Methods
Study Design and Setting
The study utilized a cross-sectional study design and was carried out in the
Oncology section of Mayo Hospital in Lahore, which is one of the largest tertiary
care hospitals in Pakistan. The data were collected in the first months of the year
2025. The objective of the study was to determine the degree of pain acceptance in
cancer patients who experienced chronic pain and the association between it and
psychological distress.
Participants and Recruitment
Eligible study subjects were adult cancer patients (18 years and above) who met
the following criteria: they reported pain that had lasted at least three consecutive
months and the pain was daily or nearly daily. Patients whose psychosis or cognitive
functions were known, or those with communication problems, or those who had
undergone any psychotherapies and behavioral interventions in the last three
months were excluded. The recruited participants were identified sequentially at the
inpatient oncology ward and outpatient oncology ward. Each of the participants was
presented with the purpose and procedures of the study, and written informed
consent was obtained. Participation was voluntary and anonymous, and the
respondents were assured that they could quit at any time without any repercussion
on their care. All questionnaires were filled individually or with the assistance of the
investigators in case of a need. All incomplete responses were not used in the final
dataset.
Study Instruments
The structured questionnaire, as a method of data collection, had three
components:
(a) Sociodemographic and Clinical Data: This section included questions about
age, gender, education, marital status, monthly income, time since diagnosis,
cancer stage, and variables associated with the pain like the number of pain areas,
the duration the pain had been present, and the use of analgesics.
(b) Pain Acceptance: Pain acceptance was assessed using the 8-item Chronic Pain
Acceptance Questionnaire (CPAQ-8), which is a valid short version of the original
CPAQ-20. There were four items measuring activity engagement (item 1, 3, 5, and
6), and four items measuring pain willingness (2, 4, 7, and 8). Each item was rated
on a 7-point Likert scale (0 = never true to 6 = always true). The total scores
ranged between 0 and 48 after reversing scores of the pain willingness subscale,
and high scores indicated a greater willingness to accept chronic pain. The English
version was administered, but to achieve a better understanding and ensure
conceptual appreciation and homogeneity among the respondents, every item was
orally clarified in Urdu.
(c) Anxiety and Depression: Psychological distress was measured with the help
of the Hospital Anxiety and Depression Scale (HADS), which contains two subscales,
anxiety (HADS-A) and depression (HADS-D), and includes 14 items. The rating of
each item was based on a 4-point scale (0–3), where a higher score represented
symptom severity. The total scores provided a general understanding of
psychological distress.
Data Handling and Statistical Analysis
Two independent researchers entered and cross-checked the data to achieve
accuracy. The summary of sociodemographic and clinical characteristics was
summarized using descriptive statistics. The CPAQ-8 and HADS scores were
considered continuous, and sociodemographic and pain-related features were
considered categorical. Independent samples t-tests and one-way analysis of
variance (ANOVA) were used for group comparison. Upon revealing significant
results with ANOVA, post hoc tests were applied: the Games-Howell test was used in
case of violation of Levene’s test of homogeneity of variances. In the ass
umption of equal variances, the Tukey HSD test was used. Pearson’s correlation
coefficients were used to analyze the correlation between variables of psychological
distress (HADS-A, HADS-D, and total HADS scores) and pain acceptance. Multiple
linear regression analysis was done to determine independent predictors of pain
acceptance, including variables significant in the univariate analyses. All tests were
considered statistically significant at p < 0.05. IBM SPSS statistics, Version 22.0, was
used to perform the analyses.