quality-of-life instrument for use in international clinical trials in oncology. Journal of the National Cancer Institute, 85(5), 365–376.PubMedCrossRefGoogle Scholar
  29. 29.
    Fayers, P. M., Aaronson, N. K., Bjordal, K., Groenvold, M., Curran, D., & Bottomley, A. (2001). The EORTC QLQ-C30 scoring manual. Brussels: European Organisation for Research and Treatment of Cancer.Google Scholar
  30. 30.
    Stromgren, A. S., Groenvold, M., Pedersen, L., Olsen, A. K., & Sjogren, P. (2002). Symptomatology of cancer patients in palliative care: Content validation of self-assessment questionnaires against medical records. European Journal of Cancer, 38(6), 788–794.PubMedCrossRefGoogle Scholar
  31. 31.
    Field, A. P. (2005). Discovering statistics using SPSS: (and sex, drugs and rock ‘n’ roll). London: Thousand Oaks.Google Scholar
  32. 32.
    Wang, X. S., Laudico, A. V., Guo, H., Mendoza, T. R., Matsuda, M. L., Yosuico, V. D., et al. (2006). Filipino version of the M. D. Anderson symptom inventory: Validation and multisymptom measurement in cancer patients. Journal of Pain and Symptom Management, 31(6), 542–552.PubMedCrossRefGoogle Scholar
  33. 33.
    Wang, Y., Shen, J., & Xu, Y. (2011). Symptoms and quality of life of advanced cancer patients at home: A cross-sectional study in Shanghai, China. Supportive Care in Cancer, 19(6), 789–797.PubMedCrossRefGoogle Scholar
  34. 34.
    Kurita, G. P., Lundorff, L., Pimenta, C. A., & Sjogren, P. (2009). The cognitive effects of opioids in cancer: A systematic review. Supportive Care in Cancer, 17(1), 11–21.PubMedCrossRefGoogle Scholar
  35. 35.
    Mercadante, S., Porzio, G., Ferrera, P., Fulfaro, F., Aielli, F., Ficorella, C., et al. (2006). Low morphine doses in opioid-naive cancer patients with pain. Journal of Pain and Symptom Management, 31(3), 242–247.PubMedCrossRefGoogle Scholar
  36. 36.
    Morita, T., Tsunoda, J., Inoue, S., & Chihara, S. (1999). Contributing factors to physical symptoms in terminally-ill cancer patients. Journal of Pain and Symptom Management, 18(5), 338–346.PubMedCrossRefGoogle Scholar
  37. 37.
    Klepstad, P., Borchgrevink, P. C., & Kaasa, S. (2000). Effects on cancer patients’ health-related quality of life after the start of morphine therapy. Journal of Pain and Symptom Management, 20(1), 19–26.PubMedCrossRefGoogle Scholar
  38. 38.
    Park, K. U. (2008). Assessment of change of quality of life in terminally ill patients under cancer pain management using the EORTC Core Quality of Life Questionnaire (QLQ-C30) in a Korean sample. Oncology, 74(Suppl 1), 7–12.PubMedCrossRefGoogle Scholar
  39. 39.
    Elmqvist, M. A., Jordhoy, M. S., Bjordal, K., Kaasa, S., & Jannert, M. (2009). Health-related quality of life during the last three months of life in patients with advanced cancer. Supportive Care in Cancer, 17(2), 191–198.PubMedCrossRefGoogle Scholar
  40. 40.
    Fredheim, O. M., Kaasa, S., Fayers, P., Saltnes, T., Jordhoy, M., & Borchgrevink, P. C. (2008). Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients. Acta Anaesthesiologica Scandinavica, 52(1), 143–148.PubMedCrossRefGoogle Scholar
  41. 41.
    Tavoli, A., Montazeri, A., Roshan, R., Tavoli, Z., & Melyani, M. (2008). Depression and quality of life in cancer patients with and without pain: The role of pain beliefs. BMC Cancer, 8, 177.PubMedCrossRefGoogle Scholar
  42. 42.
    Gunnarsdottir, S., Donovan, H. S., & Ward, S. (2003). Interventions to overcome clinician- and patient-related barriers to pain management. The Nursing Clinics of North America, 38(3), 419–434.PubMedCrossRefGoogle Scholar
  43. 43.
    Berry, P. H., & Dahl, J. L. (2000). The new JCAHO pain standards: Implications for pain management nurses. Pain Management Nursing, 1(1), 3–12.PubMedCrossRefGoogle Scholar
  44. 44.
    Klepstad, P., Fladvad, T., Skorpen, F., Bjordal, K., Caraceni, A., Dale, O., et al. (2011). The influence from genetic variability on opioid use for cancer pain. An European study of 2294 cancer pain patients. Pain, 152(2), 1139–1145.PubMedCrossRefGoogle Scholar
  45. 45.
    EUROCARE. (2011). The EUROCARE-4 database on cancer survival in Europe. Accessed 9 June 2011.

Copyright information

© Springer Science+Business Media B.V. 2012

Authors and Affiliations

  • Sigridur Zoëga
    • 1
    Email author
  • Nanna Fridriksdottir
    • 1
    • 2
  • Valgerdur Sigurdardottir
    • 1
  • Sigridur Gunnarsdottir
    • 1
    • 2
  1. 1.Landspítali, The National University Hospital of IcelandReykjavikIceland
  2. 2.University of IcelandReykjavikIceland

Personalised recommendations