Cancer Pain, Anxiety, and Depression in Admitted Patients at a Tertiary Care Hospital: A Prospective Observational Study

INTRODUCTION

Pain is one of the most common and studied symptoms in cancer patients. Cancer pain has a multimodal etiology-primary disease process, treatment effects, metastatic pathology, and sequelae in survivors. Cancer diagnosis resulting in high levels of emotional distress is a well-known human fact and is also established in studies.[12] Psychological symptoms of distress such as depression and anxiety are known to occur in a significant number of cancer patients and survivors.[34] These psychological symptoms may result in alteration of the patient's capability to tolerate the illness burden as well as various difficult treatment regimens that may have extended hospitalization. This may eventually result in worsening of quality of life and an appreciable increase in suicide risk.[56] Depression and pain are causally inter-related, where one may cause the other.[78] Spiegel et al., 1994[9] have, in fact, argued that pain may cause depression and that the same neurotransmitter pathways are shared by both depression and pain.

The total pain experienced by a cancer patient varies with a number of psychological factors, these factors may alter the pain perception not only in terms of intensity of pain but also the suffering experienced by the patient.[10] These psychological factors have not been well studied. Quantitative studies evaluating the association of cancer pain and distress symptoms such as depression and anxiety in a prospective manner are required in the Indian scenario. This study was designed to determine the anxiety and depression score in admitted cancer patients and correlate with their pain score.

SUBJECTS AND METHODS

RESULTS

A total of 393 patients were enrolled in the study and included in the analysis. There were 54.2% of female patients; the overall mean age was 52.1 years ± 13.84 standard deviation. Majority (83.7%) patients were in the age group 30–69 years. The most common primary sites of cancer in male were head and neck, hematological, and gastrointestinal; in female were genitourinary, breast, and gastrointestinal in that order. The most common pathology was carcinoma (78.6%). It was interesting to note that only 30% of patients were in the early stage of cancer, and 31.8% of patients had metastasis. Around half the patients had received chemotherapy (56.2%) or surgery (43%), but only 14.5% of patients had received radiotherapy [Table 1].

It was found that 41.5% of patients had moderate or severe pain at admission. The prevalence of anxiety was 20.3%, and depression was 24.8% [Table 2].

DISCUSSION

A meta-analysis on the prevalence of any type of cancer pain was published by van den Beuken-van Everdingen et al.[11] They found the prevalence of cancer pain to be 39.3%, 55.0%, and 66.4% after curative treatment, during anticancer treatment and in advanced or terminal disease, respectively. Moderate-to-severe pain, using NPS score was reported in 38.0% (NPS > 4) of all patients in the meta-analysis. In the present study, the NPS score of 4–10 indicating moderate or severe pain was found in 41.5% of patients.

In our study, one-fourth patients were found to have depression and one-fifth anxiety. These distress symptoms cannot be neglected because various studies have conclusively shown an association between depressive disorders and reduction in quality-of-life indices, compliance to treatment modalities, the psychological perception of different physical symptoms and most importantly prognosis. In a meta-analysis, in cancer patients, the pooled mean prevalence of depression ranged from 8% to 24%.[12]

Cancer pain is now recognized as the fifth vital sign. Depression and anxiety in cancer patients is still not evaluated and recorded routinely. Bhatnagar et al.,[13] in their retrospective review of 686 pain assessment forms found that function psychological symptoms were recorded at a low rate-anxiety 1.2% and depression 4.4% in cancer patients. Many cancer patients imagine a prolonged, painful dying process and equate cancer with death and treatments which may be debilitating to say the least. Cancer is perceived as threat and a source of anxiety in many. Assimilating medical information relating to cancer and making informed medical decisions is often overwhelming for patients – all while continuing to manage various responsibilities such as family, work, and other. Cancer care professionals must recognize anxiety early and mange it in cancer patient populations. The challenge lies in judging if the anxiety in a patient is disproportionate to the threat presented by cancer since it is to be realized that the disease is associated with some real threat in every case. It may be normal for the patient to experience anxiety for 7–10 days after receiving the bad news. The levels of this normal anxiety may vary as the degree of real threat varies with the history and progression of cancer. Not only cancer but also treatment can affect the psychosocial well-being, placing these patients at risk of depression,[14] sleep dysfunction and fatigue[15] during treatment and on follow-up. Kandasamy et al., 2011[16] found in advanced cancer patients that spiritual well-being was a significant component of the quality of life, and that it was closely related to various physical and psychological symptoms of distress, especially in palliative care setting.

Worsening pain may increase psychological distress symptoms such as depression and anxiety, and the effect is evident across the cancer disease spectrum. Zaza and Baine,[17] in their systematic review, found a strong association between cancer pain and psychological distress (mood disturbance, anxiety, and depression). In this study, we found that as the severity of pain increased; the prevalence of anxiety increased by 23.6%, and depression by 19%. Melkam Alemayehu et al.,[18] found OR of major depressive illness to be four in patients with pain than in patients with no pain. In this study, the OR of depression was 2.29, and anxiety 4.44 in patients with pain as compared to patients with no pain. In a study on Indian patients, Lewis et al.,[19] found a positive correlation between distress and pain score in 30 patients receiving radiation therapy for the head-and-neck cancer. In the present study, the linear correlation between pain and anxiety or depression was mildly positive, but it was moderately positive between anxiety and depression.

CONCLUSIONS

The prevalence of moderate and severe pain is high in admitted cancer patients in this study. A fair proportion of cancer patients have anxiety and depression which needs to be recognized and addressed adequately. There is strong association between the presence and severity of pain and distress symptoms such as anxiety and depression in admitted cancer patients at all stages of disease. However, the results of this study are not enough to conclude the causality of depression and anxiety in cancer patients to the pain they experience, further cohort studies are required to better understand this important aspect.