Patients with cancer who report higher levels of anxiety and depression experience more intense pain associated with their diseases, according to a new study.

Social support, such as having support from family or friends in times of illness, was found to reduce that relationship.

Researchers from Atrium Health’s Levine Cancer Institute, a community-based multisite academic hybrid institution in North Carolina, observed the associations in a diverse patient group, meaning the mental health–pain connection may be a widespread occurrence.

“What we found is that there’s certainly a need to evaluate for psychological psychiatric symptoms when addressing pain. Anxiety, depression and social support are modifiable factors that can greatly impact a patient’s pain experience,” said study author Sarah Kathryn Galloway, PhD, a psychologist in the Department of Supportive Oncology at the institute. “This [study] also demonstrates the need for interdisciplinary multimodal care, so [using] both pharmaceutical and nonpharmaceutical interventions for pain. Psychiatric and social factors can differentially impact patients across their journey with cancer.”

Anxiety and depression commonly occur in patients with cancer and are highly comorbid with pain (Psychosomatics 2018;59[5]:464-471). Dr. Galloway said while clinicians know that social support can be beneficial for coping, recovery and adaptation to chronic disease, mixed evidence exists on the relationship between cancer pain and social support. “In some studies, social support is associated with decreased pain intensity, and in others, we find no association between social support and pain intensity,” Dr. Galloway said.

This retrospective analysis included patients participating in a tablet-based psychosocial screening on their first consultation with a cancer specialist at Levine Institute, from January 2017 to January 2019. Approximately 11,815 patients with stage I through IV cancer were matched to the Atrium Health cancer registry , with a final sample of 7,333 patients. Those with noncancer pain were excluded from the study.

Patients rated their pain over the past two weeks on a scale of zero to 10, their depression using the Patient Health Questionnaire-2, and their anxiety with the Generalized Anxiety Disorder 2-item scale. The researchers created a proxy to measure social support of four different items that targeted both the quality and presence of emotional and instrumental support, asking whether:

• someone is available to listen to the patient when they need to talk;
• problems are occurring with the patient’s personal relationships;
• someone is available to help the patient when sick; and
• the patient is having problems getting to treatment.

The sample, although somewhat diverse demographically (Table), was roughly divided across disease stages, with slightly more patients having stage I disease. The mean level of pain was 3, with 17% of the sample having severe pain. The mean level of anxiety was 1.4, with 21% of the sample having clinically significant anxiety. The mean level of depression was 1.1, with 18% of the sample having clinically significant depression. “In terms of social support, the mean score was 6.5,” Dr. Galloway said. “Patients [reporting] severe pain were both younger, had lower levels of education, and lower household incomes.”The researchers also found that a higher percentage of American Indian and black patients reported severe pain than those who were white. “This is a very interesting finding and something that we are going to start to dive a little bit further into,” Dr. Galloway said. “As you might expect, there was a statistically significant difference with patients of advanced disease endorsing severe pain. There were a higher percentage of patients with tumors at the thoracic, musculoskeletal, gastrointestinal and gynecologic sites that endorsed severe pain.”

The findings were presented at the 2019 Supportive Care in Oncology Symposium and published in the Journal of Clinical Oncology (2019;37[suppl 31]:76).

Pain Relief From the Community

For patients screened within three months of diagnosis and then one year after diagnosis, social support and depression were significantly related to pain intensity, after accounting for a large swath of demographic characteristics, including age, race/ethnicity and tumor site. As depression increased, pain increased (P<0.001), and as social support increased, pain decreased (P=0.009). A similar pattern was seen for anxiety as depression. “Anxiety, depression and social support was independently predictive of pain intensity, and this relationship held for both patients within three months of diagnosis and those greater than one year at diagnosis,” Dr. Galloway said. “At one year from diagnosis, the effect of depression, anxiety and pain differs by level of social support.”

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In a discussion of the study at the meeting, Richard T. Lee, MD, an associate professor in the Division of Hematology and Oncology at Case Western Reserve School of Medicine, in Cleveland, said the research was significant. He was impressed that more than 20% of the patients in the study were minorities. Symptom clusters are really important to keep in mind, as symptoms do not generally occur by themselves, Dr. Lee said.

“One of the great findings here is that anxiety, depression and social support independently predict pain intensity. I think it is important to understand how all different types of symptoms interact with each other and that social support can modulate anxiety and depression,” he said. “I’ve had patients who report worse pain, but I come to find out it’s really not that their pain is worse, but that they’ve run into an issue with their job or their insurance coverage, and now they can’t afford their pain medicine. There are so many different factors to pain.”

—Kate O’Rourke

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Drs. Galloway and Lee reported no relevant financial disclosures.