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Pain or fatigue: which correlates more with suffering in hospitalized cancer patients?

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Abstract

Background

The association of pain and suffering seems intuitive, but evidence substantiating this association is lacking. In studies of cancer patients, fatigue, rather than pain, is the most prevalent and debilitating symptom. This study aimed to compare the correlation of pain and fatigue to suffering, and identify other potential sources of suffering in cancer patients treated in a palliative care unit.

Methods

One hundred fifty cancer patients were surveyed. Fifteen variables were measured on a 0- to 10-point scale: suffering, pain, level of acceptable pain, effect of pain on quality of life, fatigue, level of acceptable fatigue, effect of fatigue on quality of life, and specific types of suffering. Univariable associations with suffering were made with Pearson correlation (continuous variables) or t test (binary predictors). Multivariable associations with suffering were assessed with linear regression analysis and bootstrapping.

Results

In multivariable analysis, highest pain (parameter estimate 0.38) had a greater impact on suffering than highest fatigue (parameter estimate 0.21). When other variables were assessed, 38% of the variability in suffering was accounted for by pain “now”, fatigue in the past 24 hours, and age.

Conclusion

The most important predictors of greater suffering in hospitalized cancer patients are pain, younger age, and fatigue. Despite their significant effect on suffering, other underlying contributors to suffering have yet to be identified. Designing interventions to reduce fatigue, in addition to pain management, may help in alleviating overall suffering.

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References

  1. Miaskowski C, Barsevick A, Berger A et al (2017) Advancing symptom science through symptom cluster research: expert panel proceedings and recommendations. J Natl Cancer Inst 24:109

    Google Scholar 

  2. Cleeland CS, Bennett GJ, Dantzer R, Dougherty PM, Dunn AJ, Meyers CA, Miller AH, Payne R, Reuben JM, Wang XS, Lee BN (2003) Are the symptoms of cancer and cancer treatment due to a shared biologic mechanism? A cytokine-immunologic model of cancer symptoms. Cancer 97:2919–2925

    Article  PubMed  Google Scholar 

  3. Kelley KW, Bluthe RM, Dantzer R et al (2003) Cytokine-induced sickness behavior. Brain Behav Immun 17(Suppl 1):S112–S118

    Article  CAS  PubMed  Google Scholar 

  4. Seruga B, Zhang H, Bernstein LJ, Tannock IF (2008) Cytokines and their relationship to the symptoms and outcome of cancer. Nat Rev Cancer 8:887–899

    Article  CAS  PubMed  Google Scholar 

  5. Kwekkeboom KL, Tostrud L, Costanzo E, Coe CL, Serlin RC, Ward SE, Zhang Y (2018) The role of inflammation in the pain, fatigue, and sleep disturbance symptom cluster in advanced cancer. J Pain Symptom Manage 55:1286–1295

    Article  PubMed  PubMed Central  Google Scholar 

  6. Deshields TL, Potter P, Olsen S, Liu J (2014) The persistence of symptom burden: symptom experience and quality of life of cancer patients across one year. Support Care Cancer 22:1089–1096

    Article  PubMed  Google Scholar 

  7. Given CW, Given B, Azzouz F, Kozachik S, Stommel M (2001) Predictors of pain and fatigue in the year following diagnosis among elderly cancer patients. J Pain Symptom Manage 21:456–466

    Article  CAS  PubMed  Google Scholar 

  8. Kroenke K, Johns SA, Theobald D, Wu J, Tu W (2013) Somatic symptoms in cancer patients trajectory over 12 months and impact on functional status and disability. Support Care Cancer 21:765–773

    Article  PubMed  Google Scholar 

  9. Chapman CR, Gavrin J (1993) Suffering and its relationship to pain. J Palliat Care 9:5–13

    Article  CAS  PubMed  Google Scholar 

  10. Cassel EJ (1982) The nature of suffering and the goals of medicine. N Engl J Med 306:639–645

    Article  CAS  PubMed  Google Scholar 

  11. Cassell EJ (1983) The relief of suffering. Arch Intern Med 143:522–523

    Article  CAS  PubMed  Google Scholar 

  12. Duffee CM (2019) Pain versus suffering: a distinction currently without a difference. J Med Ethics 24;medethics-2019-105902

  13. Clark D (1999) 'Total pain’, disciplinary power and the body in the work of Cicely Saunders, 1958-1967. Soc Sci Med 49:727–736

    Article  CAS  PubMed  Google Scholar 

  14. Baines BK, Norlander L (2000) The relationship of pain and suffering in a hospice population. Am J Hosp Palliat Care 17:319–326

    Article  CAS  PubMed  Google Scholar 

  15. Kuuppelomaki M, Lauri S (1998) Cancer patients’ reported experiences of suffering. Cancer Nurs 21:364–369

    Article  CAS  PubMed  Google Scholar 

  16. Wilson KG, Chochinov HM, McPherson CJ et al (2007) Suffering with advanced cancer. J Clin Oncol 25:1691–1697

    Article  PubMed  Google Scholar 

  17. Merskey H (1994) Logic, truth and language in concepts of pain. Qual Life Res 3(Suppl 1):S69–S76

    Article  PubMed  Google Scholar 

  18. Farrar JT, Young JP Jr, LaMoreaux L, Werth JL, Poole RM (2001) Clinical importance of changes in chronic pain intensity measured on an 11-point numerical pain rating scale. Pain 94:149–158

    Article  PubMed  Google Scholar 

  19. Firdous S, Berger A, Jehangir W, et al (2020) How should we assess pain: do patients prefer a quantitative or qualitative scale? A study of patient preferences Am J Hosp Palliat Care 1049909120945599

  20. Patrick DL, Ferketich SL, Frame PS et al (2004) National Institutes of Health State-of-the-Science Conference Statement: symptom management in cancer: pain, depression, and fatigue, July 15-17, 2002. J Natl Cancer Inst Monogr 32:9–16

    Google Scholar 

  21. Mock V, Atkinson A, Barsevick A, Cella D, Cimprich B, Cleeland C, Donnelly J, Eisenberger MA, Escalante C, Hinds P, Jacobsen PB, Kaldor P, Knight SJ, Peterman A, Piper BF, Rugo H, Sabbatini P, Stahl C, National Comprehensive Cancer Network (2000) NCCN practice guidelines for cancer-related fatigue. Oncology (Williston Park) 14:151–161

    CAS  Google Scholar 

  22. Holley S (2000) Cancer-related fatigue. Suffering a different fatigue. Cancer Pract 8:87–95

    Article  CAS  PubMed  Google Scholar 

  23. Watanabe SM, Nekolaichuk C, Beaumont C, Johnson L, Myers J, Strasser F (2011) A multicenter study comparing two numerical versions of the Edmonton Symptom Assessment System in palliative care patients. J Pain Symptom Manage 41:456–468

    Article  PubMed  Google Scholar 

  24. Ruijs CD, Kerkhof AJ, van der Wal G, Onwuteaka-Philipsen BD (2013) Symptoms, unbearability and the nature of suffering in terminal cancer patients dying at home: a prospective primary care study. BMC Fam Pract 14:201

    Article  PubMed  PubMed Central  Google Scholar 

  25. Lokker ME, Offerman MP, van der Velden LA et al (2013) Symptoms of patients with incurable head and neck cancer: prevalence and impact on daily functioning. Head Neck 35:868–876

    Article  PubMed  Google Scholar 

  26. Teunissen SC, Wesker W, Kruitwagen C et al (2007) Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage 34:94–104

    Article  PubMed  Google Scholar 

  27. Radbruch L, De Lima L, Knaul F, et al (2020) Redefining palliative care--a new consensus-based definition. J Pain Symptom Manage 6;S0885-3924(20)30247-5

  28. Tavares AP, Paparelli C, Kishimoto CS et al (2017) Implementing a patient-centred outcome measure in daily routine in a specialist palliative care inpatient hospital unit: an observational study. Palliat Med 31:275–282

    Article  PubMed  Google Scholar 

  29. White KR, Stover KG, Cassel JB, Smith TJ (2006) Nonclinical outcomes of hospital-based palliative care. J Healthc Manag 51:260–273 discussion 73-74

    PubMed  Google Scholar 

  30. Good P, Stafford B (2001) Inpatient palliative medicine is evidence based. Palliat Med 15:493–498

    Article  CAS  PubMed  Google Scholar 

  31. Walsh D (2001) The Harry R. Horvitz Center for Palliative Medicine (1987-1999): development of a novel comprehensive integrated program. Am J Hosp Palliat Care 18:239–250

    Article  CAS  PubMed  Google Scholar 

  32. Lloyd-Williams M, Spiller J, Ward J (2003) Which depression screening tools should be used in palliative care? Palliat Med 17:40–43

    Article  PubMed  Google Scholar 

  33. Taylor L, Lovell N, Ward J, Wood F, Hosker C (2013) Diagnosis of depression in patients receiving specialist community palliative care: does using a single screening question identify depression otherwise diagnosed by clinical interview? J Palliat Med 16:1140–1142

    Article  PubMed  PubMed Central  Google Scholar 

  34. Frankl VE (1982) The suffering person in search of meaning. Osterr Krankenpflegez 35:10–12

    CAS  PubMed  Google Scholar 

  35. de Williams AC, Davies HT, Chadury Y (2000) Simple pain rating scales hide complex idiosyncratic meanings. Pain 85:457–463

    Article  PubMed  Google Scholar 

  36. Coulombe MA, Lawrence KS, Moulin DE, Morley-Forster P, Shokouhi M, Nielson WR, Davis KD (2017) Lower functional connectivity of the periaqueductal gray is related to negative affect and clinical manifestations of fibromyalgia. Front Neuroanat 11:47

    Article  PubMed  PubMed Central  Google Scholar 

  37. Al-Shahri MZ, Eldali AM, Al-Zahrani O (2012) Prevalence and severity of suffering among patients with advanced cancer. Support Care Cancer 20:3137–3140

    Article  PubMed  Google Scholar 

  38. Benedict S (1989) The suffering associated with lung cancer. Cancer Nurs 12:34–40

    Article  CAS  PubMed  Google Scholar 

  39. Krikorian A, Limonero JT, Roman JP, Vargas JJ, Palacio C (2014) Predictors of suffering in advanced cancer. Am J Hosp Palliat Care 31:534–542

    Article  PubMed  Google Scholar 

  40. Gravier AL, Shamieh O, Paiva CE, Perez-Cruz PE, Muckaden MA, Park M, Bruera E, Hui D (2020) Meaning in life in patients with advanced cancer: a multinational study. Support Care Cancer 28:3927–3934

    Article  PubMed  Google Scholar 

  41. Lethborg C, Aranda S, Cox S, Kissane D (2007) To what extent does meaning mediate adaptation to cancer? The relationship between physical suffering, meaning in life, and connection to others in adjustment to cancer. Palliat Support Care 5:377–388

    Article  PubMed  Google Scholar 

  42. Cheng KK, Yeung RM (2013) Impact of mood disturbance, sleep disturbance, fatigue and pain among patients receiving cancer therapy. Eur J Cancer Care (Engl) 22:70–78

    Article  CAS  Google Scholar 

  43. Bamonti PM, Moye J, Naik AD (2018) Pain is associated with continuing depression in cancer survivors. Psychol Health Med 23:1182–1195

    Article  PubMed  PubMed Central  Google Scholar 

  44. van der Vliet QM, Paulino Pereira NR, Janssen SJ et al (2017) What factors are associated with quality of life, pain interference, anxiety, and depression in patients with metastatic bone disease? Clin Orthop Relat Res 475:498–507

    Article  PubMed  Google Scholar 

  45. Ramsenthaler C, Gao W, Siegert RJ, Edmonds PM, Schey SA, Higginson IJ (2019) Symptoms and anxiety predict declining health-related quality of life in multiple myeloma: a prospective, multi-centre longitudinal study. Palliat Med 33:541–551

    Article  PubMed  Google Scholar 

  46. Charalambous A, Kouta C (2016) Cancer related fatigue and quality of life in patients with advanced prostate cancer undergoing chemotherapy. Biomed Res Int 2016:3989286

    Article  PubMed  PubMed Central  Google Scholar 

  47. Seo Y, Oh H, Seo W (2010) Causal relationships among factors associated with cancer-related fatigue. Eur J Oncol Nurs 14:380–386

    Article  PubMed  Google Scholar 

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Acknowledgements

An abstract, reporting preliminary study findings, had been presented in various formats at three meetings: (1) as an oral presentation at the Annual Assembly of the American Academy of Hospice and Palliative Medicine on March 10, 2016 in Chicago, Illinois, USA; (2) as a poster at the Annual Meeting of the Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) from June 23 to 25, 2016 in Adelaide, Australia; and (3) as a poster at the 21st International Congress on Palliative Care from October 18 to 21, 2016, in Montreal, Quebec, Canada.

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Authors and Affiliations

  1. Department of Palliative and Supportive Care, Cleveland Clinic, 9500 Euclid Ave. CA-53, Cleveland, OH, 44195, USA

    Mellar P. Davis, Renato V. Samala, Chirag Patel, Armida Parala-Metz & Ruth Lagman

  2. Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA

    Lisa A. Rybicki

Authors
  1. Mellar P. Davis
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  2. Lisa A. Rybicki
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Contributions

Mellar P. Davis, Chirag Patel, Ruth Lagman, and Armida Parala-Metz contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Mellar P. Davis, Chirag Patel, Ruth Lagman, Armida Parala-Metz, and Lisa A. Rybicki. The first draft of the manuscript was written by Mellar P. Davis, Renato V. Samala, and Lisa A. Rybicki.

Corresponding author

Correspondence to Renato V. Samala.

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Ethics approval

The study protocol was approved by Cleveland Clinic’s Institutional Review Board (IRB).

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As approved by the IRB, verbal informed consent was obtained from all individual participants included in the study.

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The authors declare no conflict of interest.

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Davis, M.P., Rybicki, L.A., Samala, R.V. et al. Pain or fatigue: which correlates more with suffering in hospitalized cancer patients?. Support Care Cancer 29, 4535–4542 (2021). https://doi.org/10.1007/s00520-021-05996-2

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  • DOI: https://doi.org/10.1007/s00520-021-05996-2

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