© 2003 U.S. Cancer Pain Relief Committee 0885-3924/03/$–see front matter Published by Elsevier. All rights reserved. PII S0885-3924(02)00542-0
Vol. 25 No. 1 January 2003 Journal of Pain and Symptom Management 29
Original Article
Effect of Cancer Pain on Performance Status,
Mood States, and Level of Hope Among
Taiwanese Cancer Patients
Chia-Chin Lin, PhD, RN, Yuen-Liang Lai, MD and Sandra E. Ward, PhD, RN School of Nursing (C.-C.L.), and School of Medicine (Y.-L.L.), Taipei Medical University; Hospice & Palliative Care Center (Y.-L.L.), McKay Memorial Hospital; Center for General Education (Y.-L.L.), National Yang-Ming University, Taipei, Taiwan; and School of Nursing (S.E.W.), University of Wisconsin-Madison, Madison, Wisconsin, USA
Abstract
The purposes of this study were: 1) to compare performance status, mood states, and level of hope between patients with cancer pain and patients without cancer pain; and 2) to determine the relationships of pain intensity and pain interference with daily life to performance status, mood states, and level of hope. A total of 233 Taiwanese cancer patients with pain and 251 without pain participated. The self report instruments consisted of the Chinese version of the Profile of Mood States (POMS) short form, the Chinese version of the Herth Hope Index, the Brief Pain Inventory-Chinese version (BPI-C), the Chinese version of the Karnorfsy
Performance Scale (KPS), and a demographic questionnaire. The major findings of this study were that cancer patients with pain reported significantly lower levels of performance status and higher levels of total mood disturbance than did cancer patients who did not experience pain after controlling for sex, disease stage, and recruitment site. In addition, patients with cancer pain experienced significantly more anger, fatigue, depression, confusion, and lethargy than did patients without pain after controlling for sex, disease stage, and recruitment site. Among patients with pain, pain intensity was significantly correlated with performance status and mood state, but not with level of hope. Pain interference with daily life was significantly correlated both with performance status, mood state, and level of hope. Pain intensity and pain interference were significantly correlated with each mood state as well as with total mood disturbance. This study has demonstrated the effect of cancer pain on patients’ physical, psychological, and spiritual life and has supported the multidimensional notion of the cancer pain experience in Taiwanese patients. J Pain Symptom Manage 2003;25:29–37. © 2003 U.S. Cancer Pain Relief Committee. Published by Elsevier. All rights reserved.
Key Words
Pain, cancer, performance status, mood states, hope
Introduction
Cancer pain has been postulated as a multi-dimensional phenomenon1–3 having a
signifi-cant impact on the overall quality of a cancer patient’s life by influencing physical, psycho-logical, and spiritual aspects.4 Pain is the end
Address reprint requests to: Chia-Chin Lin, PhD, RN, School of Nursing, Taipei Medical University, 250 Wu-Hsing Street, Taipei, 110, Taiwan.
30 Lin et al. Vol. 25 No. 1 January 2003
product of a complex process that may involve emotional, spiritual, cognitive, and sensory components.5 The concept of pain as a
multi-dimensional phenomenon has greatly influ-enced the management and assessment of can-cer pain. However, up until the last decade, very few researchers comprehensively addressed the simultaneous impact of pain on cancer pa-tients’ physical, psychological, and spiritual well-being (i.e., quality of life).6 Only recently has
the relationship between pain and quality of life dimensions been considered in the overall management of cancer pain.4 There is a
pau-city of research comprehensively exploring the effect of cancer pain on important patient out-comes,7 such as performance status, mood
states, and level of hope. Moreover, there has been no study extensively investigating the ef-fect of cancer pain in Taiwanese patients. Therefore, the purpose of this study is to inves-tigate the impact of cancer pain on perfor-mance status, mood states, and level of hope among Taiwanese patients.
Performance status is a global assessment of a patient’s ability for ambulation and self-care.8
Since the first introduction of performance sta-tus assessment,9 it has become an important
prognostic indicator and a useful measure of the effect of cancer treatments.10,11 Recently,
performance status has been applied in cancer pain research to examine the relationship of performance status to cancer symptoms,12 its
effect on neuropsychological performance,13
its predictive ability of adequate pain manage-ment,14 and its usefulness as an outcome
indi-cator of pain treatment.15
Pain causes not only physical but also psy-chological distress. Intense pain may cause pa-tients’ anxiety or worry about disease progres-sion or death to increase,16 which in turn may
increase patients’ mood disturbance. Although many studies have explored the relationship between pain and mood states, very little re-search has been done to compare the mood states between patients with cancer pain and patients without cancer pain.17
The effect of cancer pain on spiritual aspects of patients’ lives has been little explored or un-derstood. Hope is considered to be an impor-tant component of the spiritual dimension of quality of life in cancer patients with pain.18
Hope is a multidimensional dynamic life force characterized by a confident yet uncertain
ex-pectation of achieving a future good which, to the hoping person, is realistically possible and personally significant.19 Cancer pain may
cre-ate a sense of hopelessness because patients fear that their lives are not worth continuing or patients lose the meaning of living if they must live in pain.20 There has been no empirical
study exploring the effect of cancer pain on pa-tients’ levels of hope.
Therefore, the purposes of this study were as follows: 1) to compare performance status, mood states, and levels of hope between patients with cancer pain and patients without cancer pain; and 2) to determine the relationships among pain and pain interference with daily life, per-formance status, mood states, and level of hope among Taiwanese cancer patients.
Methods
Subjects and Setting
This study was conducted at the oncology units and outpatient radiotherapy clinics of two teaching hospitals in the Taipei area of Taiwan from August 1999 to July 2000. A convenience sample consisting of inpatients and outpatients with and without cancer-related pain was re-cruited. To be included in the study patients had to a) be over the age of 18, b) have been given a diagnosis of cancer, and c) be able to communicate in Mandarin or Taiwanese. In addition to these criteria, to be included in the pain group patients had to have experienced pain related to cancer in the last 24 hours (1 or more on a 0–10 scale). Pain caused by surgery or other procedures was excluded.
A total of 233 cancer patients with pain and 251 cancer patients without pain (n 484) par-ticipated in this study. Table 1 presents a demo-graphic and pain profile of study participants. Compared to patients without pain, those with pain were more likely to be male, their disease was more likely to have metastasized, and they were more likely to be recruited from inpatient units (Table 1). Cancer sites in patients with pain included colorectal (16%), lung (16%), breast (10%), nasopharyngeal (9%), liver (9%), oral (8%), cervical (8%), gastric (6%), prostate (5%), lymphoma (5%), brain (3%), and vari-ous other types (5%). Cancer sites in patients without pain included breast (26%), colorectal (18%), liver (11%), cervical (10%), lung (8%), gastric (6%), nasopharyngeal (6%), oral (4%),
Vol. 25 No. 1 January 2003 Effect of Cancer Pain on Taiwanese Cancer Patients 31
lymphoma (4%), brain (3%), and various other types (4%).
Instruments
The instruments consisted of the short form of Profile of Mood States (POMS),21 the Herth
Hope Index,22 the Brief Pain
Inventory-Chi-nese version (BPI-C),23 the Karnofsky
Perfor-mance Scale (KPS),24 and a demographic
ques-tionnaire. Before data collection, the POMS short form, the Herth Hope Index, and the KPS scale were translated into Mandarin Chi-nese using the translation and back-translation procedure and were verified by a panel of ex-perts to ensure semantics of the Taiwan version of these questionnaires.
Profile of Mood States (POMS) Short Form. The POMS short form21 was used to assess the
pa-tient’s mood states in this study. The POMS short form consists of 30 items (based on the 65-item questionnaire in the long form) and con-tains the same six scales measured by the long form. The POMS measures tension, depression, anger, fatigue, confusion, and vigor. A compos-ite score, the total mood disturbance (TMD) score,
is computed by summing each of the individual scores for tension, depression, anxiety, fatigue, and confusion, with vigor scores subtracted to indicate patients’ total mood disturbance. Each item of the POMS short form is scored on a 5-point Likert scale ranging from 0 (not at all) to 4 (extremely). The reliabilities (Cronbach’s ) ranged from 0.75–0.95 for an outpatient sample.21 The reliability (Cronbach’s ) for the
POMS subscales ranged from 0.75–0.93 for pa-tients with pain and ranged from 0.71–0.91 for patients with no pain (Table 2).
Herth Hope Index (HHI). Hope was measured by the Herth Hope Index.22 The HHI, a 12-item
adapted version of the Herth Hope Scale (HHS),25 assesses the multidimensional aspects
of hope in adults. Each item is rated from 1 (strongly disagree) to 4 (strongly agree) and to-tal scores range from 12 to 48, with a higher score reflecting greater hope. The HHI has dem-onstrated test–retest reliability, internal consis-tency, criterion-related validity, divergent valid-ity, and construct validity.22 In this study, the
alpha coefficient of the HHI was 0.77 for patients with pain and 0.75 for patients with no pain. Table 1
Mean (SD) and Number (%) of Demographic and Pain Characteristics of Cancer Patients With Pain (n 233) and Without Pain (n 251)
Characteristics Patients With Pain Patients Without Pain t or 2
Age (years) 58.06 (14.52) 58.50 (14.77) t (482) 0.32, ns Education (years) 8.28 (5.11) 8.81 (5.15) t (482) 1.15, ns Worst pain 5.20 (3.34) — — Least pain 1.03 (1.60) — — Average pain 2.43 (2.14) — — Pain now 1.54 (2.01) — —
Composite pain intensity 2.55 (1.95)
Pain interference 3.79 (2.76) — — Sex, n (%) 2 (1) 9.36, P 0.003a Male 128 (54.90) 103 (41.00) Female 105 (45.10) 148 (59.00) Marital status, n (%) 2 (1) 0.35, ns Married 187 (80.30) 196 (78.10) Other 46 (19.70) 55 (21.90) Religious affiliation 2 (3) 0.47, ns Buddhist or Taoist 176 (75.60) 183 (72.90) Christian 19 (8.00) 23 (9.20) None 36 (15.50) 43 (17.10) Other 2 (0.90) 2 (0.80) Disease stage, n (%) 2 (1) 58.99, P 0.00a Localized 44 (18.88) 132 (52.59) Metastasized 189 (81.12) 119 (47.41) Recruitment sites 2 (1) 27.63, P 0.00a Inpatient 168 (72.10) 122 (48.60) Outpatient 65 (27.90) 129 (51.40) ns not significant. aP 0.01.
32 Lin et al. Vol. 25 No. 1 January 2003
Brief Pain Inventory-Chinese Version (BPI-C). The Brief Pain Inventory-Chinese version23 was used
in this study to assess the multidimensional na-ture of pain, including intensity and subse-quent interference with life activities in the preceding 24 hours. The first part of the BPI consists of four single-item measures of pain in-tensity: worst pain, least pain, average pain, and pain now. Each item is rated from 0 (no pain) to 10 (the worst pain I can imagine). The composite of the pain intensity score (i.e., the average of worst pain, least pain, average pain, and pain now) was computed to represent pa-tients’ overall pain intensity.23 The second part
of the BPI consists of seven items that assess the extent to which pain interferes with gen-eral activity, mood, walking, working, relations with others, sleeping, and enjoyment of life. Each item is rated on a 0–10 scale. An interfer-ence score was computed, which was the aver-age of the seven items. The reliability and va-lidity of the BPI-C in a Taiwanese sample with cancer pain has been demonstrated.16 In this
study, the internal consistency for overall pain intensity and pain interference was 0.85 and 0.90, respectively.
Karnofsky Performance Scale (KPS). Patients’ per-formance status was assessed by the Karnofsky Performance Scale. The KPS is rated by a re-search assistant on a scale of 1–100, in steps of 10. The KPS assigns percentages based on per-formance as follows: normal activity, 100%; mi-nor symptoms, 90%; moderate symptoms, 80%; self-care only, 70%; needs some help, 60%; needs much help, 50%; disabled, 40%; needs special care, 30%; needs active support, 20%;
moribund, 10%; and dead, 0%. The KPS has been documented to have predictive validity.26 Demographic Questionnaire. A demographic sheet covering basic questions regarding age, sex, ed-ucation, and marital status was developed for this study.
Procedure
Approval for this study was obtained from the Human Subject Committees of the two hospitals involved. Patients who met the selection criteria were approached individually by the research as-sistant who described the study and obtained oral consent. Patients were given a questionnaire that they were asked to fill out independently, with no assistance from others. If a patient was unable to complete the questionnaire on his/her own, the research assistant read questionnaire items to each patient and recorded the answers.
Statistical Analysis
Descriptive statistics were used to describe the sample characteristics in terms of demo-graphic and disease-related variables. Chi-square or t-tests were used to examine the relationship between patient characteristics and character-istics of pain versus no pain. T-tests were em-ployed to determine if scores of performance status, mood states, and level of hope differed in response to patients’ experiences of pain. Among patients experiencing cancer-related pain, Pearson’s correlations were used to ex-plore the relationship among pain intensity, pain interference, performance status, mood states, and level of hope. All significance levels were set at 0.01.
Table 2
Peformance Status (KPS), Emotional States, and Levels of Hope for Patients With Pain (n 233) vs. No Pain (n 251)
Internal Consistency Mean (SD)
Pain No Pain Pain No Pain t value
KPS — — 71.90 (18.11) 84.29 (13.71) 8.48a
Hope 0.77 0.75 32.54 (4.19) 33.80 (3.88) 3.43a
Total mood disturbance 0.94 0.91 15.78 (20.98) 6.75 (16.49) 5.10a
Tension 0.79 0.75 3.69 (3.72) 2.94 (3.07) 2.41 Anger 0.75 0.71 3.95 (3.65) 2.65 (2.92) 4.30a Fatigue 0.91 0.90 4.82 (4.86) 2.92 (3.60) 4.87a Depression 0.93 0.89 4.70 (5.08) 3.45 (4.23) 2.95a Vigor 0.92 0.91 6.44 (3.98) 8.36 (4.14) 5.12a Confusion 0.78 0.74 5.46 (4.29) 3.88 (3.34) 4.50a aP 0.01.
Vol. 25 No. 1 January 2003 Effect of Cancer Pain on Taiwanese Cancer Patients 33
Results
Comparisons of Performance Status, Mood Disturbance, and Level of Hope Between Patients With Cancer Pain and Patients Without Cancer Pain
The performance status, level of hope, and mood disturbance scores for cancer patients with pain and without pain are presented in Ta-ble 2. Cancer patients with pain reported signif-icantly lower levels of performance status, lower levels of hope, and higher levels of total mood disturbance than did cancer patients who did not experience pain. Also, patients with cancer pain experienced significantly more anger, fa-tigue, depression, confusion, and lethargy than did patients without pain. In patients experi-encing cancer pain, the three highest mood disturbance scores were confusion, fatigue, and depression. In patients experiencing no pain, the three highest mood disturbance scores were confusion, depression, and tension.
Because patients who experienced pain ver-sus patients who experienced no pain differed significantly by sex, disease stage, and recruit-ment site, it was necessary to control for the po-tential effect these differences may have had on important outcome variables (i.e., perfor-mance status, mood disturbance, and levels of hope) by performing regression analyses. Re-sults indicated that even after controlling for the effect of sex, disease stage, and recruitment site, the patient experience of pain versus no pain was a significant predictor for perfor-mance status (B 8.98, P 0.01), total mood disturbance (B 7.43, P 0.01), anger (B 1.22, P 0.01), fatigue (B 1.51, P 0.01), vigor (B 1.33, P 0.01), and confu-sion (B 1.48, P 0.01). However, levels of
hope, tension, and depression did not differ between patients with pain and patients with-out pain after controlling for sex, disease stage, and recruitment site.
Relationships Among Pain Intensity, Pain Interference, Performance Status, Mood Disturbance, and Level of Hope for Patients With Pain
For patients with pain (n 233), pain inten-sity was significantly correlated with perfor-mance status (r 0.18, P 0.01) and mood states (r 0.26, P 0.01), but not with level of hope. Pain interference was significantly corre-lated with performance status (r 0.43, P 0.01), mood states (r 0.53, P 0.01), and level of hope (r 0.31, P0.01) (Table 3). Relationships of pain intensity and pain inter-ference to each mood state are presented in Ta-ble 3. Pain intensity and pain interference were significantly correlated with each mood state as measured by the POMS as well as significantly correlated with the total mood disturbance.
Discussion
The results of this study provide several portant implications for understanding the im-pact of cancer pain on patients’ performance status, emotional state, and level of hope. The findings of this study support the multidimen-sional notion of the cancer pain experience1
and demonstrate the effect of cancer pain on the physical, psychological, and spiritual aspects of Taiwanese patients’ quality of life. There have been very few studies that directly com-pare performance status of cancer patients without pain to those with pain,27 and the
re-Table 3
Relationship of Pain Intensity and Pain Interference to Performance Status, Each Mood State Measured by the POMS, and Level of Hope (n 223)
Variables Pain Intensity Pain Interference
Performance status 0.18a 0.43a
Total mood disturbance 0.26a 0.53a
Tension 0.18a 0.38a Anger 0.23a 0.45a Fatigue 0.28a 0.53a Depression 0.28a 0.43a Vigor 0.14a 0.42a Confusion 0.16a 0.37a Level of Hope 0.11 0.31a aP 0.01.
34 Lin et al. Vol. 25 No. 1 January 2003
sults of this study show that pain has deleteri-ous effects on Taiwanese patients’ functional status. In this study, patients with cancer pain had significantly lower performance status (KPS) scores than did patients without cancer pain. Both patients’ pain intensity and pain in-terference with daily life were negatively corlated with performance status scores. These re-sults are consistent with the findings in a study conducted in the United States by Miaskowski and Dibble,27 in which they found that in
breast cancer patients, pain-free patients had a significantly better performance scores than did patients without pain.
Researchers have emphasized that perfor-mance status of cancer patients is a very impor-tant prognosticator.28 Performance status
mea-sures have been widely used in oncology research and practice. Oncology researchers or practi-tioners have applied performance measures for the following purposes:8 1) to select
pa-tients for inclusion in treatment trials, 2) to stratify patients on the basis of performance status evaluation at the beginning of a clinical trial, 3) to measure the efficacy of treatment, and 4) to measure the quality of survival of can-cer patients. When cancan-cer pain has deleterious effects on patients’ performance status, this ef-fect may confound the treatment efficacy of a clinical trial and have an impact on the quality of survival of cancer patients. Because this study shows that cancer pain negatively affects patients’ performance status and numerous studies have documented performance status as a predictor or prognosis of survival of cancer patients,29 the question is raised as to whether
cancer pain also has a negative impact on pa-tients’ survival. Although one study shows that there is no relationship between the patients’ reporting of pain on admission and subse-quent survival time,30 more empirical research
effort is needed to explore the relationship be-tween cancer pain and patients’ survival.
Pain is not a symptom that exists in isolation. Chronic pain, especially, tends to create prob-lems, such as emotional disorder.31 This
phe-nomenon is suggested by the definition of pain as an “unpleasant sensory and emotional expe-rience associated with actual or potential tissue damage.”32 Psychological distress of cancer
pa-tients has been shown to be related to shorter survival.33,34 In contrast to the physiological
components of cancer pain, about which much
is known, there has been little prior research on other aspects of cancer pain experiences, such as psychological or spiritual distress. In this study, after controlling for sex, disease stage, and recruitment site, patients who experienced cancer-related pain reported higher levels of anger, fatigue, lethargy, confusion, and total mood disturbance than did patients who did not experience cancer-related pain. Also, levels of pain intensity and pain interference with daily life were significantly correlated with each mood state and the total mood disturbance.
In a study of 200 American cancer patients who were experiencing pain and 169 cancer patients who were pain-free, Glover et al.17
found that patients who experienced cancer pain scored significantly higher on anxiety, de-pression, anger, fatigue, confusion, and total mood disturbance, as measured by the Profile of Mood States.21 These results from the
cur-rent study conducted in Taiwan are, therefore, consistent with prior studies conducted in other countries,17,27 which may indicate that
cancer pain has a great impact on patients’ mood status and emotional distress.
It also appears that emotional state or distress could be related to survival. Recently, researchers34
demonstrated that emotional distress is signifi-cantly associated with shorter survival among lung cancer patients, independent of the influence of the biomedical prognostic factors. Moreover, a se-ries of 5-year, 10-year, and 15-year follow-up stud-ies concluded that patients’ psychological or emo-tional responses to breast cancer were significant predictors of patients’ survival.35–37 Thus, it
ap-pears that emotional state or distress could be re-lated to patients’ length of survival.
Very limited research effort has gone in to exploring the relationship between mood dis-turbance and cancer pain. In studies of pain other than cancer pain, investigators have supported the important role of unrelieved pain in emotional disturbances. Feldman and colleagues38 reported that increased pain led
to greater depressed, anxious, and angry moods in chronic pain patients. They also found that depressed mood, but not anxiety or anger, contributed to increases in pain. In one study, it was found that induced depressed mood shortened subjects’ tolerance times of labora-tory pain.39 The relation of pain to anxiety has
been explored in populations with cancer. Re-searchers have consistently concluded that
in-Vol. 25 No. 1 January 2003 Effect of Cancer Pain on Taiwanese Cancer Patients 35
creases in cancer pain are significantly related to increases in anxiety.40–42
As far as the relationship of anger to percep-tions of pain, researchers have claimed that an-ger is a critical concomitant of the chronic pain experience.43 In addition, Fernandez and Turk44
state that chronic pain patients may underre-port anger because of denial. In fact, anger is one of the most salient emotional correlates of pain, even though past research has been pri-marily confined to the study of depression and anxiety.44 This notion is further supported by a
recent study of chronic pain, in which anger to-ward oneself was significantly associated with pain intensity, and overall anger was signifi-cantly related to perceived disability.45
The relationship between cancer pain and fatigue has been sparsely explored, although pain and fatigue are two of the most common problems experienced by oncology patients.46
Pain and fatigue have several components in common47 and chronic pain is commonly
asso-ciated with fatigue.48 One study revealed that
poor sleepers reported greater pain intensity and pain unpleasantness than did good sleep-ers in a sample of chronic pain patients.49
How-ever, whether poor sleep among cancer pain patients contributes to their fatigue remains controversial. Therefore, additional research is warranted to comprehensively explore the re-lationship between cancer pain and fatigue.
For patients with progressive life-threatening diseases, pain can add greatly to the debilitat-ing effects of the disease and foster hopeless-ness and fear.31 Cancer threatens patients’
ex-istence and cancer pain may cause suffering which leads to spiritual distress for cancer pa-tients.50 Very few studies have investigated the
relationship between cancer pain and spiritual dimensions. One such study included 78 can-cer patients who were being treated for pain-related problems and found that unrelieved cancer pain has an impact on existential con-cerns.41 The study further found that patients
with higher pain scores expressed significantly more fear about the future. In this study, after controlling for gender, disease stage, and re-cruitment site, levels of hope did not differ be-tween patients with pain and patients without pain. However, pain interference with daily life, but not pain intensity, was significantly negatively correlated with level of hope. The lack of significant differences in levels of hope
between patients with cancer pain and patients without cancer pain could be due to the limita-tion of the use of hope measurement tool (i.e., HHI, which was originated in a Western coun-try) in the Taiwanese culture. For example, the majority of the participants in this study were Buddhists and Taoists. It is common for Tai-wanese patients to hope for not carrying the Karma into to the next life and hope for a bet-ter reincarnation. However, these concepts are not captured in the Herth Hope Index. There-fore, development of a hope measurement tool or modification of the current hope mea-surement tools for Taiwanese culture may be needed.
Another explanation for the significant rela-tionship between levels of hope and pain inter-ference, but not pain intensity, in this study could be related to the notion of suffering. Chapman and Gavrin31 have maintained that
unrelieved pain can not only create an over-whelming degree of personal discomfort but contribute to suffering in a more insidious way. Suffering is the perceived damage to the integ-rity of the self and represents a subjective sense of identity.51 When cancer pain occurs, it can
contribute to a disparity between who a person believes himself or herself to have been and, because of pain, who the person has actually become. This disparity is the essence of suffer-ing because it may threaten the integrity of self, not only in the present but also in the fu-ture.31 The contribution of disturbing
incon-gruity between perceived self and actual self to suffering may explain why pain interference with daily life and not pain intensity signifi-cantly negatively correlated with level of hope.
The spiritual dimension of cancer pain has been explored much less than other aspects, such as physical or psychological pain. The spir-itual dimension of cancer pain may include is-sues such as hopefulness, suffering, religiosity, uncertainty, positive changes, sense of purpose, meaning of pain, and transcendence.20
Re-search has documented that the impact of can-cer pain and the meaning of cancan-cer pain affects the spiritual dimension of cancer patients and may cause great distress.52 The findings of this
study support the notion that cancer pain inter-ference with daily life may create a sense of hopelessness, perhaps resulting from patients’ fear that their lives are not worth continuing if they must live in pain.18 Recent research41 has
36 Lin et al. Vol. 25 No. 1 January 2003
demonstrated that unrelieved cancer pain in-creases patients’ fear about the future, which contributes to existential suffering and may in turn threaten patients’ levels of hope.
The magnitudes of the correlations between pain intensity and performance status, mood state, and level of hope were quite small (from 0.1–0.3), although some were statistically signif-icant. On the other hand, the magnitudes of the correlations between pain interference with daily life and performance status, mood state, and level of hope were large (ranged from 0.3– 0.5). This finding may imply that pain interfer-ence with daily life may have more of a negative impact on performance status, mood state, and level of hope than does pain intensity among Taiwanese cancer patients. Therefore, when cli-nicians perform a cancer pain assessment, not only pain intensity but also pain interference with daily life should be carefully assessed.
In conclusion, this study has demonstrated that Taiwanese cancer patients, similar to cancer patients in Western countries, are affected in many dimensions of their lives by cancer pain. The similarity in these patient responses indi-cates that the negative impact of cancer pain is not culture specific. It is important for clinicians to make every effort to prevent cancer pain and to relieve pain effectively and promptly. Based on experiences from Western countries, pain therapy that addresses only one component of the pain experience might be destined to fail.53
Interventions that address the multidimensional aspect of pain by relieving the patient’s physical burden, psychological disturbance, and spiritual distress are more likely to lead to long-term ben-efits, not only for patients in Western countries but also for Taiwanese patients.
Acknowledgments
The authors would like to express their ut-most gratitude to Denise Dipert for her assis-tance in editing this manuscript. This study was supported by Grant NSC88-2314-B-038-106 from the National Science Council of Taiwan.
References
1. Ahles TA, Blanchard EB, Ruckdeschel JC. Multidi-mensional nature of cancer pain. Pain 1983;17:277–288. 2. Clark WC, Ferrer-Brechner T, Janal MN, et al. The dimensions of pain: a multidimensional scaling
comparison of cancer patients and healthy volun-teers. Pain 1989;37:23–32.
3. Cleeland CS, Nakamura Y, Mendoza TR, et al. Dimensions of the impact of cancer pain in a four country sample: new information from multidimen-sional scaling. Pain 1996;67:267–273.
4. Ahmedzai S. Recent clinical trials of pain con-trol: impact on quality of life. Eur J Cancer 1995;31: S2–S7.
5. Chapman CR. Psychological interventions or pain: potential mechanisms. In: Payne R, Patt RB, Hill CS, eds. Assessment and treatment of cancer pain. Progress in pain research and management, vol. 12. Seattle: IASP, 1998;109–131.
6. Ferrell BR, Wisdom C, Wenzl C. Quality of life as an outcome variable in the management of can-cer pain. Cancan-cer 1989;63(Suppl):2321–2327.
7. Miaskowski C, Zimmer EF, Barrett KM, et al. Dif-ferences in patients’ and family caregivers’ percep-tions of the pain experience influence patient and caregiver outcomes. Pain 1997;72:217–226.
8. Orr ST, Aisner J. Performance status assessment among oncology patients: a review. Cancer Treat Rep 1986;70:1423–1429.
9. Karnofsky DA, Ableman WH, Craver LF. The use of the nitrogen mustards in the palliative treat-ment of carcinoma. Cancer 1948;1:634–656. 10. Aisner J, Hansen HH, Commentary: current sta-tus of chemotherapy for non-small cell lung cancer. Cancer Treat Rep 1981;65:979–986.
11. Ganz PA, Lee JJ, Siau J. Quality of life assess-ment. An independent prognostic variable for sur-vival in lung cancer. Cancer 1991;67:3131–3135. 12. Chang VT, Hwang SS, Feuerman M, et al. Symp-tom and quality of life survey of medical oncology patients at a veterans affairs medical center: a role for symptom assessment. Cancer 2000;88:1175–1183. 13. Sjogren P, Olsen AK, Thomsen AB, Dalberg J. Neuropsychological performance in cancer pa-tients: the role of oral opoiods, pain and perfor-mance status. Pain 2000;86:237–245.
14. Larue F, Colleau SF, Brasseur L, et al. Multicen-tre study of cancer pain and its Multicen-treatment in France. BMJ 1995;310:1034–1037.
15. Brema F, Pastorino G, Martini MC, et al. Oral tramadol and buprenorphine in tumor pain. An Italian multicentre trial. Int J Clin Pharmacol Res 1996;16:109–116.
16. Lin CC. Barriers to the analgesic management of cancer pain: a comparison of attitudes of Taiwan-ese patients and their family caregivers. Pain 2000; 88:7–14.
17. Glover J, Dibble, SL, Dodd MJ, et al. Mood states of oncology outpatients: does pain make a differ-ence? J Pain Symptom Manage 1995;10:120–128. 18. Ferrell BR. The impact of pain on quality of life. Nurs Clin North Am 1995;30:609–616.
Vol. 25 No. 1 January 2003 Effect of Cancer Pain on Taiwanese Cancer Patients 37
19. Dufault K, Martocchio BC. Hope: Its spheres and dimensions. Nurs Clin North Am 1985;20:379–391. 20. Ferrell BR. The impact of pain on quality of life: a decade of research. Nurs Clin North Am 1995;30: 609–616.
21. McNair, DM, Lorr M, Droppleman LF. EdITS man-ual of the Profile of Mood States. San Diego, CA: Ed-ITS/Educational and Industrial Testing Service, 1992. 22. Herth K. Abbreviated instrument to measure hope: development and psychometric evaluation. J Adv Nurs 1992;17:1251–1259.
23. Wang XS, Mendoza TR, Gao SZ, et al. The Chi-nese version of the Brief Pain Inventory (BPI-C): its development and use in a study of cancer pain. Pain 1996;67:407–416.
24. Karnofsky D, Burchenal JH. The clinical evalua-tion of chemotherapeutic agents in cancer. In: Ma-cleod CM, ed. Evaluation of chemotherapeutic agents. New York: Columbia University Press, 1949;199–205. 25. Herth K. Development and refinement of an in-strument to measure hope. Schol Inquiry Nurs Pract 1991;5:39–51.
26. Buccheri G, Ferrigno D, Tamburini M. Karnofsky and ECOG performance status scoring in lung cancer: a prospective, longitudinal study of 536 patients from a single institution. Eur J Cancer 1996;32A:1135–1141. 27. Miaskowski C, Dibble SL. The problem of pain in outpatients with breast cancer. Oncol Nurs Fo-rum 1995;22:791–797.
28. Buccheri G, Ferrigno D. Prognostic factors in lung cancer: tables and comments. Eur Resp J 1994; 7:1350–1364.
29. Faul C, Gerszten K, Edwards R, et al. A phase I/II study of hypofractionated whole abdominal radiation therapy in patients with chemoresistant ovarian carci-noma: Karnofsky score determines treatment out-come. Int J Radiat Oncol Biol Phys 2000;47:749–754. 30. Stein WM, Miech RP. Cancer pain in the elderly hospice patient. J Pain Sympt Manag 1993;8:474–482. 31. Chapman CR, Gavrin J. Suffering: the contribu-tions of persistent pain. Lancet 1999;353:2233–2237. 32. Merskey H. Pain terms: a list with definitions and a note on usage. Recommended by the interna-tional Association for the Study of Pain (IASP) Sub-committee on Taxonomy. Pain 1979;6:249–252. 33. Gilbar O. The connection between the psycho-logical condition of breast cancer patients and sur-vival: a follow-up after eight years. Gen Hosp Psych 1996;18:266–270.
34. Faller H, Bulzebruck H, Drings P, et al. Coping, distress, and survival among patients with lung can-cer. Arch Gen Psychiatry 1999;56:756–762.
35. Greer S, Morris T, Pettingale KW. Psychological response to breast cancer: effect on outcome. Lan-cet 1979;2:785–787.
36. Pettingale KW, Morris T, Greer S. Mental atti-tudes to cancer: an additional prognostic factor. Lancet 1985;1:750.
37. Greer S, Morris T, Pettingale, KW, et al. Psycho-logical response to breast cancer and 15-year out-come. Lancet 1990;335:49–50.
38. Feldman SI, Downey G, Schaffer-Meitz R. Pain, negative mood, and perceived support in chronic pain patients: a daily diary study of people with re-flex sympathetic dystrophy syndrome. J Consult Clin Psychol 1999;67:776–785.
39. Zelman DC, Howland EW, Nichols SN, et al. The effects of induced mood on laboratory pain. Pain 1991;46:105–111.
40. Velikova G, Selby PJ, Snaith PR, et al. The rela-tionship of cancer pain to anxiety. Psychother Psy-chosom 1995;63:181–184.
41. Strang P. Existential consequences of unre-lieved cancer pain. Palliat Med 1997;11:299–305. 42. Portenoy RK, Payne D, Jacobsen P. Break-through pain: characteristics and impact in patients with cancer pain. Pain 1999;81:129–134.
43. Wade JB, Price DD, Hamer RM, et al. An emo-tional component analysis of chronic pain. Pain 1990;40:303–310.
44. Fernandez E, Turk DC. The scope and signifi-cance of anger in the experience of chronic pain. Pain 1995;61:165–175.
45. Okifuji A, Truk DC, Curran SL. Anger in chronic pain: investigations of anger targets and intensity. J Psychosomatic Res 1999;47:1–12.
46. Miaskowski C, Lee KA. Pain, fatigue, and sleep disturbances in oncology outpatients receiving radi-ation therapy for bone metastasis: a pilot study. J Pain Symptom Manage 1999;17:320-332.
47. Kaaa S, Loge JH, Knobel H, et al. Fatigue. Mea-sures and relation to pain. Acta Anaesthesio Scand 1999;43:939–947.
48. Covington EC. Depression and chronic fatigue in the patient with chronic pain. Primary Care 1991; 18:341–358.
49. Morin CM, Gibson D, Wade J. Self-reported sleep and mood disturbance in chronic pain patients. Clin J Pain 1998;14:311–314.
50. Georgesen J, Dungan JM. Managing spiritual dis-tress in patients with advanced cancer pain. Cancer Nurs 1996;19:376–383.
51. Wilke JT. Personal identity in the light of brain physiology and cognitive psychology. J Med Philos 1981;6:323–333.
52. Ferrell BR, Taylor EJ, Grant M, et al. Searching for the meaning of pain. Cancer Prac 1993;1:185–193. 53. Ashburn, MA, Staats PS. Management of chronic pain. Lancet 1999;353:1865–1869.
