Gender and ethnic differences in cancer pain experience: a multiethnic survey in the United States

Five Dimensions of Needs for Help: The Efficacy of a Technology-Based Intervention Among Asian American Breast Cancer Survivors

Cancer survivors including Asian American breast cancer survivors have reported their high needs for help during their survivorship process. With the COVID-19 pandemic, the necessity of technology-based programs to address their needs for help without face-to-face interactions has been highlighted. The purpose of this randomized intervention study was to determine the efficacy of a technology-based program in reducing various types of needs for help among this specific population. This was a randomized clinical trial with repeated measures. A total of 199 participants were included in the data analysis. The recruitment settings included both online and offline communities/groups for Asian Americans. The needs for help were assessed using the Support Care Needs Survey-34 Short Form (SCNS) subscales measuring psychological, information, physical, support, and communication needs. Data analysis was conducted through an intent-to-treat approach. In the mixed effect models, psychological needs, information needs, physical needs, and communication needs decreased over time (P < .001). However, there were no significant group * time effects. Social support significantly mediated the effects of a technology-based intervention on psychological, information, and support needs at the pre-test and the post-1 month. This study supported significant decreases in the needs for help of Asian American breast cancer survivors by a technology-based intervention. Further studies are needed with other racial/ethnic groups of cancer survivors to confirm the efficacy of a technology-based intervention in reducing cancer survivors' needs for help during their survivorship process.

Social Determinants of Health and Cancer Pain in the US: Scoping Review

Social determinants of health (SDOH) are structural factors that yield health inequities. Within the context of cancer, these inequities include screening rates and survival rates, as well as higher symptom burden during and after treatment. While pain is one of the most frequently reported symptoms, the relationship between SDOHs and cancer pain is not well understood. The purpose of this study is to describe and synthesize the published research that has evaluated the relationships between SDOH and cancer pain. A systematic search of PubMed, CINAHL, and Embase was conducted to identify studies in which cancer pain and SDOH were described. In all, 20 studies met the inclusion criteria. In total, 14 studies reported a primary aim related to SDOH and cancer pain. Demographic variables including education or income were used most frequently. Six specific measurements were utilized to measure SDOH, such as the acculturation scale, the composite measure of zip codes for poverty level and blight prevalence, or the segregation index. Among the five domains of SDOH based on Healthy People 2030, social and community was the most studied, followed by economic stability, and education access and quality. The neighborhood and built environment domain was the least studied. Despite increasing attention to SDOH, the majority of published studies use single-dimension variables derived from demographic data to evaluate the relationships between SDOH and cancer pain. Future research is needed to explore the intersectionality of SDOH domains and their impact on cancer pain. Additionally, intervention studies should be conducted to address existing disparities and to reduce the incidence and impact of cancer pain.

Racial/Ethnic Disparities in Peripartum Pain Assessment and Management

OBJECTIVE

This study was conducted to determine if there were racial/ethnic disparities in pain assessment and management from labor throughout the postpartum period.

METHODS

This was a retrospective cohort study of all births from January 2019 to December 2021 in a single urban, quaternary care hospital, excluding patients with hysterectomy, ICU stay, transfusion of more than 3 units of packed red blood cells, general anesthesia, or evidence of a substance abuse disorder. We characterized and compared patterns of antepartum and postpartum pain assessments, epidural use, pain scores, and postpartum pain management by racial/ethnic group with bivariable analyses. Multivariable regression was performed to test for an association between race/ethnicity and amount of opioid pain medication in milligram equivalent units, stratified by delivery mode.

RESULTS

There were 18,085 births between 2019 and 2021 with available race/ethnicity data. Of these, 58.3% were white, 15.0% were Hispanic, 11.9% were Asian, 7.4% were Black, and the remaining 7.4% were classified as Other/Declined. There were no significant differences by race/ethnicity in the number of antepartum or postpartum pain assessments or the proportion of patients who received epidural analgesia. Black and Hispanic patients reported the highest maximum postpartum pain scores after vaginal and cesarean birth compared to white and Asian patients. However, Black and Hispanic patients received lower daily doses of opioid medications than white patients, regardless of delivery mode. After adjusting for patient factors and non-opioid medication dosages, all other racial/ethnic groups received less opioid medication than white patients.

CONCLUSION

Inequities were found in postpartum pain treatment, including among patients reporting the highest pain levels.

Targeting TRPV1 for Cancer Pain Relief: Can It Work?

Chronic intractable pain affects a large proportion of cancer patients, especially those with metastatic bone disease. Blocking sensory afferents for cancer pain relief represents an attractive alternative to opioids and other drugs acting in the CNS in that sensory nerve blockers are not addictive and do not affect the mental state of the patient. A distinct subpopulation of sensory afferents expresses the capsaicin receptor TRPV1. Intrathecal resiniferatoxin, an ultrapotent capsaicin analog, ablates TRPV1-expressing nerve endings exposed to the cerebrospinal fluid, resulting in permanent analgesia in women with cervical cancer metastasis to the pelvic bone. High-dose capsaicin patches are effective pain killers in patients with chemotherapy-induced peripheral neuropathic pain. However, large gaps remain in our knowledge since the mechanisms by which cancer activates TRPV1 are essentially unknown. Most important, it is not clear whether or not sensory denervation mediated by TRPV1 agonists affects cancer progression. In a murine model of breast cancer, capsaicin desensitization was reported to accelerate progression. By contrast, desensitization mediated by resiniferatoxin was found to block melanoma growth. These observations imply that TRPV1 blockade for pain relief may be indicated for some cancers and contraindicated for others. In this review, we explore the current state of this field and compare the analgesic potential of TRPV1 antagonism and sensory afferent desensitization in cancer patients.

A randomized controlled trial testing a virtual program for Asian American women breast cancer survivors

A culturally tailored virtual program could meet the survivorship needs of Asian American women breast cancer survivors (AABC). This study aims to determine the efficacy of a culturally tailored virtual information and coaching/support program (TICAA) in improving AABC's survivorship experience. A randomized clinical trial (NCT02803593) was conducted from January 2017 to June 2020 among 199 AABC. The intervention group utilized TICAA and the American Cancer Society [ACS] website while the control group used only ACS website for 12 weeks. The outcomes were measured using the SCNS-34SF (needs; primary), the MSAS-SF (symptoms; secondary), and the FACT-B (quality of life; secondary). The data were analyzed using an intent-to-treat approach. The intervention group showed significant reductions in their needs from the baseline (T0) to post 4 weeks (T1) and to post 12 weeks (T2). Although the changes were not statistically significant, the intervention group had decreased symptoms from T0 to T2 while the control group had an increase in their symptoms. The intervention group had a significant increase in their quality of life from T0 to T2. A culturally tailored virtual program could therefore improve quality of life in AABC patients. Trial Registration: To Enhance Breast Cancer Survivorship of Asian Americans (TICAA), NCT02803593, https://clinicaltrials.gov/ct2/show/NCT02803593?titles=TICAA&draw=2&rank=1.

Differences in Symptom Burden in Primary Brain Tumor Patients Based on Sex, Race, and Ethnicity: a Single-Center Retrospective Study

BACKGROUND

Symptom burden affects quality of life and prognosis in primary brain tumor (PBT) patients. Knowing whether symptom burden varies based on sex, race, or ethnicity may affect the interpretation of the relationship between symptoms and survival may reveal issues with applying the tools to measure symptom burden to different groups and may identify inequities in symptom management that need to be addressed at a system level. To determine whether symptoms in PBT patients vary across demographic groups, we conducted a retrospective chart review of symptom burden collected as part of routine care in a diverse population.

METHODS

Patient demographics and scores on the MD Anderson Symptom Inventory-Brain Tumor (MDASI-BT) module were extracted from the electronic medical record for patients seen in the Inova Neuro-oncology Clinic between March 2021 and June 2022. MDASI-BT scores were compared based on side of tumor, sex, race, and ethnicity for the entire population and for the subset with gliomas.

RESULTS

We included 125 people, of whom 85 had gliomas. For both the entire group and the subgroup with gliomas, about 40% were female and about 40% were non-White race. No differences in symptom burden were seen between males and females. Pain and numbness/tingling symptom burden were higher in both the entire population and the glioma subgroup for people of Hispanic/Latino/Spanish ethnicity and for people of races other than White or Middle Eastern self-identification.

CONCLUSIONS

Pain, weakness, and numbness/tingling varied significantly across racial and ethnic groups. Further research is needed to validate this finding in other populations and determine its cause.

Sociodemographic and Clinical Characteristics Associated With Worst Pain Intensity Among Cancer Patients

AIMS

Patients with cancer have pain due to their cancer, the cancer treatment and other causes, and the pain intensity varies considerably between individuals. Additional research is needed to understand the factors associated with worst pain intensity. Our study aim was to determine the association between worst pain intensity and sociodemographics and cancerspecific factors among patients with cancer.

DESIGN

A total of 1,280 patients with cancer recruited from multiple cancer centers over 25 years in the United States were asked to complete a questionnaire that collected respondents' demographic, chronic pain, and cancer-specific information.

SETTINGS

Worst, least, and current pain intensities were captured using a modified McGill Pain Questionnaire (pain intensity measured on 0-10 scale). A generalized linear regression analysis was utilized to assess the associations between significant bivariate predictors and worst pain intensity scores.Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain.

CONCLUSIONS

Our study sample was non-Hispanic White (64.5%), non-Hispanic Black (28.3%), and Hispanic (7.2%). On average, participants were 59.4 (standard deviation = 14.4) years old. The average worst pain intensity score was 6.6 (standard deviation = 2.50). After controlling for selected covariates, being Hispanic (β = 0.6859), previous toothache pain (β = 0.0960), headache pain (β = 0.0549), and stomachache pain (β = 0.0577) were positively associated with worse cancer pain. Notably, year of enrollment was not statistically associated with pain. Findings identified being Hispanic and having previous severe toothache, stomachache, and headache pain as significant predictors of worst pain intensity among patients with cancer. After controlling for selected covariates, we did not note statistical differences in worst pain during a 25-year period. Therefore,studies focused on improving the management of pain among patients with cancer should target interventions for those with Hispanic heritage and those with past history of severe common pain.

Symptom Burden Is Lower in Asian and Pacific Islander and Black Men Admitted to Home-Based Palliative Care in an Integrated Health Care System

Background: Little is known about racial/ethnic differences in symptom severity among patients receiving home-based palliative care (HomePal). Objectives: To determine whether symptom severity differs between White patients and patients of color receiving HomePal and whether gender moderates the difference. Design: This is a cross-sectional exploratory study. Setting/Subjects: Baseline data were from 2090 patients receiving HomePal in Kaiser Permanente Southern California. Measurements: Multivariable median regression analyses were carried out across race/ethnicity groups and stratified by gender to assess differences in Edmonton Symptom Assessment System (ESAS) scores at HomePal admission. Results: Asian/Pacific Islander men and Black men had lower ESAS scores compared than White men (-5 [-7.8, -2.2], p = 0.0005 and -5.4 [-8.7, -2.1], p = 0.001, respectively); there were marginal ESAS differences across race/ethnic groups for women. Conclusion: Patients of color reported lower symptom severity than White patients. More research is needed to understand how the intersection of culture and gender affects symptom experience and reporting in patients living with serious illness. Trial Registration: ClinicalTrials.gov: NCT#03694431.

The Impact of Primary Language Spoken on the Pain Experience of Children With Cancer

The purpose of the current prospective cohort study was to determine if acculturation, measured by primary language spoken, impacts the pain response of children being treated for cancer during an experimental pain task. Sixty-seven Spanish-speaking and English-speaking children ages 6 to 18 years being treated for cancer provided ratings of pain and upset severity during the completion of the cold pressor task (CPT). One week following the CPT, participants provided their recollection of average pain and upset during the CPT. Repeated measures analysis of variance revealed Spanish-speaking children reported significantly higher pain (F1,64=5.58, P=0.02) and upset (F1,64=7.69, P=0.007) ratings during the CPT compared with English-speaking children. Also, Spanish-speaking children were over 4 times as likely to remove their hands from the water before the CPT 4-minute uninformed ceiling compared with English-speaking children (P=0.002). These findings suggest that cultural and contextual factors, including the level of acculturation, are important considerations in the assessment and management of pain in children with cancer. Future research should continue to examine the mechanisms underlying the association between acculturation and the symptom experience for children receiving treatment for cancer.

Cancer Pain: An Evolutionary Concept Analysis

BACKGROUND

Cancer pain is among the most severe types of pain and is among the most common types of cancer-related problems. Yet, many ambiguities surround the concept of cancer pain and its attributes.

OBJECTIVE

This study aimed to analyze the concept of cancer pain.

METHODS

This concept analysis was conducted using the Rodgers' evolutionary method. Nursing, psychology, social sciences, and medicine literature were reviewed through searching online databases. In total, 52 articles were included and analyzed through thematic analysis.

RESULTS/CONCLUSION

The attributes of cancer pain are known origin, sharp, burning, piercing, or throbbing quality, varying duration (acute, chronic, or breakthrough), intolerability, and moderate to severe intensity. Its antecedents are cognitive system, pain-related beliefs, coping strategies, family and social support, financial status, and cultural, ethnic, racial, and religious values. Its consequences include physical, psychological, existential and spiritual, and social consequences, and reduced quality of life. This concept analysis concludes that cancer pain is different from other types of acute and chronic pain. Thus, specific interventions are needed for its assessment and management.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

The results of this concept analysis can broaden the case manager/health care team and other health care providers' knowledge about cancer pain and help them make better decisions and take more effective interventions for its management. The information in the article can be used to inform the case manager/health care team when it may be time to consider palliative care or even hospice care. Also, the information, itself, is crucial for case managers to understand when a patient has cancer pain.

Pain Symptomatology and Management in Pediatric Ehlers-Danlos Syndrome: A Review

Ehlers-Danlos syndromes (EDS) are a group of connective tissue disorders that manifest with hyperextensibility of joints and skin, and general tissue fragility. While not a major criterion for clinical diagnosis, pain is a frequently endorsed symptom across subtypes of EDS. As such, the present review aims to summarize research to date on pain characteristics and management, and the relationship between such pain symptomatology and quality of life in pediatric EDS. Characteristics of pain, including theorized etiology, relative intensity and extent of pain are described, as well as descriptions of frequently endorsed pain sites (musculoskeletal, and non-musculoskeletal). Interventions related to the management of musculoskeletal (e.g., pharmaceutical intervention, physical therapy) and non-musculoskeletal pain (e.g., pharmaceutical and psychological interventions) are discussed, highlighting the need for additional research related to pediatric pain management in the context of hypermobility syndromes. In addition, the relationship between pain in pediatric EDS and quality of life is described. Finally, limitations of literature to date are described and recommendations for future lines of research are outlined.

Decreasing menopausal symptoms of Asian American breast cancer survivors through a technology-based information and coaching/support program

OBJECTIVE

One of the most prevalent and distressing symptoms after breast cancer treatment is menopausal symptoms. Asian American breast cancer survivors have lower quality of life and often receive inadequate management of menopausal symptoms compared to other racial/ethnic groups. Technology-based programs could be a solution to fill the gap in care. The purpose of this study was to test the efficacy of a technology-based information and coaching/support program on menopausal symptoms of Asian American breast cancer survivors.

METHODS

This study adopted a randomized pretest/post-test group design among 91 Asian American breast cancer survivors (42 in an intervention group who used the program and the American Cancer Society Web site and 49 in a control group who used only the American Cancer Society Web site). The intervention was a theory-driven and culturally tailored intervention program that aimed to provide information and coaching/support using computers and mobile devices. Multiple instruments were used to measure background characteristics and menopausal symptoms at pretest, post 1-month, and post 3 months. An intent-to-treat linear mixed-model growth curve analysis was used to analyze the data.

RESULTS

The intervention group showed a significant decrease in the distress scores of menopausal symptoms over time: physical (β = -0.07, P = 0.08), psychological (β = -0.13, P = 0.05), psychosomatic (β = -0.17, P = 0.06), and total symptoms (β = -0.19, P = 0.01). Theory-based variables including attitudes, social influences, and self-efficacy partially mediated the impact of the intervention on the distress scores of menopausal symptoms (P < 0.10).

CONCLUSIONS

The program was effective in alleviating menopausal symptoms of Asian American breast cancer survivors.

Multicultural approaches of cancer pain

PURPOSE OF REVIEW

Pain continues to be a prevalent symptom in cancer patients. Patient's ethnicity may influence the experience of pain with variations in pain outcomes among different ethnic groups. The objective of this thematic review is to investigate the relationship between ethnicity and cancer pain experience, assessment and management.

RECENT FINDINGS

Cancer pain is not only a biophysiological construct but is rather a multidimensional concept of physiological and psychosocial responses, including the biocultural dimension. Culture can significantly affect patients' cancer pain-related beliefs and behaviors and patient's ethnicity may influence the experience of pain.We found a scarcity of data and an inconsistent literature that highlights gaps in knowledge, research and clinical practice concerning effective cancer pain management in a multicultural context.

SUMMARY

To face disparities among ethnic minorities in cancer pain management, well-designed randomized controlled trials and robust qualitative research on cancer pain-related issues should inform good clinical practice. A close worldwide collaboration between researchers and clinicians and professional organizations is warranted.

Pain Knowledge and Attitudes Among Nurses in Cancer Care in Norway

The purpose of this study was to survey knowledge on, and attitudes to, pain and pain management among a cohort of Norwegian Nurses in cancer care, and to explore whether there is any association between various demographic variables and knowledge level. This is a web-based survey and nurses were recruited from the Forum for Cancer Nursing. Nurses completed the questionnaire "Nurses' Knowledge and Attitudes Survey Regarding Pain (NKAS)". Univariate and multivariate linear regression analysis were used to evaluate the association between knowledge and attitudes and demographic variables. Nurses from all over Norway answered. The majority were women and most had education above bachelor level. Mean NKAS total score was 31 points (75%). Significant associations were found between NKAS total score and pain management course (p = 0.01) and workplace (p = 0.04). Nurses in cancer care in Norway have relatively good pain knowledge. The potential for improvement is the greatest with regard to pharmacology and nurses' attitudes to how patients express pain. Our findings suggest that an extensive pain management course with patient histories may result in more theoretical knowledge being applied to the patients. In a time with large migration among nurses, our findings indicate that pain management courses should be aware of cultural differences in the educational training.

Social disparities and symptom burden in populations with advanced cancer: specialist palliative care providers' perspectives

Disparities in access to palliative care services for populations with social disparities have been reported in Western countries. Studies indicate that these populations tend to report higher symptom distress than other population groups. We need to further investigate how social disparities influence symptom burden to improve symptom relief in these populations.

PURPOSE

To examine the perspectives of specialist palliative care providers concerning the relationship between social disparities and symptom burden in populations with advanced cancer.

METHODS

Two sequential qualitative studies that followed a combination of interpretive and critical methodologies. The interpretive approach was outlined by van Manen's hermeneutic phenomenology while the critical component was informed by the works of Paulo Freire. Participants involved two specialist palliative care teams from a large acute care hospital and a large cancer center in Western Canada. Participants included 11 palliative care providers including registered nurses, nurse practitioners, physicians, and pharmacists.

RESULTS

Participants perceived that social conditions that might aggravate symptom burden included low income, low education, lack of social support, language barriers, and rurality. The relationship between income and symptom burden reflected diverse views. Participants identified populations prone to complex symptom burden including homeless individuals, Indigenous people, people with a history of addictions, and people with mental health or psychosocial issues.

CONCLUSION

Participants perceived that social disparities may increase symptom complexity in populations with advanced cancer. Participants did not identify ethnicity and gender as influencing symptom burden. Further research is needed to examine the interactions of social disparities, patient individuality, and symptom burden.

The Relationship between Acculturation and Experimental Pain Sensitivity in Asian Americans with Knee Osteoarthritis

Multiple studies in healthy populations and clinical samples have shown that ethnic minorities have greater pain sensitivity than their majority counterparts. Acculturation is speculated to be one of the sociocultural factors contributing to pain sensitivity since cultural beliefs and practices can influence the way patients perceive and respond to pain. However, the relationship of acculturation to pain sensitivity in minority populations remains poorly understood. Therefore, in this cross-sectional study, we examined the relationship between acculturation and experimental pain sensitivity in 50 Asian Americans residing in North Central Florida with knee osteoarthritis pain. The Suinn-Lew Asian Self Identity Acculturation Scale was used to assess acculturation, and multimodal quantitative sensory testing was performed to measure experimental sensitivity, including heat pain tolerance, pressure pain threshold, and punctate mechanical pain. Descriptive and regression analyses were performed. Participants' mean age was 55.7 years, and about half of this sample were Korean American (56%). The participants had lived in the United States for 21 years on average. Regression analyses indicated that lower acculturation to American culture may contribute to greater experimental pain sensitivity. Asian Americans who were more acculturated to the American culture had higher heat pain tolerance (beta = 0.61, P=0.01), higher pressure pain threshold (beta = 0.59, P=0.02), and lower ratings of punctate mechanical pain (beta = -0.70, P < 0.01). These findings add to the literature regarding sociocultural factors associated with pain in Asian Americans; additional research with a larger and more diverse sample of Asian Americans is warranted for cross-validation.

What to Consider in a Culturally Tailored Technology-Based Intervention?

The purpose of this article is to identify practical issues in implementing a culturally tailored technology-based intervention among Asian American survivors of breast cancer. In a large-scale technology-based breast cancer intervention study, research team members wrote memos on issues in implementing a culturally tailored technology-based intervention and plausible reasons for the issues. Then, the content of the research diaries was analyzed, along with written records of the research team. The practical issues found in the research process included those related to (1) technology literacy and preferences; (2) language issues; (3) cultural attitudes, beliefs, and values; (4) intervention staff competence; (5) security and confidentiality issues; and (6) time and geographical constraints. Based on the issues, several recommendations are proposed for future research using culturally tailored technology-based interventions among racial and ethnic minorities.

Living with Symptoms: A Qualitative Study of Black Adults with Advanced Cancer Living in Poverty

Cancer is associated with disease-related and treatment-related symptoms. Little is known about the symptom experience of black individuals with advanced cancer especially those with limited financial resources. Therefore, the purpose of this study was to explore the symptom experience of black adults with advanced cancer living in poverty. This qualitative descriptive study focused on the perspectives of the participants experiencing at least two symptoms related to cancer. A purposive sample of 27 individuals receiving care at a public hospital in a southeastern city participated in the study. Semi-structured audiotaped interviews were conducted by two research interviewers. Content analysis was used to develop themes to describe the symptom experience. Two main themes emerged in terms of the participants' symptom experiences: (1) "living in pain," which included the overwhelming experience of pain, both physical and emotional, and (2) "symptoms associated with functioning in everyday life." Participants frequently used the context of activities in their daily lives to explain symptoms, including the effect of symptoms on the activities of eating, moving and doing, and communicating. People with advanced cancer work to negotiate a high frequency of multiple distressful symptoms of severe-to-moderate severity. Information gained from this study can help guide research in symptom science and provide direction for clinicians working with this minority group.

Depression and Pain in Asian and White Americans With Knee Osteoarthritis

Few studies have examined the underlying psychosocial mechanisms of pain in Asian Americans. Using the biopsychosocial model, we sought to determine whether variations in depression contribute to racial group differences in symptomatic knee osteoarthritis pain between Asian Americans and non-Hispanic white Americans. The sample consisted of 100 participants, including 50 Asian Americans (28 Korean Americans, 9 Chinese Americans, 7 Japanese Americans, 5 Filipino Americans, and 1 Indian American) and 50 age- and sex-matched non-Hispanic white Americans with symptomatic knee osteoarthritis pain. The Centers for Epidemiologic Studies Depression Scale was used to assess symptoms of depression, and the Western Ontario and McMaster Universities Osteoarthritis Index and the Graded Chronic Pain Scale were used to measure clinical pain. In addition, quantitative sensory testing was used to measure experimental sensitivity to heat- and mechanically-induced pain. The results indicated that higher levels of depression in Asian Americans may contribute to greater clinical pain and experimental pain sensitivity. These findings add to the growing literature regarding ethnic and racial differences in pain and its associated psychological conditions, and additional research is warranted to strengthen these findings.

PERSPECTIVE

This article shows the contribution of depression to clinical pain and experimental pain sensitivity in Asian Americans with knee osteoarthritis. Our results suggest that Asian Americans have higher levels of depressive symptoms and that depression plays a relevant role in greater clinical pain and experimental pain sensitivity in Asian Americans.

Differences in Clinical Pain and Experimental Pain Sensitivity Between Asian Americans and Whites With Knee Osteoarthritis

OBJECTIVE

Ethnicity has been associated with clinical and experimental pain responses. Whereas ethnic disparities in pain in other minority groups compared with whites are well described, pain in Asian Americans remains poorly understood. The purpose of this study was to characterize differences in clinical pain intensity and experimental pain sensitivity among older Asian American and non-Hispanic white (NHW) participants with knee osteoarthritis (OA).

METHODS

Data were collected from 50 Asian Americans ages 45 to 85 (28 Korean, 9 Chinese, 7 Japanese, 5 Filipino, and 1 Indian) and compared with 50 age-matched and sex-matched NHW individuals with symptomatic knee OA pain. The Western Ontario and McMaster Universities Osteoarthritis Index and Graded Chronic Pain Scale were used to assess the intensity of clinical knee pain. In addition, quantitative sensory testing was used to measure experimental sensitivity to heat-induced and mechanically induced pain.

RESULTS

Asian American participants had significantly higher levels of clinical pain intensity than NHW participants with knee OA. In addition, Asian American participants had significantly higher experimental pain sensitivity than NHW participants with knee OA.

DISCUSSION

These findings add to the growing literature regarding ethnic and racial differences in clinical pain intensity and experimental pain sensitivity. Asian Americans in particular may be at risk for clinical pain and heightened experimental pain sensitivity. Further investigation is needed to identify the mechanisms underlying ethnic group differences in pain between Asian Americans and NHWs, and to ensure that ethnic group disparities in pain are ameliorated.

Consistency and Accuracy of Multiple Pain Scales Measured in Cancer Patients From Multiple Ethnic Groups

BACKGROUND

Standardized pain-intensity measurement across different tools would enable practitioners to have confidence in clinical decision making for pain management.

OBJECTIVES

The purpose was to examine the degree of agreement among unidimensional pain scales and to determine the accuracy of the multidimensional pain scales in the diagnosis of severe pain.

METHODS

A secondary analysis was performed. The sample included a convenience sample of 480 cancer patients recruited from both the Internet and community settings. Cancer pain was measured using the Verbal Descriptor Scale (VDS), the visual analog scale (VAS), the Faces Pain Scale (FPS), the McGill Pain Questionnaire-Short Form (MPQ-SF), and the Brief Pain Inventory-Short Form (BPI-SF). Data were analyzed using a multivariate analysis of variance and a receiver operating characteristic curve.

RESULTS

The agreement between the VDS and VAS was 77.25%, whereas the agreement was 71.88% and 71.60% between the VDS and FPS, and VAS and FPS, respectively. The MPQ-SF and BPI-SF yielded high accuracy in the diagnosis of severe pain. Cutoff points for severe pain were more than 8 for the MPQ-SF and more than 14 for the BPI-SF, which exhibited high sensitivity and relatively low specificity.

CONCLUSION

The study found substantial agreement between the unidimensional pain scales and high accuracy of the MPQ-SF and the BPI-SF in the diagnosis of severe pain.

IMPLICATIONS FOR PRACTICE

Use of 1 or more pain screening tools that have validated diagnostic accuracy and consistency will help classify pain effectively and subsequently promote optimal pain control in multiethnic groups of cancer patients.

The Influence of Social Structure on Cancer Pain and Quality of Life

The aim of this study was to investigate whether social structure is associated with cancer pain and quality of life using the Social Structure and Personality Research Framework. This study was a secondary analysis of data from 480 cancer patients. The measurements included socioeconomic variables, self-reported cancer pain using the McGill Pain Questionnaire–Short Form (MPQ-SF), and quality of life measured using the Functional Assessment of Cancer Therapy Scale (FACT-G). The data were analyzed using moderated multiple regression. Cancer pain and quality of life differed significantly with income. The associations between income and pain and quality of life were significant only for the high education group (≥ partial college), and these associations were greater for Caucasians than for their counterparts ( p < .05). When developing interventions, nurses should consider the influence of socioeconomic variables on pain and quality of life while considering possible moderating factors such as education.

Issues in Developing and Evaluating a Culturally Tailored Internet Cancer Support Group

The purpose of this article is to explore practical issues in developing and implementing a culturally tailored Internet Cancer Support Group for a group of ethnic minority patients with cancer-Asian Americans. Throughout the research process of the original study testing the Internet cancer support group, the research team made written records of practical issues and plausible rationales for the issues. Weekly group discussion among research team members was conducted, and the discussion records were evaluated and analyzed using a content analysis (with individual words as the unit of analysis). The codes from the analysis process were categorized into idea themes, through which the issues were extracted. The issues included those in (1) difficulties in using multiple languages, (2) collaboration with the information technology department and technical challenges, (3) difficulties in recruitment, (4) difficulties in retention, (5) optimal timing, and (6) characteristics of the users. Based on the findings, we suggest that researchers plan a workable translation process, check technical needs in advance, use multiple strategies to recruit and retain research participants, plan the right time for data collection, and consider characteristics of the users in the study design.

Dopamine D3 receptor knockout mice exhibit abnormal nociception in a sex-different manner

Pain is a complex and subjective experience. Previous studies have shown that mice lacking the dopamine D3 receptor (D3RKO) exhibit hypoalgesia, indicating a role of the D3 receptor in modulation of nociception. Given that there are sex differences in pain perception, there may be differences in responses to nociceptive stimuli between male and female D3RKO mice. In the current study, we examined the role of the D3 receptor in modulating nociception in male and female D3RKO mice. Acute thermal pain was modeled by hot-plate test. This test was performed at different temperatures including 52°C, 55°C, and 58°C. The von Frey hair test was applied to evaluate mechanical pain. And persistent pain produced by peripheral tissue injury and inflammation was modeled by formalin test. In the hot-plate test, compared with wild-type (WT) mice, D3RKO mice generally exhibited longer latencies at each of the three temperatures. Specially, male D3RKO mice showed hypoalgesia compared with male WT mice when the temperature was 55°C, while for the female mice, there was a statistical difference between genotypes when the test condition was 52°C. In the von Frey hair test, both male and female D3RKO mice exhibited hypoalgesia. In the formalin test, the male D3RKO mice displayed a similar nociceptive behavior as their sex-matched WT littermates, whereas significantly depressed late-phase formalin-induced nociceptive behaviors were observed in the female mutants. These findings indicated that the D3 receptor affects nociceptive behaviors in a sex-specific manner and that its absence induces more analgesic behavior in the female knockout mice. © 2016 Wiley Periodicals, Inc.

Update on Prevalence of Pain in Patients With Cancer: Systematic Review and Meta-Analysis

CONTEXT

Cancer pain has a severe impact on quality of life and is associated with numerous psychosocial responses. Recent studies suggest that treatment of cancer pain has improved during the last decade.

OBJECTIVES

The aim of this review was to examine the present status of pain prevalence and pain severity in patients with cancer.

METHODS

A systematic search of the literature published between September 2005 and January 2014 was performed using the databases PubMed, Medline, Embase, CINAHL, and Cochrane. Articles in English or Dutch that reported on the prevalence of cancer pain in an adult population were included. Titles and abstracts were screened by two authors independently, after which full texts were evaluated and assessed on methodological quality. Study details and pain characteristics were extracted from the articles with adequate study quality. Prevalence rates were pooled with meta-analysis; meta-regression was performed to explore determinants of pain prevalence.

RESULTS

Of 4117 titles, 122 studies were selected for the meta-analyses on pain (117 studies, n = 63,533) and pain severity (52 studies, n = 32,261). Pain prevalence rates were 39.3% after curative treatment; 55.0% during anticancer treatment; and 66.4% in advanced, metastatic, or terminal disease. Moderate to severe pain (numerical rating scale score ≥5) was reported by 38.0% of all patients.

CONCLUSION

Despite increased attention on assessment and management, pain continues to be a prevalent symptom in patients with cancer. In the upcoming decade, we need to overcome barriers toward effective pain treatment and develop and implement interventions to optimally manage pain in patients with cancer.

Immigration transition and sleep-related symptoms experienced during menopausal transition

The transition due to immigration from one country to another country (referred to as immigration transition henceforth) is inherently stressful, placing an additional dimension of stress to midlife women in the menopausal transition. However, few studies have examined the association of immigration to sleep-related symptoms experienced by midlife women in the menopausal transition. The authors' purpose for this study was to explore the associations of immigration to sleep-related symptoms among four major racial/ethnic groups of 1,054 midlife women in the United States. This was a secondary analysis of data from two national surveys that were collected from 2005 to 2013. The instruments included questions on background characteristics, health and menopausal status, immigration transition, and the Sleep Index for Midlife Women. The data were analyzed using t-tests, chi-square tests, correlation analyses, and hierarchical multiple regression analyses. Immigrants reported fewer total numbers of and lower total severity scores of sleep-related symptoms than non-immigrants (p < .01). Yet, when background characteristics and health and menopausal status were controlled, self-reported racial/ethnic identity was the only significant factor associated with sleep-related symptoms (ΔR² = 0.02, p < .01). Health-care providers need to consider self-reported racial/ethnic identity as a factor significantly related to sleep-related symptoms during the menopausal transition.

Non-pharmacological cancer pain interventions in populations with social disparities: a systematic review and meta-analysis

INTRODUCTION

Global advances in pain relief have improved the quality of life of cancer populations. Yet, variation in cancer pain outcomes has been found in populations with social disparities compared to mainstream groups. Populations with social disparities bear an inequitable distribution of resources such as ethnic minorities, low income individuals, and women in vulnerable circumstances.

RESEARCH PURPOSE

A systematic review and meta-analysis of the effect of non-pharmacological cancer pain interventions in cancer populations with social disparities of income, ethnicity, or gender.

METHODS

Randomized controlled trials, controlled trials, and before and after studies were targeted through comprehensive multidatabase searches. Two reviewers independently screened titles/abstracts for potentially relevant studies and reviewed the full text of relevant articles for inclusion. Data were extracted from included studies by one reviewer and verified by another reviewer. Four reviewers independently completed quality assessment. Studies were grouped by intervention. Effects were evaluated for heterogeneity and pooled.

RESULTS

The search found 5219 potential records. Full text of 26 reports was evaluated. Three randomized controlled trials (RCTs) met inclusion criteria, targeting ethnic minorities and underserved populations and/or women. Interventions included education, coaching, and online support groups. Studies found no significant differences in pain reduction between intervention and control groups or between ethnic minorities and their counterparts. A high risk of bias was found in all studies. Meta-analysis found no statistically significant difference on pain intensity among underserved groups, ethnic minorities, or between ethnic minorities and white counterparts.

CONCLUSION

Results show the need to examine supportive care interventions particularly in populations with social disparities.

Non-pharmacological cancer pain interventions in populations with social disparities: a systematic review and meta-analysis

INTRODUCTION

Global advances in pain relief have improved the quality of life of cancer populations. Yet, variation in cancer pain outcomes has been found in populations with social disparities compared to mainstream groups. Populations with social disparities bear an inequitable distribution of resources such as ethnic minorities, low income individuals, and women in vulnerable circumstances.

RESEARCH PURPOSE

A systematic review and meta-analysis of the effect of non-pharmacological cancer pain interventions in cancer populations with social disparities of income, ethnicity, or gender.

METHODS

Randomized controlled trials, controlled trials, and before and after studies were targeted through comprehensive multidatabase searches. Two reviewers independently screened titles/abstracts for potentially relevant studies and reviewed the full text of relevant articles for inclusion. Data were extracted from included studies by one reviewer and verified by another reviewer. Four reviewers independently completed quality assessment. Studies were grouped by intervention. Effects were evaluated for heterogeneity and pooled.

RESULTS

The search found 5219 potential records. Full text of 26 reports was evaluated. Three randomized controlled trials (RCTs) met inclusion criteria, targeting ethnic minorities and underserved populations and/or women. Interventions included education, coaching, and online support groups. Studies found no significant differences in pain reduction between intervention and control groups or between ethnic minorities and their counterparts. A high risk of bias was found in all studies. Meta-analysis found no statistically significant difference on pain intensity among underserved groups, ethnic minorities, or between ethnic minorities and white counterparts.

CONCLUSION

Results show the need to examine supportive care interventions particularly in populations with social disparities.

Apoyo con Cariño: a pilot randomized controlled trial of a patient navigator intervention to improve palliative care outcomes for Latinos with serious illness

CONTEXT

Latinos experience significant health disparities at the end of life compared with non-Latinos.

OBJECTIVES

To determine the feasibility of a patient navigator intervention to improve palliative care outcomes for Latino adults with serious illness.

METHODS

This was a pilot randomized controlled trial that included 64 Latino adults with life-limiting illness randomized to an intervention or a control group. All participants received a packet of linguistically matched materials on palliative care. In addition, intervention participants received up to five home visits from the bilingual, bicultural patient navigator. Visits focused on addressing barriers to palliative care through education, activation, and culturally tailored messaging. Outcomes included feasibility and advance care planning rates, documentation of pain management discussions in the medical record, and hospice utilization.

RESULTS

Of the 32 patients randomized to the intervention arm, 81% had at least one home visit (range 1-5) with the patient navigator. Overall, advance care planning was higher in the intervention group (47% [n = 15] vs. 25% [n = 8], P = 0.06), and 79% of intervention participants had a discussion about pain management documented in their medical record vs. 54% of control patients (P = 0.05). Hospice enrollment between the two groups (n = 18 decedents) was similar (n = 7 intervention vs. n = 6 control); length of stay in the intervention group was 36.4 ± 51.6 vs. 19.7 ± 33.6 days for control patients (P = 0.39).

CONCLUSION

A culturally tailored patient navigator intervention was feasible and suggests improved palliative care outcomes for Latinos facing advanced medical illness, justifying a fully powered randomized controlled trial.

Unresolved Pain Interference among Colorectal Cancer Survivors: Implications for Patient Care and Outcomes

OBJECTIVE

Using a large sample of colorectal cancer (CRC) survivors we 1) describe pain interference (PI) prevalence across the cancer continuum; 2) identify demographic and clinical factors associated with PI and changes in PI; and 3) examine PI's relationship with survivors' job changes.

METHODS

CRC participants of the Cancer Care Outcomes Research and Surveillance Consortium completed surveys during the initial phase of care (baseline, < 1 year, n = 2,961) and follow-up (about 1-year postdiagnosis, n = 2,303). PI was measured using the SF-12 item. Multiple logistic regression was used to identify predictors of PI. Model 1 evaluated moderate/high PI at baseline, Model 2 evaluated new/continued/increasing PI postdiagnosis follow-up, and Model 3 restricted to participants with baseline PI (N = 603) and evaluated predictors of equivalent/increasing PI. Multivariable logistic regression was also used to examine whether PI predicted job change.

RESULTS

At baseline and follow-up, 24.7% and 23.7% of participants reported moderate/high PI, respectively. Among those with baseline PI, 46% had equivalent/increasing PI at follow-up. Near diagnosis and at follow-up, female gender, comorbidities, depression, chemotherapy and radiation were associated with moderate/high PI while older age was protective of PI. Pulmonary disease and heart failure comorbidities were associated with equivalent/increasing PI. PI was significantly associated with no longer having a job at follow-up among employed survivors.

CONCLUSION

Almost half of survivors with PI during the initial phase of care had continued PI into post-treatment. Comorbidities, especially cardiovascular and pulmonary conditions, contributed to continued PI. PI may be related to continuing normal activities, that is, work, after completed treatment.

Hispanic Inpatient Pain Intensity

Hispanic adults experience significant pain, but little is known about their pain during hospitalization. The purpose of this research was to describe Hispanic inpatients' pain intensity and compare their pain intensity with that of non-Hispanic patients. A post hoc descriptive design was used to examine 1,466 Hispanic inpatients' medical records (63.2% English speakers) and 12,977 non-Hispanic inpatients' medical records from one hospital for 2012. Mean documented pain intensity was mild for both Hispanic and non-Hispanic inpatients. Pain intensity was greater for English-speaking Hispanic patients than Spanish speakers. The odds of being documented with moderate or greater pain intensity decreased 30% for Spanish-speaking patients. Greater pain intensity documented for English-speaking Hispanic inpatients suggests underreporting of pain intensity by Spanish-speaking patients. Practitioners should use interpreter services when assessing and treating pain with patients who speak languages different from the practitioners' language(s).

African Americans’ Perceptions of Pain and Pain Management

Purpose: The purpose of this systematic review is to explore the perceptions of acute, persistent, and disease-specific pain and treatment options held by adult African Americans. Underassessment and undermanagement of pain in African Americans has been well documented; however, the cultural continuum of pain perceptions and their influence on pain assessment and management has not been synthesized. Design: Electronic database searches of the Cumulative Index for Nursing and Allied Health Literature and PubMed, Web-based searches of the pain-specific journals plus a manual search of reference lists identified 41 relevant articles addressing perceptions of pain and/or pain management. Findings: Analysis of the literature revealed six themes: (a) meaning of pain, (b) description of pain, (c) coping with pain, (d) impact of pain, (e) patient–provider relationship, and (f) treatment approaches. Conclusion: These findings warrant further research and indicate the need for more precise evaluation of pain in African Americans, highlighting an imperative to incorporate cultural patterns into pain management practice and education.

African American cancer survivors: do cultural factors influence symptom distress?

PURPOSE

The purpose of this study was to examine how the cultural factors, stigma, being strong, and religiosity influence symptom distress in African American cancer survivors.

METHODS

This descriptive correlational study was designed using the Sociocultural Stress and Coping Framework. Seventy-seven African American cancer survivors, recruited from oncology clinics and the community in North Carolina, completed a questionnaire that consisted of measures of demographic and illness characteristics, the Perceived Stigma Scale, the Ways of Helping Questionnaire, the Religious Involvement Scale, and the Symptom Distress Scale.

RESULTS

The two cultural factors that were significantly associated with symptom distress were stigma (β = .23, p < .05) and organized religion (β = -.50, p < .05). No significant associations were found between being strong or nonorganized religiosity and symptom distress. The most commonly reported symptoms were fatigue (M = 2.44, SD = 1.20), pain (M = 2.26, SD = 1.43), and insomnia (M = 1.95, SD = 1.25).

CONCLUSIONS

The findings of this study indicate that the cultural factors, stigma, and organized religiosity were significantly associated with symptom distress.

IMPLICATIONS FOR PRACTICE

The results from this study can be used to guide researchers in developing culturally appropriate interventions aimed at alleviating symptom distress in African American cancer survivors.

Predictors of Quality of Life in Cancer Survivors: White and Asian American Women

The purpose of this study is to compare the pathways through which multiple contextual factors influence the quality of life in Asian American and White women living with cancer. This is a secondary analysis of the data from 95 Asian American women and 113 White women. The data were analyzed using hierarchical multiple regression analyses and structural equation modeling. Multiple factors explained higher percent of total variances of the quality of life scores in Whites compared with that in Asian Americans.

Clinical features of depression in Asia: results of a large prospective, cross-sectional study

INTRODUCTION

The objective of this study was to investigate the clinical features of depression in Asian patients.

METHODS

It was a cross-sectional, observational study of depression in China, Korea, Malaysia, Singapore, Taiwan, and Thailand. Participants were drug-free outpatients with depressed mood and/or anhedonia. Symptoms and clinical features were assessed using the Montgomery-Asberg Depression Rating Scale, Symptoms Checklist 90-Revised (SCL-90-R), and the Fatigue Severity Scale. Other measures included the Medical Outcome Survey 36-Item Short-Form Health Survey (SF-36), the Sheehan Disability Scale, and the Multidimensional Scale of Perceived Social Support (MSPSS).

RESULTS

A total of 547 outpatients with major depressive disorder were included in the analyses. Among the Montgomery-Asberg Depression Rating Scale symptoms, "reported sadness" and "reduced sleep" had the highest severity, with means (SDs) of 3.4 (1.2) and 3.4 (1.6), respectively. Apart from the SCL-90-R depression and anxiety domains, the SCL-90-R obsession-compulsion syndrome had the highest domain score, with a mean (SD) of 1.9 (0.9). Among eight domains, the mean (SD) SF-36 pain subscale score of 58.4 (27.7) was only second to that for the SF-36 physical function. In comparison to other disability domains, the Sheehan Disability Scale work/school had the highest subscale score, with a mean (SD) of 6.5 (2.9). The mean (SD) MSPSS "family" subscale score of 4.7 (1.7) was higher than the MSPSS "friends" and "significant others" subscale scores.

DISCUSSION

This study suggests that pain has a minimal impact on the quality of life in Asian patients with depression. Noteworthy issues in this population may include insomnia, obsessive-compulsive symptoms, working/school disability, and family support.

Sexual activity and body image: examining gender variability and the influence of psychological distress in cancer patients

Psychosocial factors impacting on the overall quality of life for cancer patients may differ between men and women. This study examined the influence that psychological distress, clinical, and social variables have on sexual activity and body image in adult oncology patients. Symptom data was collected from the Memorial Symptom Assessment Scale (MSAS). Analysis indicated women and patients with reported functional limitations were more likely to be less satisfied with how they looked. The final model showed that younger adults, Caucasians, those who were married and patients with some functional limitations were more likely to have problems with sexual interest/activity. Gender was not a significant predictor of having problems with sexual interest/activity. These results can be used by clinicians to identify patients who may be at an increased risk for negative body image and problems in sexual functioning. Further research regarding gender differences in cancer-related psychological symptoms is needed to assist healthcare professionals in providing comprehensive care while alleviating unresolved and interrelated health and psychosocial symptoms.

Practical guidelines for feminist research in nursing

With increasing interests in oppressed groups, the number of feminist studies in nursing has steadily increased. Despite the increasing number of feminist studies, very few articles have been written to provide practical guidelines for feminist research in nursing. In this article, guidelines for feminist research in nursing are proposed on the basis of 3 previous feminist studies. First, characteristics of feminist research are concisely described. Then, the 3 studies that are the basis for the guidelines are described. Finally, practical guidelines for feminist nursing research are proposed on the basis of 10 idea categories related to issues/concerns from the 3 studies.

Long-term breast cancer survivors' symptoms and morbidity: differences by sexual orientation?

PURPOSE

Because little is known about morbidity and symptoms among sexual minority women with breast cancer, that is, lesbian or bisexual-identified women, and women with a preference for a woman partner, we examined differences by sexual orientation in long-term survivors' symptoms and morbidity, considering arm morbidity, systemic therapy side effects, hypertension, and number of comorbidities.

METHODS

From a state cancer registry, we recruited 257 heterosexual and 69 sexual minority women (SMW) with a diagnosis of primary, nonmetastatic breast cancer. To increase the number of SMW, we used convenience recruitment methods and obtained an additional 112 SMW who fit the same eligibility criteria as the registry-derived sample. Using a telephone survey, we collected demographic and self-reported data on arm morbidity and systematic therapy side effects, using the European Organization for Research and Treatment of Cancer Quality of Life scale, QLQ-BR23 and a comorbidity measure developed for breast cancer survivors.

RESULTS

Sexual orientation was more strongly associated with arm morbidity and systemic side effects than with high blood pressure and comorbidities. Sexual orientation related indirectly to systemic side effects and arm morbidity through cancer treatments and some demographic factors.

CONCLUSIONS

Our finding that SMW respond more negatively to certain cancer treatments compared to heterosexual women suggests an opportunity to intervene with education and support for SMW breast cancer survivors for whom these life-saving treatments are necessary.

IMPLICATIONS FOR CANCER SURVIVORS

Because breast cancer survivors are at risk for multiple severe and persistent symptoms, assessing such symptoms is an important aspect of survivorship care. Cultural differences in perception of symptoms, communication issues, cultural barriers to reporting of symptoms, and different cultural norms about expressing pain or impairments have been established by studies. Knowledge about differences in impairment and symptoms by sexual orientation will help providers' efforts to provide high quality care to breast cancer survivors and may enhance cancer survivorship.

Practical guidelines for qualitative research using online forums

With an increasing number of Internet research in general, the number of qualitative Internet studies has recently increased. Online forums are one of the most frequently used qualitative Internet research methods. Despite an increasing number of online forum studies, very few articles have been written to provide practical guidelines to conduct an online forum as a qualitative research method. In this article, practical guidelines in using an online forum as a qualitative research method are proposed based on three previous online forum studies. First, the three studies are concisely described. Practical guidelines are proposed based on nine idea categories related to issues in the three studies: (a) a fit with research purpose and questions, (b) logistics, (c) electronic versus conventional informed consent process, (d) structure and functionality of online forums, (e) interdisciplinary team, (f) screening methods, (g) languages, (h) data analysis methods, and (i) getting participants' feedback.

Symptom clusters among multiethnic groups of cancer patients with pain

OBJECTIVE

Considering recent inconsistent findings on ethnic differences in cancer pain experience, there is a need to clarify the association of ethnicity to cancer pain experience through diverse approaches. However, there currently exist only a small number of studies on ethnic differences in cancer pain experience in general, and few symptom cluster studies specifically related to ethnic differences in cancer pain experience. The purpose of this study was to cluster cancer patients who reported similar cancer pain experience, and to determine ethnic differences in the clusters.

METHOD

This was a secondary analysis of the data from a larger Internet study on cancer pain experience of four major ethnic groups of cancer patients in the United States. Only 388 subjects who responded to the questions on cancer pain, cancer symptoms, and functional status were included for this secondary analysis. The data were analyzed using hierarchical cluster analysis and multinomial logistic analysis.

RESULTS

A three-cluster solution was adopted: 1) Cluster 1 with low pain, low symptoms, and high functional status, 2) Cluster 2 with moderate pain, low symptoms, and moderate functional staus, and 3) Cluster 3 with high pain, moderate symptoms, and low functional status. In Cluster 2, there were ethnic difference in the cancer pain and funtional status scores; Asian Americans reported lower pain scores than did other ethnic groups, and African Americans had higher funtional status scores than did other ethnic groups. In Cluster 3, there were ethnic difference in the symptom scores (p < 0.05); African Americans reported higher symptom scores than did whites.

SIGNIFICANCE OF RESULTS

The results of this study add an important piece of information on ethnic differences in symptom clusters. This study suggests further national scope studies on clustering multiethnic groups of cancer patients by cancer pain experience.

Predictors of cancer-related pain improvement over time

OBJECTIVE

To determine the predictors of pain improvement among patients being treated for cancer-related pain over 12 months.

METHODS

A secondary analysis of the telephone care Indiana Cancer Pain and Depression trial was performed. Patients (n = 274) were interviewed at baseline and after 1, 3, 6, and 12 months. Pain improvement outcomes included both a continuous measure (Brief Pain Inventory score) and a categorical measure (pain improved versus pain not improved). Predictor variables included change in depression, age, sex, race, marital status, socioeconomic disadvantage, medical comorbidity, type of cancer, and phase of cancer. Multivariable repeated measures were conducted, adjusting for intervention group assignment, baseline pain severity, and time in months since baseline assessment.

RESULTS

Factors significantly predicting both continuous and categorical pain improvement included participating in the intervention group (β = -0.92, p < .001, odds ratio [OR] = 2.53, 95% confidence interval [CI] = 1.65-3.89), greater improvement in depression (β = -0.31, p = .003, OR = 1.84, 95% CI = 1.35-2.51), higher socioeconomic status (Socioeconomic Disadvantage index; β = 0.25, p = .034; OR = 0.73, 95% CI = 0.56-0.94), and fewer comorbid conditions (β = 0.20, p = .002; OR = 0.84, 95% CI = 0.73-0.96). Patients with more severe pain at baseline or with recurrent or progressive cancer were less likely to experience continuous or categorical pain improvement, respectively.

CONCLUSIONS

Effective management of depression and comorbid conditions along with improvement of social services could be critical components of a comprehensive pain management. Patients with more severe pain or with recurrent or progressive cancers may require closer monitoring and adequate treatment of pain. Trial Registration clinicaltrials.gov Identifier: NCT00313573.

Pain outcomes of inpatient pain and palliative care consultations: differences by race and diagnosis

BACKGROUND

Pain management disparities exist among patients not receiving palliative care. We examined pain outcomes for disparities among patients receiving palliative care.

METHODS

At a 542-bed teaching hospital in Honolulu, The Queens' Medical Center Pain and Palliative Care Department collected patient characteristics and pain severity (initial, final) for each consultation from 2005 through 2009. Analyses compared pain levels by race (white, Asian, Hawaiian/Pacific Islander [PI], other) and consultation diagnosis (cancer, noncancer medical, surgical [59% orthopedic], other). Multiple regression models analyzed factors associated with lower final pain levels and pain reduction.

RESULTS

Study population included 4658 patients. No final pain was reported by more non-white patients (33%-39%) than white (27%, p<0.0001) and more cancer and noncancer medical patients (45%-54%) than surgical/other patients (20%-31%, p<0.0001). Asian (adjusted odds ratio [aOR] 1.24; 95% confidence interval [CI] 1.06-1.46; p=0.007) and PI (aOR 1.46, 95% CI 1.20-1.77, p=0.0001) races had increased likelihoods of lower final pain severity versus whites, controlling for age, gender, Karnofsky score, preconsult length of stay, and initial pain severity. Surgical diagnoses had decreased likelihood of lower final pain levels versus cancer (aOR 0.38, 95% CI 0.32-0.46, p<0.0001). Among 2304 patients reporting moderate/severe initial pain, 1738 (75.4%) reported pain reduction to mild/no final pain. PI race was associated with pain reduction versus whites (aOR 1.57, 95% CI 1.17-2.10, p=0.003). Surgical diagnoses had decreased likelihood of pain reduction vs. cancer (aOR 0.52, 95% CI 0.39-0.71, p<0.0001).

CONCLUSION

Pain outcomes were similar or better among non-white races than whites. Surgical patients reported more final pain than cancer patients.

Hospice referrals and code status: outcomes of inpatient palliative care consultations among Asian Americans and Pacific Islanders with cancer

CONTEXT

Intensive palliative care consultations for plan of care may reduce racial differences in end-of-life care.

OBJECTIVES

To compare cancer patients' hospice referrals and code status changes after inpatient palliative care consultations by patient ethnicity and consultation intensity.

METHODS

This observational cohort study prospectively recorded data for all adult cancer patients receiving palliative care consultations at the largest teaching hospital in Hawaii from 2005 through 2009. Chi-squared analyses compared hospice referral and code status changes with "Do Not Attempt Resuscitation" by patient characteristics and consultation intensity (more intensive plan of care vs. pain and/or symptom management without plan of care). Multiple logistic regression models analyzed factors associated with hospice referral and code status change.

RESULTS

The 1362 consultations generated 454 (33.3%) hospice referrals and 234 (17.2%) code status changes. Controlling for age, gender, Karnofsky score, and preconsultation hospital days, Asian, Pacific Islander, and "other" ethnicities demonstrated increased likelihood of hospice referral vs. whites (adjusted odds ratios [AORs] 1.46-2.34, P<0.05). Intensive plan-of-care consultations were strongly associated with hospice referral (AOR 3.08, 95% confidence interval [CI] 2.33-4.07, P<0.0001). Controlling for consultation intensity reduced the association between ethnicity and hospice referral (AORs 1.35-2.06, P=0.03, "other" ethnicity; P=nonsignificant, Asian and Pacific Islander). Intensive consultations were strongly associated with code status change (AOR 2.96; 95% CI 2.08-4.22, P<0.0001). Ethnicity was not significantly associated with code status change.

CONCLUSION

Consultation intensity was the strongest predictor of hospice referrals and code status changes and reduced the ethnic variations associated with hospice referral.

The DSCP-CA: a decision support computer program--cancer pain management

The purpose of this study was to develop a decision support system using fuzzy logic that would support nurses' decisions about cancer pain management, especially for ethnic minority cancer patients. The study had two phases: (1) data collection and (2) development of the decision support computer program. In the data collection phase, an Internet survey of 428 cancer patients and four ethnic-specific online forums (about 30 participants per forum) were conducted to gather data on the cancer pain experience of the four major ethnic groups in the United States. The development phase included two components: (1) development of three modules, including a knowledge base module, a decision module, and a self-adaptation module; and (2) a 3-month evaluation of the decision support computer program by oncology nurses and subsequent incorporation of their feedback into the program. The Internet survey and online forum data were processed into fuzzy and crisp data sets, and ethnic-specific algorithms for the decision module were developed. Using the self-adaptation module, the decision support computer program was further refined as additional data were processed. Then, the decision support computer program was further developed by adding additional components suggested by the oncology nurses.

The Use of Internet Cancer Support Groups by Asian Americans and White Americans Living With Cancer

Purpose: To explore the use of Internet cancer support groups (UICSG) by Asians and Whites living with cancer and determine the factors influencing their UICSG. Design and Method: A cross-sectional Internet study among 30 Asians and 30 Whites. The instruments included (a) questions on sociodemographic and cultural factors, and disease status, (b) the Support Care Needs Survey-34 Short Form, (c) the 2003 Health Information National Trends Survey subscale on Internet usage, and (d) the UICSG Questionnaire. The data were analyzed using the Wilcoxon rank-sum test and nonparametric multiple regression analyses. Results: There was a significant ethnic difference in the UICSG, but there were no ethnic differences in general Internet use or needs for help. Across the ethnic groups, the significant factors influencing the UICSG included “self-reported ethnic identity,” “born in the United States,” and “general Internet use.” Conclusion: Nurses should consider the cultural factors that influence the UICSG.

Defining racial and ethnic disparities in pain management

BACKGROUND

Substantial pain prevalence is as high as 40% in community populations. There is consistent evidence that racial/ethnic minority individuals are overrepresented among those who experience such pain and whose pain management is inadequate.

QUESTIONS/PURPOSES

The objectives of this paper are to (1) define parameters of and summarize evidence pertinent to racial/ethnic minority disparities in pain management, (2) identify factors contributing to observed disparities, and (3) identify strategies to minimize the disparities.

METHODS

Scientific literature was selectively reviewed addressing pain epidemiology, differences in pain management of non-Hispanic whites versus racial/ethnic minority groups, and patient and physician factors contributing to such differences.

RESULTS

Racial/ethnic minorities consistently receive less adequate treatment for acute and chronic pain than non-Hispanic whites, even after controlling for age, gender, and pain intensity. Pain intensity underreporting appears to be a major contribution of minority individuals to pain management disparities. The major contribution by physicians to such disparities appears to reflect limited awareness of their own cultural beliefs and stereotypes regarding pain, minority individuals, and use of narcotic analgesics.

CONCLUSIONS

Racial/ethnic minority patients with pain need to be empowered to accurately report pain intensity levels, and physicians who treat such patients need to acknowledge their own belief systems regarding pain and develop strategies to overcome unconscious, but potentially harmful, negative stereotyping of minority patients.