Original Article The Impact of Pain on the Quality of Life of Taiwanese Oncology Patients Shu-Yuan Liang, PhD, RN,* Shu-Fang Wu, PhD, RN,* Ta-Chung Chao, PhD, MD,†,‡ Ling-Ming Tseng, PhD, MD,†,§ Wei-Wen Wu, PhD, RN,* Tsae-Jyy Wang, PhD, RN,* and Yu-Yin Lu, PhD, RN* ---
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From the *College of Nursing, National Taipei University of Nursing and Health Sciences; †Department of Medicine, School of Medicine, National Yang-Ming University; ‡ Division of Hematology-Oncology, Medical Oncology, Department of Medicine, Taipei Veterans General Hospital; § Division of General Surgery, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. Address correspondence to Shu-Yuan Liang, PhD, RN, Associate Professor, College of Nursing, National Taipei University of Nursing and Health Sciences, 365 Ming Te Road, Beitou, Taipei 112, Taiwan. E-mail: [email protected] Received October 24, 2013; Revised May 23, 2014; Accepted May 27, 2014. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.05.009
ABSTRACT:
This study explored the relationship between participants’ pain experience and quality of life (QOL). One hundred nine patients aged 18 years and older who had taken prescribed opioid analgesics for cancer-related pain at a teaching hospital in Taipei, Taiwan, completed the Brief Pain Inventory and European Organization for Research and Treatment of Cancer Quality of Life Group Questionnaire. The results indicated that participants in this study had experienced a mean functional QOL of 55.47 (SD 21.48), a mean symptom QOL of 41.97 (SD 16.89), and a mean global QOL of 42.13 (SD 20.69). Participants reported that in the previous 7 days, they had experienced a mean least pain of 1.75 (SD 0.18) and a mean worst pain of 6.81 (SD 0.24). The mean score for average pain intensity was 4.14 (SD 0.21), whereas the mean for current pain level was 2.53 (SD 0.21). The mean pain interference in the patients’ daily activities was 3.50 (SD 0.22) on a scale ranging from 0 to 10. Furthermore, a significant correlation existed between global (r ¼ L0.375, p < .01), functional (r ¼ L0.300, p < .01), and symptom (r ¼ 0.405, p < .01) QOL and worst pain. Moreover, the results indicated a significant correlation between global (r ¼ L0.461, p < .01), functional (r ¼ L0.430, p < .01), and symptom (r ¼ 0.505, p < .01) QOL and pain interference. The current results support the observation that cancer pain substantially affects a patient’s quality of life. The findings provide empirical support for the need for better programmatic efforts to improve pain management in Taiwanese oncology outpatients. Ó 2015 by the American Society for Pain Management Nursing
BACKGROUND Pain is a major symptom for many patients experiencing a progressive stage of cancer. Research has revealed that approximately 43% to 63% of cancer patients—and 58% to 73% of those experiencing an advanced stage—suffer from chronic pain during active cancer therapy (van den Beuken-van Everdingen Pain Management Nursing, Vol 16, No 2 (April), 2015: pp 128-136
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et al., 2007). Unrelieved pain may prompt suicidal ideation among cancer patients. Therefore, pain is the most feared consequence for many cancer patients (Holtan et al., 2007). Pain is a significant and obvious cause of patient suffering, overwhelming all aspects of personal quality of life (QOL) (Eyigor, Eyigor, & Uslu, 2010; Holtan et al., 2007). In particular, pain results in the manifestation of beliefs of uncertainty and hopelessness and feelings of loss of control (Fortier, Batista, Wahi, Maurer, & Kain, 2012; Mystakidou et al., 2007; Vallerand, Templin, Hasenau, & Riley-Doucet, 2007), with emotional distress being the most consistent psychological variable associated with pain reported within cancer populations (Lehto, Ojanen, Dyba, Aromaa, & Kellokumpu-Lehtinen, 2006; Mantyh, 2006). Although interpretations of the definition of QOL differ, there is general agreement that the definition should include several aspects of the assessed individual’s life. For instance, QOL can be described as a condition of well-being that consists of physical, psychological, social, and spiritual aspects (Kyranou et al., 2013). As survival rates of cancer patients in multimodal therapy have increased, QOL has become a crucial indicator for cancer management in patients, although pain is widely considered to be one of the most important determinants of QOL (Tavoli, Montazeri, Roshan, Tavoli, & Melyani, 2008). At present, it is unclear exactly which pain experiences (intensity, interference, and relief) and patient characteristics interact to influence the QOL of patients who experience cancer pain. The aims of the present study included the following: (1) to describe the participants’ pain experience and QOL, (2) to describe the participants’ differences in QOL, and (3) to explore the relationship between the participants’ pain experience and QOL.
METHODS Study Population, Procedure, and Setting The sampling frame comprised all cancer patients with pain who had been admitted to the oncology units of one teaching hospital in the Taipei area of Taiwan. Patients were eligible for enrollment if they met the following inclusion criteria: (1) had a cancer diagnosis; (2) had been prescribed opioid analgesics for cancerrelated pain on an around-the-clock as-needed basis and had consumed them for at least the previous week; (3) were older than 18 years of age; and (4) were conscious and able to sign a consent form. The study was approved by the ethics committee of the institution in which the researcher worked, as well as the teaching hospital.
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Data were collected from a convenience sample. Information about the patients who had been prescribed opioid analgesics for cancer-related pain and patients’ ages were identified using hospital medical charts. Participants who met the eligibility criteria were invited to participate by the research investigator. Patients who indicated interest were provided further verbal information. When verbal consent was received, the patient information sheet, consent form, and selfadministered questionnaire were provided so that the prospective patient could decide whether to continue participation. After participants had finished the questionnaire, the researcher checked for any missing information to document. The patients were asked to complete items they had missed, and then they were thanked for their valuable contributions. The researcher collected information about relevant medical characteristics from the patients’ medical records.
MEASURES Demographic and Medical Variables Gender, age (years), education (years), spouse, religious practice, work status, financial source, and living status with family/relative/friend were included as demographic variables (Table 1). In addition, location of cancer, metastases status, time duration that the patient had experienced pain (months), and opioid side effects were included as medical variables (Table 2). Brief Pain Inventory—Taiwanese Version Pain experience was measured by the Brief Pain Inventory—Taiwanese Version (BPI-T) (Ger, Ho, Sun, Wang, & Cleeland, 1999). The BPI-T is a self-reporting instrument that assesses the multidimensional nature of pain, including its intensity and interference in life activities during the week preceding. Pain intensity is measured using four main variables: pain worst, pain least, pain average, and pain now, each ranging between 0 and 10, 0 signifying ‘‘no pain’’ and 10 signifying ‘‘pain as bad as you can imagine.’’ For a total interference score, one variable can be computed by taking the average of seven items, each ranging from 0 to 10, with zero signifying ‘‘does not interfere’’ and 10 signifying ‘‘interfere completely.’’ This score indicates the extent to which pain has interfered with general activity, mood, walking, working, relations with others, sleeping, and enjoyment of life. The BPI is a well-known and often-used instrument for patients with cancer pain and has been validated in many nations (Badia et al., 2003; Ferreira, Teixeira, Mendoza, & Cleeland, 2011; Yun et al., 2004). The construct validity of the BPI was checked by developers of the instrument, using factor analysis
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TABLE 1. Demographic Data of the Sample (N ¼ 109) Variables
Groups
Percentage
Age (years) Gender
Mean
SD
51.93
10.68
Female Male
39 70
35.8 64.2
Primary school or below Junior high school Senior high school Diploma or above
21 24 34 30
19.3 22.0 31.2 27.5
None Yes
23 86
21.1 78.9
None Yes
17 92
15.6 84.4
Unemployed Employed
72 37
66.1 33.9
By self By others
63 46
57.8 42.2
80,001
44 37 28
40.4 33.9 25.7
5 104
4.6 95.4
Educational level
Partner Religion Employment status Financial means Household income/month (NTD)
Living status Alone With others
(Cleeland & Ryan, 1994). The four pain intensity items were loaded onto one factor, and the seven pain interference items were loaded onto the other. The coefficient alphas for the two scales—intensity and interference—reached at least 0.80. In a sample of 20 inpatients with cancer, the test-retest reliability of the pain-worst scale was 0.93 over a 2-day period. A significant correlation was found between the ratings for pain severity and ratings for pain interference (Cleeland & Ryan, 1994). Confirmatory factor analysis of the BPI-T clearly identified the same two scales (Ger et al., 1999). The coefficient alpha for the internal reliability scale of BPI-T was 0.81 for severity and 0.89 for interference (Ger et al., 1999). Lastly, the intraclass correlation coefficient for the test-retest reliability was 0.79 for pain severity and 0.81 for pain interference (Ger et al., 1999). European Organization for Research and Treatment of Cancer Quality of Life Group Questionnaire (Version 3.0) The European Organization for Research and Treatment of Cancer Quality of Life Group Questionnaire
(EORTC QLQ-C30) contains scales and items addressing the functional status and symptomatic aspects for the Quality of Life (QOL) scale and two items for a global QOL scale. The functional scale of QOL includes 15 items in five dimensions, including physical, role, cognitive, emotional, and social status. Moreover, the symptomatic aspect of QOL contains 13 items reflecting various symptoms that patients have experienced. For functional and symptom QOL scales, there are 4point responses ranging from 1 to 4, with 1 signifying ‘‘not at all’’ and 4 signifying ‘‘very much.’’ For the global QOL scale, there are 7-point responses ranging from 1 to 7, with 1 signifying ‘‘very poor’’ and 7 signifying ‘‘excellent.’’ Each score was transformed into a 0- to 100-point scale value, with a higher the score indicating more positive functioning QOL and global QOL but greater distress concerning the QOL symptom aspects. The EORTC QLQ-C30 is a widely used questionnaire that has been validated for many types of cancer patients and in many countries (Aaronson, Ahmedzai, & Bergman, 1993; Arraras et al., 2002; Hoopman, Muller, Terwee, & Aaronson, 2006; Park, 2008) and
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TABLE 2. Medical Characteristics of the Sample (N ¼ 109) Variables/Groups Sites of cancer Digestive tract Head and neck Others Metastases Yes No Time patient has had pain (months) Frequency of pain A little of the time Most of the time All of the time Opioids patients has taken (days) Side effect of opioids Yes No Pain management Analgesics Analgesics and other approaches
Frequency
Percentage
38 31 40
34.9 28.4 36.7
85 24
78.0 22.0
41 39 29
96.3 3.7
47 62
43.1 56.9
Data Analysis IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY) was used to analyze the data. Descriptive statistics (mean and percentages) were used to characterize the total sample, pain experience, and quality of life. The association among demographic/medical characteristics (continuous variables), pain experience (continuous variables), and quality of life (continuous variables) were assessed using Pearson product-moment correlations. Group differences for quality of life were analyzed using independent-sample t-tests and ANOVA.
RESULTS Demographic Characteristics The sample consisted of 109 cancer patients, all recruited from one teaching hospital in the Taipei area of Taiwan. Most subjects were men (64.2%). Participants ranged in age from 28 to 85 years old, with a mean age of 51.9 years (SD ¼ 10.68 years). Most subjects possessed an educational level of senior high school (31.2%), had a religious affiliation (84.4%), had a partner (78.9%), and lived with others (families/relatives/friends) (95.4%). Most subjects indicated they were ‘‘unemployed’’ (72%) (see Table 1).
SD
9.84
10.85
90.64
149.07
37.6 35.8 26.6
105 4
was transculturally adapted into and validated for Chinese (Zhao & Kanda, 2000).
Mean
Medical Characteristics The sample represented a heterogeneous group of individuals with various cancer diagnoses. The sites of cancer for the 109 subjects were the digestive tract (34.9%) and cancer of the head and neck (28.4%), with 78% reporting a diagnosis of metastatic disease. Participants had reported being in pain from 1 to 49 months, with the mean duration of pain being 9.84 months (SD ¼ 10.85 months). The majority of subjects combined analgesics and other approaches to cancer pain (56.9%) and experienced side effects of opioids (96.3%) (see Table 2). Pain Experience among Taiwanese Oncology Patients with Cancer Information on pain was collected from the BPI (Short Form) (Cleeland, 1985; Ger et al., 1999). Measurements of pain intensity ranged from 0 to 10 when assessing current pain severity as well as at its worst, at its least, and on its average, for the previous 7 days. The participants reported that they had experienced a mean least pain of 1.75 (SD 0.18) in the previous 7 days and a mean worst pain of 6.81 (SD 0.24). The mean score for pain intensity on average in the previous 7 days was 4.14 (SD 0.21). The mean score for current pain level was 2.53 (SD 0.21). The mean pain interference with the patients’ daily activities was 3.50 (SD 0.22) on a scale ranging from 0, signifying no interference, to 10, signifying complete interference.
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Quality of Life among Taiwanese Oncology Patients with Cancer Information on life quality was collected using the EORTC QLQ-C30 (Aaronson et al., 1993). The scale includes subscales of functional status, symptom aspects of QOL, and a global QOL. The mean of the transformed scores of the functional status of QOL was 55.47 (SD 21.48). Moreover, for symptom aspects of QOL, the mean was 41.97 (SD 16.89), and for the global QOL, the mean was 42.13 (SD 20.69). The raw scores in addition to the transformed scores on QOL revealed that the mean of the functional status of QOL was 2.34 (SD 0.65, score range 1-4). In regard to the symptom aspects of QOL, the mean was 2.26 (SD 0.50, score range 1-4), and for the global QOL, the mean was 3.53 (SD 1.24, score range 1-7).
Pearson’s correlations were calculated to assess the relationships between patients’ pain experience and QOL. The results indicated the worst pain that patients experienced was significantly and negatively correlated with global (r ¼ 0.375, p < .01) and functional (r ¼ 0.300, p < .01) QOL; however, it was positively correlated with symptom (r ¼ 0.405, p < .01) QOL. Moreover, the results indicated the pain interference was significantly negatively correlated with global (r ¼ 0.461, p < .01) and functional (r ¼ 0.430, p < .01) QOL; however, it was positively correlated with symptom (r ¼ 0.505, p < .01) QOL. These results suggest that lower perceived worst pain and pain interference were related to greater QOL (Table 4).
DISCUSSION Relationship among Demographic/Medical Characteristics, Pain Experience, and Quality of Life Independent-sample t-tests or ANOVAs were conducted to examine differences in QOL among selected demographic and medical groups. As presented in Table 3, there was a significant difference in the global QOL for persons of different financial means (t ¼ 2.07, p < .05) and household income levels (F ¼ 5.03, p < .05). These results indicate that participants who reported their financial source as themselves and possessed lower household income experienced a higher global QOL than participants who had a financial source of other and possessed higher household income levels. Moreover, there was a significant difference in the functional QOL for persons of different household incomes (F ¼ 3.63, p < .05), sites of cancer (F ¼ 3.37, p < .05) and metastases (t ¼ 2.89, p < .05). Participants with a lower household income, cancer of the head and neck, and no reported metastasis experienced a higher functional QOL than did participants with a higher household income, cancer of digestive tract, and a metastasis instance. Participants who had reported being in pain all the time experienced a higher symptom QOL than did participants with a little or most of time in pain. Nevertheless, the Pearson’s correlation results indicate that the time duration of pain reported by the patient (months) was not significantly associated with QOL for the global (r ¼ 0.132, p > .05), functional (r ¼ 0.156, p > .05), and symptom (r ¼ 0.075, p > .05) aspects. In addition, the opioids that patients had ingested (days) were not significantly associated with the QOL for the global (r ¼ 0.047, p > .05), functional (r ¼ 0.011, p > .05), and symptom (r ¼ 0.095, p > .05) aspects (see Table 3).
This study described the QOL and pain experience of cancer patients in the Taipei area of Taiwan, and it explored the relationship among QOL, pain experience, and demographic characteristics. The results of this study revealed that, on average, patients experienced moderate levels of pain and pain interference. The worst pain that the patients experienced in the previous 7 days was less than the severe level. Overall, the study results conform to those reported by those of other nations (Vallerand et al., 2007). However, the pain level results of this study are lower than those of studies previously conducted in Taiwan (Liang, Li, Wu, Wang, & Tsay, 2011), which may be due to the involvement of outpatients in previous studies and inpatients in the present study. Indeed, outpatients with an undesirable analgesic adherence may influence reported cancer pain (Liang, Wu, Tsay, Wang, & Tung, 2013). To interpret the QOL of the participants, the present study presents the transforming average scores as well as the raw mean scores of QOL (Fayers et al., 2001). These results suggest that patients experienced more than ‘‘a little’’ functioning and symptom QOL and a mean score of 3.53 (score range 1-7) for global QOL. The study patients reported a transforming average score for global QOL of 42.13 (score rang 0-100), and these results are consistent with researchers’ previous reports from Taiwan and other countries involving various cancer patient sites (Chie, Chang, Huang, & Kuo, 2003; Tavoli et al., 2008). Furthermore, the current results reveal that financial means may be an indicator for participants’ QOL. The present study found that patients with their own financial income had a better global QOL than those dependent on others. Several researchers emphasize that patients of a higher economic level displayed a
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TABLE 3. Demographic/Medical Characteristics by QOL (N ¼ 109) Global QOL Scale Variables/Groups Gender Male Female Educational level Primary school or less Junior high school Senior high school Diploma or more Partner Yes None Religion Yes None Employment status Employed Unemployed Financial means By self By others Household income/month (NTD) ① < 40,000 ② 40,001-80,000 ③ > 80,001 Living status With others Alone Primary sites of cancer ① Digestive tract ② Head and neck ③ Others Metastases Yes No Frequency of pain ① A little of the time ② Most of the time ③ All of the time Side effect of opioids Yes No Pain management Analgesics Analgesics and other approaches
Functional QOL Scale t/F
Symptom QOL Scale
M ± SD
t/F
M ± SD
43.69 20.24 39.32 21.46
1.06
57.81 22.03 51.28 20.07
1.53
42.27 16.46 41.42 17.84
0.25
44.44 22.26 40.63 18.60 40.44 20.22 43.61 22.39
0.25
59.79 22.00 59.91 22.02 49.87 20.93 55.26 20.86
1.41
38.71 18.33 42.20 18.96 42.01 13.80 44.02 17.79
0.40
41.67 20.69 43.84 21.05
0.45
54.65 21.63 58.55 21.11
0.77
41.98 17.00 41.92 16.84
0.02
41.67 21.04 44.61 19.08
0.54
54.83 21.83 58.95 19.77
0.73
42.17 17.26 40.87 15.13
0.29
42.34 20.16 42.01 21.09
0.08
60.48 19.14 52.90 22.28
1.76
40.26 14.09 42.84 18.19
0.82
M ± SD
t/F
45.63 19.39 37.32 21.64
2.07*
57.64 19.12 52.51 24.26
1.19
40.09 15.50 44.54 18.49
1.36
46.21 18.63
5.03* ①>③ ②>③
57.53 20.31
3.63* ②>③
40.44 17.20
1.02
45.05 19.39 31.85 22.57
59.88 22.93 46.43 19.22
42.31 20.73 38.33 21.73
0.42
55.58 21.59 53.33 21.20
44.08 21.83
0.74
57.08 19.86
43.82 18.51 38.96 21.30
61.79 19.32 49.06 23.24
40.82 17.57 45.88 15.37 0.23 3.37* ②>③
41.69 16.93 47.69 16.68
0.78
41.84 17.25
0.16
43.34 19.62 41.03 14.46
42.06 20.73 42.36 20.98
0.06
52.42 21.67 66.30 17.21
2.89*
41.60 16.48 43.27 18.57
0.43
45.12 20.24 44.23 17.85 35.06 23.72
2.38
55.12 20.42 60.28 19.86 49.50 24.07
2.15
39.27 15.98 39.05 16.33 49.69 17.01
4.39* ③>① ③>②
41.75 19.93 52.08 38.72
0.98
54.71 21.05 75.56 26.48
1.93
42.32 16.65 32.69 23.16
1.12
40.25 20.66 43.55 20.77
0.82
57.78 20.33 53.73 22.33
0.98
44.30 18.25 40.20 15.70
1.26
QOL ¼ quality of life. *p < .05.
satisfied QOL (Ordu Gokkaya et al., 2012). However, results of the present study were not consistent with that assertion, perhaps because cancer patients in Taiwan are supported by national insurance and
subsidized for serious illnesses. In addition, the culture relevant to volunteers in Taiwanese society includes volunteer services in the hospitals. Consequently, patients may not in fact have financial difficulty in
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TABLE 4. Correlations between Pain Experience and QOL (N ¼ 109) Worst Pain r
p
Least Pain r
p
Average Pain r
Global QOL 0.375 .000† 0.285 .003† 0.216 Functional QOL 0.300 .002† 0.127 .189 0.107 Symptom QOL 0.405 .000† 0.381 .000† 0.273
Pain Right Now
Pain Interference
p
r
p
r
p
.024* .269 .004†
0.160 0.112 0.239
.097 .244 .012*
0.461 0.430 0.505
.000† .000† .000†
Pain Relief r
p
0.232 .015* 0.082 .399 0.179 .062
QOL ¼ quality of life. *p < .05. † p < .01.
addressing their disease. These patients with lower income levels may possess individual meaning and contentment with their life situations and are therefore more satisfied with their QOL compared with patients of higher income levels (Kleftaras & Psarra, 2012). This interpretation of an association between patients’ income and QOL, however, should be investigated systematically in a future study. In contrast, patients with different cancer sites may possess different levels of functional QOL. The present study revealed that participants with head and neck cancer possessed higher levels of functional QOL than did other patients. These results may be attributed to patients with other types of cancer, including various genitourinary cancers, who experience distress regarding physical, role, cognitive, emotional, and social functions (Curigliano et al., 2009; Skaali et al., 2011; Talcott & Clark, 2005). Similarly, patients with metastatic cancer displayed lower levels of functional QOL than patients without metastatic cancer. These results should alert health professionals that they need to pay closer attention to patients with metastatic cancer. This study revealed that patients’ reports of pain intensity and pain interference were significantly correlated with quality of life. Participants who experienced higher levels of pain and interference reported lower levels in the functional and global domain of QOL and higher levels in the symptom domain of QOL. Therefore, it is particularly important for clinicians to assess patients’ pain experience so that, if needed, cancer pain can be the target of treatment by health professionals. Importantly, regarding pain interference, this study revealed that patients tended to have a somewhat stronger association with QOL than pain intensity. The present results supported the suggestions of Wilson (2011), which indicated that pain interference may be an important focus for pain control that should
be integrated into existing pain management models and nursing practices. Because the existing pain assessment of nursing practice only includes a universal dimension with pain intensity, these current results emphasize the need for better efforts to improve pain control, particularly the assessment and management of pain interference. Management of pain interference is an important issue for QOL, whereas the analgesic adherence for pain experience is not concurrent with pain relief (Liang et al., 2013). The complex encounters of pain experience, mainly pain interference, may be the core component and require the involvement of various approaches such as cognitive behavioral therapy (Osborn, Demoncada, & Feuerstein, 2006), problem-solving training (Strong et al., 2008), and social support (Hughes et al., 2014) to improve QOL because of the pain intensity may, through pain interference, overwhelm patients’ QOL. The present study is limited in that it only involved a cross-sectional investigation. The results could not determine the direction of causality within the relationship between pain experience and participants’ quality of life. In addition, participants were only recruited from an urban teaching hospital, which was a sample based on convenience rather than scope. This approach may limit the generalizability of our findings.
CONCLUSIONS Studying quality of life is an important issue for oncology patients. Assessments of quality of life are necessary for a complete overview of treatment outcomes. Understanding quality of life helps to determine the impact of cancer pain on patients’ well-being. The study results are similar to those of Black et al. (2011) and Rustoen (Rustoen, Moum, Padilla, Paul, & Miaskowski, 2005) and support the proposition that
The Impact of Pain on Quality of Life
cancer pain substantially affects patients’ quality of life. The study results identify significant issues in cancer pain management.
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Acknowledgments This study was partially supported by the National Science Council Taiwan (NSC 98-2314-B-227-002).
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Holtan, A., Palliative, N. A., Nordøy, T., Haugen, D. F., Kaasa, S., Mohr, W., & Kongsgaard, U. E. (2007). Prevalence of pain in hospitalised cancer patients in Norway: A national survey. Palliative Medicine, 21(1), 7–13. Hughes, S., Jaremka, L. M., Alfano, C. M., Glaser, R., Povoski, S. P., Lipari, A. M., Agnese, D. M., Farrar, W. B., Yee, L. D., Carson W. E. 3rd, Malarkey, W. B., & KiecoltGlaser, J. K. (2014). Social support predicts inflammation, pain, and depressive symptoms: Longitudinal relationships among breast cancer survivors. Psychoneuroendocrinology, 42, 38–44. Kleftaras, G., & Psarra, E. (2012). Meaning in life, psychological well-being and depressive symptomatology: A comparative study. Psychology, 3(4), 337–345. Kyranou, M., Paul, S. M., Dunn, L. B., Puntillo, K., Aouizerat, B. E., Abrams, G., Hamolsky, D., West, C., Neuhaus, J., Cooper, B., & Miaskowski, C. (2013). Differences in depression, anxiety, and quality of life between women with and without breast pain prior to breast cancer surgery. European Journal of Oncology Nursing, 17(2), 190–195. Lehto, U. S., Ojanen, M., Dyba, T., Aromaa, A., & Kellokumpu-Lehtinen, P. (2006). Baseline psychosocial predictors of survival in localised breast cancer. British Journal of Cancer, 94, 1245–1252. Liang, S. Y., Wu, S. F., Tsay, S. L., Wang, T. J., & Tung, H. H. (2013). Prescribed opioids adherence amongst Taiwanese oncology outpatients. Pain Management Nursing, 14(3), 155–160. Liang, S. Y., Li, C. C., Wu, S. F., Wang, T. J., & Tsay, S. L. (2011). The prevalence and impact of pain among Taiwanese oncology outpatients. Pain Management Nursing, 12, 197– 205. Mantyh, P. W. (2006). Cancer pain and its impact on diagnosis, survival and quality of life. Nature Reviews Neuroscience, 7(10), 797–809. Mystakidou, K., Tsilika, E., Parpa, E., Pathiaki, M., Patiraki, E., Galanos, A., & Vlahos, L. (2007). Exploring the relationships between depression, hopelessness, cognitive status, pain, and spirituality in patients with advanced cancer. Archives of Psychiatric Nursing, 21(3), 150–161. Ordu Gokkaya, N. K., Gokce-Kutsal, Y., Borman, P., Ceceli, E., Dogan, A., Eyigor, S., & Karapolat, H. (2012). Pain and quality of life (QoL) in elderly: The Turkish experience. Archives of Gerontology and Geriatrics, 55(2), 357–362. Osborn, R. L., Demoncada, A. C., & Feuerstein, M. (2006). Psychosocial interventions for depression, anxiety, and quality of life in cancer survivors: Meta-analyses. International Journal of Psychiatry in Medicine, 36(1), 13–34. 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 (QLQC30) in a Korean sample. Oncology, 74(Suppl 1), 7–12. Rustoen, T., Moum, T., Padilla, G., Paul, S., & Miaskowski, C. (2005). Predictors of quality of life in
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Vallerand, A. H., Templin, T., Hasenau, S. M., & RileyDoucet, C. (2007). Factors that affect functional status in patients with cancer-related pain. Pain, 132(1-2), 82–90. van den Beuken-van Everdingen, M. H. J., 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. Wilson, M. (2011). Integrating the concept of pain interference into pain management. Pain Management Nursing, 15, 499–505. Yun, Y. H., Mendoza, T. R., Heo, D. S., Yoo, T., Heo, B. Y., Park, H. A., Shin, H. C., Wang, X. S., & Cleeland, C. S. (2004). Development of a cancer pain assessment tool in Korea: A validation study of a Korean version of the Brief Pain Inventory. Oncology, 66(6), 439–444. Zhao, H., & Kanda, K. (2000). Translation and validation of the standard Chinese version of the EORTC QLQ-C30. Quality of Life Research, 9, 129–137.
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From the *College of Nursing, National Taipei University of Nursing and Health Sciences; †Department of Medicine, School of Medicine, National Yang-Ming University; ‡ Division of Hematology-Oncology, Medical Oncology, Department of Medicine, Taipei Veterans General Hospital; § Division of General Surgery, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan. Address correspondence to Shu-Yuan Liang, PhD, RN, Associate Professor, College of Nursing, National Taipei University of Nursing and Health Sciences, 365 Ming Te Road, Beitou, Taipei 112, Taiwan. E-mail: [email protected] Received October 24, 2013; Revised May 23, 2014; Accepted May 27, 2014. 1524-9042/$36.00 Ó 2015 by the American Society for Pain Management Nursing http://dx.doi.org/10.1016/ j.pmn.2014.05.009
ABSTRACT:
This study explored the relationship between participants’ pain experience and quality of life (QOL). One hundred nine patients aged 18 years and older who had taken prescribed opioid analgesics for cancer-related pain at a teaching hospital in Taipei, Taiwan, completed the Brief Pain Inventory and European Organization for Research and Treatment of Cancer Quality of Life Group Questionnaire. The results indicated that participants in this study had experienced a mean functional QOL of 55.47 (SD 21.48), a mean symptom QOL of 41.97 (SD 16.89), and a mean global QOL of 42.13 (SD 20.69). Participants reported that in the previous 7 days, they had experienced a mean least pain of 1.75 (SD 0.18) and a mean worst pain of 6.81 (SD 0.24). The mean score for average pain intensity was 4.14 (SD 0.21), whereas the mean for current pain level was 2.53 (SD 0.21). The mean pain interference in the patients’ daily activities was 3.50 (SD 0.22) on a scale ranging from 0 to 10. Furthermore, a significant correlation existed between global (r ¼ L0.375, p < .01), functional (r ¼ L0.300, p < .01), and symptom (r ¼ 0.405, p < .01) QOL and worst pain. Moreover, the results indicated a significant correlation between global (r ¼ L0.461, p < .01), functional (r ¼ L0.430, p < .01), and symptom (r ¼ 0.505, p < .01) QOL and pain interference. The current results support the observation that cancer pain substantially affects a patient’s quality of life. The findings provide empirical support for the need for better programmatic efforts to improve pain management in Taiwanese oncology outpatients. Ó 2015 by the American Society for Pain Management Nursing
BACKGROUND Pain is a major symptom for many patients experiencing a progressive stage of cancer. Research has revealed that approximately 43% to 63% of cancer patients—and 58% to 73% of those experiencing an advanced stage—suffer from chronic pain during active cancer therapy (van den Beuken-van Everdingen Pain Management Nursing, Vol 16, No 2 (April), 2015: pp 128-136
The Impact of Pain on Quality of Life
et al., 2007). Unrelieved pain may prompt suicidal ideation among cancer patients. Therefore, pain is the most feared consequence for many cancer patients (Holtan et al., 2007). Pain is a significant and obvious cause of patient suffering, overwhelming all aspects of personal quality of life (QOL) (Eyigor, Eyigor, & Uslu, 2010; Holtan et al., 2007). In particular, pain results in the manifestation of beliefs of uncertainty and hopelessness and feelings of loss of control (Fortier, Batista, Wahi, Maurer, & Kain, 2012; Mystakidou et al., 2007; Vallerand, Templin, Hasenau, & Riley-Doucet, 2007), with emotional distress being the most consistent psychological variable associated with pain reported within cancer populations (Lehto, Ojanen, Dyba, Aromaa, & Kellokumpu-Lehtinen, 2006; Mantyh, 2006). Although interpretations of the definition of QOL differ, there is general agreement that the definition should include several aspects of the assessed individual’s life. For instance, QOL can be described as a condition of well-being that consists of physical, psychological, social, and spiritual aspects (Kyranou et al., 2013). As survival rates of cancer patients in multimodal therapy have increased, QOL has become a crucial indicator for cancer management in patients, although pain is widely considered to be one of the most important determinants of QOL (Tavoli, Montazeri, Roshan, Tavoli, & Melyani, 2008). At present, it is unclear exactly which pain experiences (intensity, interference, and relief) and patient characteristics interact to influence the QOL of patients who experience cancer pain. The aims of the present study included the following: (1) to describe the participants’ pain experience and QOL, (2) to describe the participants’ differences in QOL, and (3) to explore the relationship between the participants’ pain experience and QOL.
METHODS Study Population, Procedure, and Setting The sampling frame comprised all cancer patients with pain who had been admitted to the oncology units of one teaching hospital in the Taipei area of Taiwan. Patients were eligible for enrollment if they met the following inclusion criteria: (1) had a cancer diagnosis; (2) had been prescribed opioid analgesics for cancerrelated pain on an around-the-clock as-needed basis and had consumed them for at least the previous week; (3) were older than 18 years of age; and (4) were conscious and able to sign a consent form. The study was approved by the ethics committee of the institution in which the researcher worked, as well as the teaching hospital.
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Data were collected from a convenience sample. Information about the patients who had been prescribed opioid analgesics for cancer-related pain and patients’ ages were identified using hospital medical charts. Participants who met the eligibility criteria were invited to participate by the research investigator. Patients who indicated interest were provided further verbal information. When verbal consent was received, the patient information sheet, consent form, and selfadministered questionnaire were provided so that the prospective patient could decide whether to continue participation. After participants had finished the questionnaire, the researcher checked for any missing information to document. The patients were asked to complete items they had missed, and then they were thanked for their valuable contributions. The researcher collected information about relevant medical characteristics from the patients’ medical records.
MEASURES Demographic and Medical Variables Gender, age (years), education (years), spouse, religious practice, work status, financial source, and living status with family/relative/friend were included as demographic variables (Table 1). In addition, location of cancer, metastases status, time duration that the patient had experienced pain (months), and opioid side effects were included as medical variables (Table 2). Brief Pain Inventory—Taiwanese Version Pain experience was measured by the Brief Pain Inventory—Taiwanese Version (BPI-T) (Ger, Ho, Sun, Wang, & Cleeland, 1999). The BPI-T is a self-reporting instrument that assesses the multidimensional nature of pain, including its intensity and interference in life activities during the week preceding. Pain intensity is measured using four main variables: pain worst, pain least, pain average, and pain now, each ranging between 0 and 10, 0 signifying ‘‘no pain’’ and 10 signifying ‘‘pain as bad as you can imagine.’’ For a total interference score, one variable can be computed by taking the average of seven items, each ranging from 0 to 10, with zero signifying ‘‘does not interfere’’ and 10 signifying ‘‘interfere completely.’’ This score indicates the extent to which pain has interfered with general activity, mood, walking, working, relations with others, sleeping, and enjoyment of life. The BPI is a well-known and often-used instrument for patients with cancer pain and has been validated in many nations (Badia et al., 2003; Ferreira, Teixeira, Mendoza, & Cleeland, 2011; Yun et al., 2004). The construct validity of the BPI was checked by developers of the instrument, using factor analysis
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TABLE 1. Demographic Data of the Sample (N ¼ 109) Variables
Groups
Percentage
Age (years) Gender
Mean
SD
51.93
10.68
Female Male
39 70
35.8 64.2
Primary school or below Junior high school Senior high school Diploma or above
21 24 34 30
19.3 22.0 31.2 27.5
None Yes
23 86
21.1 78.9
None Yes
17 92
15.6 84.4
Unemployed Employed
72 37
66.1 33.9
By self By others
63 46
57.8 42.2
80,001
44 37 28
40.4 33.9 25.7
5 104
4.6 95.4
Educational level
Partner Religion Employment status Financial means Household income/month (NTD)
Living status Alone With others
(Cleeland & Ryan, 1994). The four pain intensity items were loaded onto one factor, and the seven pain interference items were loaded onto the other. The coefficient alphas for the two scales—intensity and interference—reached at least 0.80. In a sample of 20 inpatients with cancer, the test-retest reliability of the pain-worst scale was 0.93 over a 2-day period. A significant correlation was found between the ratings for pain severity and ratings for pain interference (Cleeland & Ryan, 1994). Confirmatory factor analysis of the BPI-T clearly identified the same two scales (Ger et al., 1999). The coefficient alpha for the internal reliability scale of BPI-T was 0.81 for severity and 0.89 for interference (Ger et al., 1999). Lastly, the intraclass correlation coefficient for the test-retest reliability was 0.79 for pain severity and 0.81 for pain interference (Ger et al., 1999). European Organization for Research and Treatment of Cancer Quality of Life Group Questionnaire (Version 3.0) The European Organization for Research and Treatment of Cancer Quality of Life Group Questionnaire
(EORTC QLQ-C30) contains scales and items addressing the functional status and symptomatic aspects for the Quality of Life (QOL) scale and two items for a global QOL scale. The functional scale of QOL includes 15 items in five dimensions, including physical, role, cognitive, emotional, and social status. Moreover, the symptomatic aspect of QOL contains 13 items reflecting various symptoms that patients have experienced. For functional and symptom QOL scales, there are 4point responses ranging from 1 to 4, with 1 signifying ‘‘not at all’’ and 4 signifying ‘‘very much.’’ For the global QOL scale, there are 7-point responses ranging from 1 to 7, with 1 signifying ‘‘very poor’’ and 7 signifying ‘‘excellent.’’ Each score was transformed into a 0- to 100-point scale value, with a higher the score indicating more positive functioning QOL and global QOL but greater distress concerning the QOL symptom aspects. The EORTC QLQ-C30 is a widely used questionnaire that has been validated for many types of cancer patients and in many countries (Aaronson, Ahmedzai, & Bergman, 1993; Arraras et al., 2002; Hoopman, Muller, Terwee, & Aaronson, 2006; Park, 2008) and
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TABLE 2. Medical Characteristics of the Sample (N ¼ 109) Variables/Groups Sites of cancer Digestive tract Head and neck Others Metastases Yes No Time patient has had pain (months) Frequency of pain A little of the time Most of the time All of the time Opioids patients has taken (days) Side effect of opioids Yes No Pain management Analgesics Analgesics and other approaches
Frequency
Percentage
38 31 40
34.9 28.4 36.7
85 24
78.0 22.0
41 39 29
96.3 3.7
47 62
43.1 56.9
Data Analysis IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY) was used to analyze the data. Descriptive statistics (mean and percentages) were used to characterize the total sample, pain experience, and quality of life. The association among demographic/medical characteristics (continuous variables), pain experience (continuous variables), and quality of life (continuous variables) were assessed using Pearson product-moment correlations. Group differences for quality of life were analyzed using independent-sample t-tests and ANOVA.
RESULTS Demographic Characteristics The sample consisted of 109 cancer patients, all recruited from one teaching hospital in the Taipei area of Taiwan. Most subjects were men (64.2%). Participants ranged in age from 28 to 85 years old, with a mean age of 51.9 years (SD ¼ 10.68 years). Most subjects possessed an educational level of senior high school (31.2%), had a religious affiliation (84.4%), had a partner (78.9%), and lived with others (families/relatives/friends) (95.4%). Most subjects indicated they were ‘‘unemployed’’ (72%) (see Table 1).
SD
9.84
10.85
90.64
149.07
37.6 35.8 26.6
105 4
was transculturally adapted into and validated for Chinese (Zhao & Kanda, 2000).
Mean
Medical Characteristics The sample represented a heterogeneous group of individuals with various cancer diagnoses. The sites of cancer for the 109 subjects were the digestive tract (34.9%) and cancer of the head and neck (28.4%), with 78% reporting a diagnosis of metastatic disease. Participants had reported being in pain from 1 to 49 months, with the mean duration of pain being 9.84 months (SD ¼ 10.85 months). The majority of subjects combined analgesics and other approaches to cancer pain (56.9%) and experienced side effects of opioids (96.3%) (see Table 2). Pain Experience among Taiwanese Oncology Patients with Cancer Information on pain was collected from the BPI (Short Form) (Cleeland, 1985; Ger et al., 1999). Measurements of pain intensity ranged from 0 to 10 when assessing current pain severity as well as at its worst, at its least, and on its average, for the previous 7 days. The participants reported that they had experienced a mean least pain of 1.75 (SD 0.18) in the previous 7 days and a mean worst pain of 6.81 (SD 0.24). The mean score for pain intensity on average in the previous 7 days was 4.14 (SD 0.21). The mean score for current pain level was 2.53 (SD 0.21). The mean pain interference with the patients’ daily activities was 3.50 (SD 0.22) on a scale ranging from 0, signifying no interference, to 10, signifying complete interference.
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Quality of Life among Taiwanese Oncology Patients with Cancer Information on life quality was collected using the EORTC QLQ-C30 (Aaronson et al., 1993). The scale includes subscales of functional status, symptom aspects of QOL, and a global QOL. The mean of the transformed scores of the functional status of QOL was 55.47 (SD 21.48). Moreover, for symptom aspects of QOL, the mean was 41.97 (SD 16.89), and for the global QOL, the mean was 42.13 (SD 20.69). The raw scores in addition to the transformed scores on QOL revealed that the mean of the functional status of QOL was 2.34 (SD 0.65, score range 1-4). In regard to the symptom aspects of QOL, the mean was 2.26 (SD 0.50, score range 1-4), and for the global QOL, the mean was 3.53 (SD 1.24, score range 1-7).
Pearson’s correlations were calculated to assess the relationships between patients’ pain experience and QOL. The results indicated the worst pain that patients experienced was significantly and negatively correlated with global (r ¼ 0.375, p < .01) and functional (r ¼ 0.300, p < .01) QOL; however, it was positively correlated with symptom (r ¼ 0.405, p < .01) QOL. Moreover, the results indicated the pain interference was significantly negatively correlated with global (r ¼ 0.461, p < .01) and functional (r ¼ 0.430, p < .01) QOL; however, it was positively correlated with symptom (r ¼ 0.505, p < .01) QOL. These results suggest that lower perceived worst pain and pain interference were related to greater QOL (Table 4).
DISCUSSION Relationship among Demographic/Medical Characteristics, Pain Experience, and Quality of Life Independent-sample t-tests or ANOVAs were conducted to examine differences in QOL among selected demographic and medical groups. As presented in Table 3, there was a significant difference in the global QOL for persons of different financial means (t ¼ 2.07, p < .05) and household income levels (F ¼ 5.03, p < .05). These results indicate that participants who reported their financial source as themselves and possessed lower household income experienced a higher global QOL than participants who had a financial source of other and possessed higher household income levels. Moreover, there was a significant difference in the functional QOL for persons of different household incomes (F ¼ 3.63, p < .05), sites of cancer (F ¼ 3.37, p < .05) and metastases (t ¼ 2.89, p < .05). Participants with a lower household income, cancer of the head and neck, and no reported metastasis experienced a higher functional QOL than did participants with a higher household income, cancer of digestive tract, and a metastasis instance. Participants who had reported being in pain all the time experienced a higher symptom QOL than did participants with a little or most of time in pain. Nevertheless, the Pearson’s correlation results indicate that the time duration of pain reported by the patient (months) was not significantly associated with QOL for the global (r ¼ 0.132, p > .05), functional (r ¼ 0.156, p > .05), and symptom (r ¼ 0.075, p > .05) aspects. In addition, the opioids that patients had ingested (days) were not significantly associated with the QOL for the global (r ¼ 0.047, p > .05), functional (r ¼ 0.011, p > .05), and symptom (r ¼ 0.095, p > .05) aspects (see Table 3).
This study described the QOL and pain experience of cancer patients in the Taipei area of Taiwan, and it explored the relationship among QOL, pain experience, and demographic characteristics. The results of this study revealed that, on average, patients experienced moderate levels of pain and pain interference. The worst pain that the patients experienced in the previous 7 days was less than the severe level. Overall, the study results conform to those reported by those of other nations (Vallerand et al., 2007). However, the pain level results of this study are lower than those of studies previously conducted in Taiwan (Liang, Li, Wu, Wang, & Tsay, 2011), which may be due to the involvement of outpatients in previous studies and inpatients in the present study. Indeed, outpatients with an undesirable analgesic adherence may influence reported cancer pain (Liang, Wu, Tsay, Wang, & Tung, 2013). To interpret the QOL of the participants, the present study presents the transforming average scores as well as the raw mean scores of QOL (Fayers et al., 2001). These results suggest that patients experienced more than ‘‘a little’’ functioning and symptom QOL and a mean score of 3.53 (score range 1-7) for global QOL. The study patients reported a transforming average score for global QOL of 42.13 (score rang 0-100), and these results are consistent with researchers’ previous reports from Taiwan and other countries involving various cancer patient sites (Chie, Chang, Huang, & Kuo, 2003; Tavoli et al., 2008). Furthermore, the current results reveal that financial means may be an indicator for participants’ QOL. The present study found that patients with their own financial income had a better global QOL than those dependent on others. Several researchers emphasize that patients of a higher economic level displayed a
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The Impact of Pain on Quality of Life
TABLE 3. Demographic/Medical Characteristics by QOL (N ¼ 109) Global QOL Scale Variables/Groups Gender Male Female Educational level Primary school or less Junior high school Senior high school Diploma or more Partner Yes None Religion Yes None Employment status Employed Unemployed Financial means By self By others Household income/month (NTD) ① < 40,000 ② 40,001-80,000 ③ > 80,001 Living status With others Alone Primary sites of cancer ① Digestive tract ② Head and neck ③ Others Metastases Yes No Frequency of pain ① A little of the time ② Most of the time ③ All of the time Side effect of opioids Yes No Pain management Analgesics Analgesics and other approaches
Functional QOL Scale t/F
Symptom QOL Scale
M ± SD
t/F
M ± SD
43.69 20.24 39.32 21.46
1.06
57.81 22.03 51.28 20.07
1.53
42.27 16.46 41.42 17.84
0.25
44.44 22.26 40.63 18.60 40.44 20.22 43.61 22.39
0.25
59.79 22.00 59.91 22.02 49.87 20.93 55.26 20.86
1.41
38.71 18.33 42.20 18.96 42.01 13.80 44.02 17.79
0.40
41.67 20.69 43.84 21.05
0.45
54.65 21.63 58.55 21.11
0.77
41.98 17.00 41.92 16.84
0.02
41.67 21.04 44.61 19.08
0.54
54.83 21.83 58.95 19.77
0.73
42.17 17.26 40.87 15.13
0.29
42.34 20.16 42.01 21.09
0.08
60.48 19.14 52.90 22.28
1.76
40.26 14.09 42.84 18.19
0.82
M ± SD
t/F
45.63 19.39 37.32 21.64
2.07*
57.64 19.12 52.51 24.26
1.19
40.09 15.50 44.54 18.49
1.36
46.21 18.63
5.03* ①>③ ②>③
57.53 20.31
3.63* ②>③
40.44 17.20
1.02
45.05 19.39 31.85 22.57
59.88 22.93 46.43 19.22
42.31 20.73 38.33 21.73
0.42
55.58 21.59 53.33 21.20
44.08 21.83
0.74
57.08 19.86
43.82 18.51 38.96 21.30
61.79 19.32 49.06 23.24
40.82 17.57 45.88 15.37 0.23 3.37* ②>③
41.69 16.93 47.69 16.68
0.78
41.84 17.25
0.16
43.34 19.62 41.03 14.46
42.06 20.73 42.36 20.98
0.06
52.42 21.67 66.30 17.21
2.89*
41.60 16.48 43.27 18.57
0.43
45.12 20.24 44.23 17.85 35.06 23.72
2.38
55.12 20.42 60.28 19.86 49.50 24.07
2.15
39.27 15.98 39.05 16.33 49.69 17.01
4.39* ③>① ③>②
41.75 19.93 52.08 38.72
0.98
54.71 21.05 75.56 26.48
1.93
42.32 16.65 32.69 23.16
1.12
40.25 20.66 43.55 20.77
0.82
57.78 20.33 53.73 22.33
0.98
44.30 18.25 40.20 15.70
1.26
QOL ¼ quality of life. *p < .05.
satisfied QOL (Ordu Gokkaya et al., 2012). However, results of the present study were not consistent with that assertion, perhaps because cancer patients in Taiwan are supported by national insurance and
subsidized for serious illnesses. In addition, the culture relevant to volunteers in Taiwanese society includes volunteer services in the hospitals. Consequently, patients may not in fact have financial difficulty in
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TABLE 4. Correlations between Pain Experience and QOL (N ¼ 109) Worst Pain r
p
Least Pain r
p
Average Pain r
Global QOL 0.375 .000† 0.285 .003† 0.216 Functional QOL 0.300 .002† 0.127 .189 0.107 Symptom QOL 0.405 .000† 0.381 .000† 0.273
Pain Right Now
Pain Interference
p
r
p
r
p
.024* .269 .004†
0.160 0.112 0.239
.097 .244 .012*
0.461 0.430 0.505
.000† .000† .000†
Pain Relief r
p
0.232 .015* 0.082 .399 0.179 .062
QOL ¼ quality of life. *p < .05. † p < .01.
addressing their disease. These patients with lower income levels may possess individual meaning and contentment with their life situations and are therefore more satisfied with their QOL compared with patients of higher income levels (Kleftaras & Psarra, 2012). This interpretation of an association between patients’ income and QOL, however, should be investigated systematically in a future study. In contrast, patients with different cancer sites may possess different levels of functional QOL. The present study revealed that participants with head and neck cancer possessed higher levels of functional QOL than did other patients. These results may be attributed to patients with other types of cancer, including various genitourinary cancers, who experience distress regarding physical, role, cognitive, emotional, and social functions (Curigliano et al., 2009; Skaali et al., 2011; Talcott & Clark, 2005). Similarly, patients with metastatic cancer displayed lower levels of functional QOL than patients without metastatic cancer. These results should alert health professionals that they need to pay closer attention to patients with metastatic cancer. This study revealed that patients’ reports of pain intensity and pain interference were significantly correlated with quality of life. Participants who experienced higher levels of pain and interference reported lower levels in the functional and global domain of QOL and higher levels in the symptom domain of QOL. Therefore, it is particularly important for clinicians to assess patients’ pain experience so that, if needed, cancer pain can be the target of treatment by health professionals. Importantly, regarding pain interference, this study revealed that patients tended to have a somewhat stronger association with QOL than pain intensity. The present results supported the suggestions of Wilson (2011), which indicated that pain interference may be an important focus for pain control that should
be integrated into existing pain management models and nursing practices. Because the existing pain assessment of nursing practice only includes a universal dimension with pain intensity, these current results emphasize the need for better efforts to improve pain control, particularly the assessment and management of pain interference. Management of pain interference is an important issue for QOL, whereas the analgesic adherence for pain experience is not concurrent with pain relief (Liang et al., 2013). The complex encounters of pain experience, mainly pain interference, may be the core component and require the involvement of various approaches such as cognitive behavioral therapy (Osborn, Demoncada, & Feuerstein, 2006), problem-solving training (Strong et al., 2008), and social support (Hughes et al., 2014) to improve QOL because of the pain intensity may, through pain interference, overwhelm patients’ QOL. The present study is limited in that it only involved a cross-sectional investigation. The results could not determine the direction of causality within the relationship between pain experience and participants’ quality of life. In addition, participants were only recruited from an urban teaching hospital, which was a sample based on convenience rather than scope. This approach may limit the generalizability of our findings.
CONCLUSIONS Studying quality of life is an important issue for oncology patients. Assessments of quality of life are necessary for a complete overview of treatment outcomes. Understanding quality of life helps to determine the impact of cancer pain on patients’ well-being. The study results are similar to those of Black et al. (2011) and Rustoen (Rustoen, Moum, Padilla, Paul, & Miaskowski, 2005) and support the proposition that
The Impact of Pain on Quality of Life
cancer pain substantially affects patients’ quality of life. The study results identify significant issues in cancer pain management.
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Acknowledgments This study was partially supported by the National Science Council Taiwan (NSC 98-2314-B-227-002).
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