1. Predictors of Cancer-related Pain Improvement over 12 Months Hsiao-Lan Wang, PhD, RN, CMSRN, HFS Assistant Professor University of South Florida September, 2012

2. Team School of Medicine, Indiana University –Kurt Kroenke, MD –Jingwei Wu, MS –Wanzhu Tu, PhD Community Cancer Care and Community Health Network –Dale Theobald, MD, PhD School of Nursing, Indiana University –Susan M Rawl, PhD, RN, FAA

3. Acknowledgment National Cancer Institute grant awarded to Dr. Kronenke (R01 CA115369) National Institute of Nursing Research grant awarded to Dr. Wang (T32 NR007066), Indiana University.

4. Introduction Cancer-related Pain 1.6 million new cases of cancer in 2012 64% experienced cancer-related pain. 82% reported pain was undertreated by analgesia.

5. Introduction Factors related to Pain In addition to analgesics, other factors that may influence pain include: age, gender, race, socioeconomic status, comorbid conditions type of cancer, and phase of cancer. The relationship between pain and depression is well known.

6. Introduction A need to analyze in a longitudinal dataset Indiana Cancer Pain and Depression (INCPAD) Study – A randomized clinical trial to test a 12-month telephone care management intervention targeted to improve pain and/or depression –Enrolled cancer survivors from 16 urban/rural outpatient oncology clinics, IN (03/06 – 08/08). –Moderate pain improvement among patients being treated for cancer-related pain and/or depression Reference: Kroenke K, Theobald D, Wu J, Norton K, Morrison G, Carpenter J, Tu W. Effect of telecare management on pain and depression in patients with cancer: a randomized trial. JAMA. 2010; 304:163–71.

7. Research Question What are the predictors of pain improvement among patients being treated for cancer-related pain over 12 months?

8. Methods Inclusion Criteria –moderately severe cancer-related pain (BPI worst pain severity score ≥ 6) Pain occurred in the region of the primary tumor or cancer metastases and/or occurring after the onset of cancer treatment. –and/or moderately severe depression (a Patient Health Questionnaire 9-item depression scale [PHQ-9] score ≥ 10, with depressed mood and/or anhedonia).

9. Methods Exclusion Criteria –Not speak English –Moderately severe cognitive impairment –Schizophrenia or other psychoses; –A disability claim being adjudicated for pain –Pregnant –Hospice care –Pre-existing non-cancer related pain

10. Methods Secondary Analysis 274 participants who had cancer-related pain (with or without depression) –Intervention Group: 137 –Control Group: 137 Data were collected at baseline (T0), 1 month (T1), 3 months (T3), 6 months (T6), and 12 months (T12) after enrollment. Telephone Interviewer were blinded to group assignment.

11. Methods Outcome Variables Cancer-related Pain Continuous Variable: –Brief Pain Inventory (BPI) severity scale (α = 0.79) –A 0 (no pain) to 10 (pain as bad as you can imagine) point scale Binary Variable –Pain Global Rating of Improvement (PGRI) –1 as “pain improved” and 0 as “pain not improved”

12. Methods Predictor Variables Demographics –age, gender, race, marital status, and Socioeconomic Disadvantage (SED) Index. Baseline clinical factors – medical comorbidity, type of cancer, and phase of cancer Depression –Hopkins Symptom Checklist 20 item (HSCL-20) depression scale (α = 0.79) –20 items; a scale of 0 to 5

13. Statistical Anlysis Repeated measures modeling for the predictive relationship. Developed a full model by adjusting for –group assignment, –baseline BPI severity, and –time in months since baseline assessment.

14. Baseline CharacteristicsM (SD)n (%) Age58.08 (10.54) SED Index1.30 (0.98) Comorbidity (# of Diseases)2.09 (1.68) Female Gender181 (66.06) Caucasians212 (77.37) Married130 (47.45) Type of Cancer Breast Lung GI Lymph/Hema GU Others 70 (25.55) 53 (19.34) 51 (18.61) 40 (14.60) 27 (9.85) 33 (14.60) Phase of Cancer Newly Diagnosed Maintenance/Disease Free Recurrent/Progressive 104 (37.96) 110 (40.15) 60 (21.90)

15. Multivariate Predictors of Cancer-related Pain Outcome Variables BPI Severity ScorePain Global Rating of Improvement BetatpOdds Ratio 95% CIp Intervention Group-.92-4.68<.0012.531.65 – 3.89<.001 Baseline BPI.559.84<.001.90.80 – 1.02.08 Time (Months from Baseline)-.04-2.89.0041.11.05-1.14<.001 Predictor Variables Improvement in Depression (HSCL-20) SED Index Medical Comorbidity Phase of Cancer Newly-diagnosed vs. Recurrent/progressive Maintenance/disease-free vs. Recurrent/progressive -.31.25.20 -.43.09 -2.97 2.12 3.05 -1.53.32.003.034.002.07 1.84.73.84 2.12 1.11 1.35 – 2.51.56 –.94.73 –.96 1.15 – 3.90.61 – 1.99 <.001.016.015.014

16. Discussion Beneficial association between improvement in depression and pain outcomes in cancer patients over time. Negative relationship between socioeconomic disadvantage and cancer- related pain improvement.

17. Discussion Patients with a greater number of comorbid medical conditions were less likely to report improvement in their cancer-related pain. Patients with recurrent or progressive cancer had worse pain outcomes over 12 months than those who were newly- diagnosed

18. Limitations Selection bias: The INCPAD enrollment criteria. Only supported a temporal linkage from improvement in depression to lower pain.