Exploring the role of pain catastrophizing in anxiety and depression among breast cancer survivors

Abstract

BACKGROUND:

Breast cancer is the most frequently diagnosed cancer in women worldwide. Breast cancer survivors (BCSs) often face chronic adverse effects besides pain and pain catastrophizing (PC), including anxiety and depression. To understand how cognitive processes influence mental health outcomes in this population, it is important to investigate the relationship between PC and symptoms of anxiety and depression. This study aimed to explore the relationship between PC with anxiety and depression in BCS.

MATERIALS AND METHODS:

A total of 205 Iranian women with breast cancer participated (Mean = 43.55, SD = 4.92). They were gathered from two hospitals using a continuous sampling technique. The data were obtained by using four questionnaires, including a sociodemographic and disease information questionnaire, pain catastrophizing scale (PCS), Hamilton Anxiety Inventory (HAI), and Beck Depression Inventory – Short Form (BDI-s).

RESULTS:

Most participants (76.1%) reported low levels of PC, while 39.0% and 22.9% had high levels of depression and anxiety, respectively. Strong positive correlations were observed between these variables. PC was significantly correlated with depression (r = 0.80, P < 0.001) and anxiety (r = 0.77, P < 0.001). Similarly, depression was strongly associated with anxiety (r = 0.84, P < 0.001).

CONCLUSION:

This study confirms evidence that when there is more severe PC, greater levels of anxiety and depression are observed due to the presence of pain, cancer diagnosis, and treatment.

Introduction

Breast cancer encompasses various malignancies of the mammary glands and is the most prevalent cancer around the world. Breast cancer prevalence in the United States and Europe is twice that of Asian countries, although rates are rising across all regions. The lower prevalence in Asia has been linked to traditional lifestyles. However, socioeconomic development and cultural shifts, including having fewer children, later childbirth, and shorter breastfeeding durations, have increased breast cancer risk in Asia.[1] The incidence and mortality rate of this disease have had an increasing trend in Iran.[2] Analysis of Iranian cancer registry data from 2008 to 2016 estimated a 63% increase in breast cancer cases until 2025, reaching 25,013 diagnoses. This growing trend highlights the significance of implementing national cancer control strategies.[3]

Being disease-free does not necessarily mean being symptom-free, as breast cancer survivors (BCSs) experience persistent and debilitating side effects of treatment. Chronic pain, affecting about one-third of survivors, is among the most common and distressing issues. Pain is one of the most invalidating, debilitating side effects of cancer.[4] Awareness of psychological elements, such as cognitive assessments and expectations, which have been shown to be significant predictors of the pain experience, has increased in line with new understandings of the multifaceted nature of pain. In recent decades, a growing body of research has proved the vital role of psychological factors in the experience of pain.[5] Among these factors, pain catastrophizing (PC) is one of the most important psychological aspects of pain that has a significant role in greater disability. PC is currently described as an exaggerated negative emotional state triggered by real or predicted painful experiences.[6] PC has been related to poor functional outcomes, including reduced quality of life and increased disability, and may also cause elevated psychological distress, such as anxiety and depression.[7]

However, BCS frequently faces other chronic adverse effects besides pain and PC. This population also suffers from several symptoms, including anxiety and depression. Cancer diagnosis often causes psychological distress. Anxiety and depression are among the most prevalent emotional responses. These factors can arise due to the nature of the disease, its treatments, and their related physical and social consequences.[8] According to a study, cancer patients experience more severe forms of depression and anxiety than people in general. Although these symptoms rarely occur alone, most of them have been addressed separately up to this point. Consequently, recent research has grouped related and concurrent symptoms to gain a better understanding of their common genesis and impact, which could result in the creation of novel and efficient treatments.[9]

Anxiety and depression are two psychological challenges that BCSs frequently face, and PC has been identified as a critical psychological factor that may exacerbate these emotional difficulties. This study uniquely focused on the relationship between PC, anxiety, and depression among BCS in an Iranian population. While previous studies have explored these variables independently, this research integrates them to comprehensively understand how PC contributes to psychological distress in BCS. Notably, it highlights the cultural and clinical context of Iranian women, an understudied population in this area. To understand how cognitive processes influence mental health outcomes in this population, it is important to investigate the relationship between PC and symptoms of anxiety and depression. The results of this study aimed to provide insights into the mechanisms linking pain-related cognitive distortions with emotional well-being, thereby providing a basis for developing targeted psychological interventions. In summary, this study aimed to explore the relationship between PC with anxiety and depression in BCS.

Materials and Methods

Study design and setting

This study employed a cross-sectional design to investigate the relationship between pain catastrophizing with anxiety and depression among BCS. The research was conducted at two hospitals affiliated with Iran University of Medical Sciences.

Study participants and sampling

The study included 205 Iranian women diagnosed with breast cancer (Mean = 43.55 SD = 4.92) who had completed active treatment at least six months before the study. Participants were required to meet the following inclusion criteria: (1) female gender, (2) age 18 years or older, (3) ability to speak Persian, and (4) ability to understand and complete the questionnaires. Pregnant women, patients with incomplete sociodemographic information, and patients with intellectual disabilities or cognitive impairment were excluded from the study. A continuous sampling technique was employed to recruit participants. Eligible individuals were consecutively enrolled during their follow-up visits to the selected hospitals over the three-month data collection period. This method ensured that all eligible patients who visited the clinics during the study timeline were included in the sample. According to each hospital’s policies, different periods were chosen to gather data from survivors. The informed written consent form was obtained from the participants. After agreeing to participate, patients were escorted by the researchers into a private room for data collection. Participants were reassured that their place in the queue would not be lost while they were completing data collection. Data were collected by the researchers through reading each question to the participants.

Sample size justification

The sample size of 205 participants was determined based on a power analysis to detect significant correlations among PC, anxiety, and depression. The expected effect size (r = 0.30), significance level (α = 0.05), and power (β = 0.80) justified this sample size as sufficient for robust statistical analyses. This sampling approach ensured a representative sample of BCS actively engaged in follow-up care, providing reliable data for examining the study objectives.

Data collection tools and techniques

Data for this study were collected using validated and reliable questionnaires designed to measure PC, anxiety, depression, and demographic/clinical characteristics.

Sociodemographic and disease information questionnaire

It was developed by the researcher to capture information, including age, marital status, level of education, employment status, economic profile, cancer stage, and treatment history.

Pain catastrophizing scale (PCS)

It was developed by Sullivan in 1995. This questionnaire has 13 questions and aims to assess the level of PC. This questionnaire measures PC in three subscales: rumination, magnification, and helplessness and is based on a Likert scale that is scored from 1 (not at all) to 5 (always). By summing the scores of the respondents to the questions, a total score for the questionnaire is obtained.[10]

Hamilton Anxiety Inventory (HAI)

It was designed by Hamilton et al.[11] in 1959. An interviewer scores this 14-item questionnaire and covers a wide range of symptoms that are commonly recognized as symptoms of an anxiety state. It is scored on a five-point Likert scale from none (0), mild (1), moderate (2), severe (3), to very severe (4). By determining the score for each item and adding the scores for these 14 items, the final total score is obtained.

Beck Depression Inventory – Short Form (BDI-s)

It was designed by Beck in 1967. This questionnaire consists of 13 self-report items that describe specific symptoms of depression and is adapted from the 21-question form of this questionnaire. Each item of this questionnaire consists of a four-point Likert scale, scored from 0 to 3, and a total score is obtained from the sum of the item scores.[12]

Ethical consideration

Ethical approval was obtained from the Institutional Review Board of Iran University of Medical Sciences under the approval code #IR.IUMS.REC.1403.453.

Statistical analysis

Data were analyzed using Stata Statistical Software (Release 14. College Station, TX: StataCorp LLC). Descriptive statistics were utilized to summarize the sociodemographic characteristics and psychological outcomes, including PC, depression, and anxiety. Continuous variables were reported as means and standard deviations, while categorical variables were summarized using frequencies and percentages. Relationships between sociodemographic factors and psychological outcomes were assessed using independent t-tests, ANOVA, and Pearson correlation coefficients, with a significance level set at P < 0.05. Prior to performing regression analyses, the assumptions of linear regression were tested to ensure the validity of the models. The normality of residuals was evaluated using the Kolmogorov-Smirnov test and Q-Q plots. The PC variable exhibited non-normality and was, therefore, subjected to a square root transformation, which successfully normalized the variable for inclusion in the regression models. Depression and anxiety variables followed an approximately normal distribution without requiring transformations. Multicollinearity was assessed using the variance inflation factor (VIF), with all predictors demonstrating VIF values below 10, indicating no significant multicollinearity issues. Residual independence was confirmed using the Durbin-Watson statistic, which showed no significant autocorrelation. Linear regression analyses were performed separately for PC, depression, and anxiety to identify significant predictors, with statistical significance set at P < 0.05. These steps ensured that the models met the necessary assumptions, enabling robust and reliable interpretation of the results.

Results

Sociodemographic characteristics and their associations with pain catastrophizing, depression, and anxiety

The mean age of the participants was 43.55 years (SD = 4.92). Age showed no statistically significant association with PC, depression, or anxiety scores (P = 0.21, P = 0.54, and P = 0.29, respectively). Similarly, the time since the last surgery and time since cancer diagnosis did not exhibit significant relationships with PC or anxiety but showed a marginal association with depression (P = 0.02).

Marital status showed significant associations with PC and anxiety (both P = 0.05), with single participants reporting higher scores compared to their married counterparts. Educational level demonstrated significant associations with all three psychological outcomes, with non-university-educated participants reporting higher PC, depression, and anxiety scores (P = 0.003, P = 0.01, and P = 0.02, respectively). Employment status and income levels also showed significant associations with anxiety (P = 0.04 and P = 0.02, respectively). Notably, type of surgery was significantly associated with PC, depression, and anxiety, with mastectomy being linked to higher scores compared to lumpectomy (all P < 0.001).

Levels of PC, depression, and anxiety

The overall mean scores for PC, depression, and anxiety were 10.14 (SD = 7.77), 13.57 (SD = 7.41), and 17.37 (SD = 9.35), respectively. A total of 76.1%, 15.1%, and 8.8% of participants reported low, moderate, and high levels of PC, respectively. A total of 25.9%, 35.1%, and 39% of participants reported low, moderate, and high levels of depression, respectively. A total of 54.1%, 22.9%, and 22.9% of participants reported low, moderate, and high levels of depression, respectively [Table 1].

Table 1.

The levels of pain catastrophizing, depression, and anxiety (n=205)

		Range		Overall score M (SD)		Mean score M (SD)		Low n (%)		Moderate n (%)		High n (%)
Pain catastrophizing		0–34		10.14 (7.77)		9.16 (7.34)		156 (76.1)		31 (15.1)		18 (8.8)
Depression		0–29		13.57 (7.41)		12.38 (6.81)		53 (25.9)		72 (35.1)		80 (39.0)
Anxiety		2–41		17.37 (9.35)		16.45 (8.81)		111 (54.1)		47 (22.9)		47 (22.9)

The mean score of PCS: 0–15: low level; 15–24: moderate level; ≤24: high level. The mean score of depression scale: 0–7: low level; 8–15: moderate level; 16–39: high level. The mean score of anxiety scale: 0–17: low level; 18–24: moderate level; ≤25: high level. SD=Standard deviation

Correlation analysis

Strong positive correlations were observed between these variables. PC was significantly correlated with depression (r = 0.80, P < 0.001) and anxiety (r = 0.77, P < 0.001). Similarly, depression was strongly correlated with anxiety (r = 0.84, P < 0.001). Table 2 illustrates the correlations between PC, depression, and anxiety [Table 3].

Table 2.

The regression analysis showing predictors of pain catastrophizing, depression, and anxiety (n=205)

Outcome variable		Independent variables				95% confidence interval				SE		t		P
		Predictor		Stand. estimate		Lower		Upper
Pain catastrophizing F=101 P≤0.001 R2=0.67 Adjusted R2=0.66		Patient’s age		−0.221		−0.35		−0.09		0.02		−3.35		<0.001
		Last surgery (in months)		−0.16		−0.27		−0.04		0.02		−2.60		0.01
		Type of surgery
		Mastectomy		−0.50		−0.71		−0.19		0.17		−3.41		<0.001
		Marital status
		Married		−0.37		−0.67		−0.08		0.20		−2.48		0.02
		Cancer stage
		Stage II		0.42		0.13		0.70		0.1866		2.92		0.004
		Stage III		1.359		0.64		2.08		0.48		3.75		<0 .001
		Radiotherapy
		Yes		0.28		0.02		0.53		0.17		2.16		0.03
		Educational level
		University-level		−0.39		−0.66		−0.13		0.18		−2.93		<0.001
Depression F=101 P≤0.001 R2=0.67 Adjusted R2=0.66		Cancer stage
		Stage II		0.35		0.16		0.54		0.71		3.65		<0 .001
		Stage III		0.63		0.11		1.14		1.92		2.41		0.017
		Last surgery (in months)		−0.12		−0.21		−0.04		0.08		−2.94		0.004
		Pain catastrophizing		0.71		0.62		0.80		0.26		15.65		<0.001
Anxiety F=161 P≤0.001 R2=0.62 Adjusted R2=0.61		Type of surgery
		Mastectomy		−0.27		−0.46		−0.09		0.87		−2.91		0.004
		Pain catastrophizing		0.73		0.63		0.82		0.33		15.49		<0.001

R²=R-square, SE=Standard error

Table 3.

Correlation between pain catastrophizing, depression, and anxiety (n=205)

Variable		Statistic		Pain catastrophizing		Depression		Anxiety
Pain catastrophizing		Pearson’s r		1
		P		—
		95% CI upper		—
		95% CI lower		—
Depression		Pearson’s r		0.80		1
		P		< 0.001		—
		95% CI upper		0.84		—
		95% CI lower		0.74		—
Anxiety		Pearson’s r		0.77		0.84		1
		P		< 0.001		<0 .001		—
		95% CI upper		0.82		0.878		—
		95% CI lower		0.71		0.797		—

CI=Confidence Interval

Predictors of psychological outcomes

Regression analyses [Table 2] identified several predictors of PC, depression, and anxiety:

Pain catastrophizing

Significant predictors included patient age (β = −.221, P < 0.001), time since last surgery (β = −0.16, P = 0.01), type of surgery (mastectomy; β = −0.50, P < 0.001), and cancer stage. Higher cancer stages (II and III) were associated with increased PC scores (P = 0.004 and P < 0.001, respectively).

Depression

Cancer stage and PC emerged as key predictors. Stage II and III cancers were associated with higher depression scores (β = 0.35, P < 0.001; β = 0.63, P = 0.017, respectively). PC was the strongest predictor of depression (β = 0.71, P < 0.001).

Anxiety

Predictors included type of surgery (mastectomy; β = −0.27, P = 0.004) and PC (β = 0.73, P < 0.001).

The R² values for the regression models ranged from 0.30 to 0.66, indicating that a substantial proportion of variance in the outcomes was explained by the predictors.

Discussion

This study aimed to determine the relationship between anxiety and depression with PC in BCS. The results of this study demonstrate a strong correlation between BCSs’ pain catastrophizing with anxiety and depression, which is consistent with earlier studies that emphasize the psychological effects that chronic pain and anticipated pain due to cancer have on this population.

According to the study by Kardash et al. (2024),[13] there is a very strong and positive relationship between pain severity and PC with depressive symptoms. In other words, there was a significant indirect effect between pain severity and depressive symptoms mediated by PC. In addition, self-efficacy in pain is inversely related to depressive symptoms and pain severity. In the study by Kazi et al. (2021),[14] there was a significant relationship between PC with anxiety and depression, as well as the quality of life of patients. Although this study was conducted on patients with rhinosinusitis pain. In the study by Gudmunsoon et al. (2021),[15] it was shown that the direction of PC is consistent with anxiety and depression and also has a negative effect on patient performance, which decreases with the improvement of patient performance. Also, in the study by Hadlandsmyth et al. (2020),[16] the effect of PC on anxiety levels, depression, and quality of life was found to be effective.

Among individuals with various pain conditions, it is found that PC may affect anxiety and depression. This highlights the significance of PC in the context of mental health outcomes.[17] In another study by Mercadante et al. (2024),[6] PC and increased depression were associated to increased pain interference in cancer patients over time, suggesting that addressing psychological disorders is necessary for effective management. In a study by Chana et al. (2021),[18] there was a significant relationship between PC and high levels of anxiety in patients with burning mouth syndrome. In another study by Wilson et al. (2022),[19] it was shown that greater loneliness was associated with higher PC through increased depression, highlighting the importance of addressing depressive symptoms to prevent worsened PC. Identification of these psychological factors can help develop targeted interventions that might benefit patients with breast cancer experiencing depressive symptoms.[20]

The results of this study showed that there is a negative and significant relationship between PC with age, the time since the last surgery, type of surgery (lumpectomy or mastectomy), and level of education. A positive and significant relationship was observed between PC with radiotherapy and the disease stage. In the study of Shabangu et al. (2023),[21]there was also a significant relationship between age and the feeling of chronic pain, and also, there was no significant relationship between people who feel pain and people who do not feel pain with PC. Also, in another study, there is a positive correlation between age and PC, which means that young people tend to have more PC and depression after chronic pain.[18] In the study of İnci et al. (2020),[22] a significant relationship was found between education level and PC. These results are aligned with our study and emphasize how crucial it is to modify interventions to meet the particular requirements of BCS, especially those, who are younger, have had mastectomy surgery and higher stage of the disease, or have less education.

In this study, it was found that there is a positive and significant relationship between depression with higher stages of breast cancer and also anxiety has been linked to the type of surgery. These results are in line with earlier studies showing that patients with advanced stages of breast cancer are more likely to experience depressive symptoms.[23] In another study by Trinca et al. (2019),[24] patients with advanced stages of breast cancer tend to show higher depressive symptoms compared to those with earlier stages. This relationship can be due to several factors, including symptom severity, distant metastasis, and the psychological burden of BC diagnosis. Furthermore, patients with a history of depression before BC diagnosis are more likely to experience depression during their cancer treatment. On the other hand, one important factor was the type of surgery; patients who had mastectomy reported more PC than those who had lumpectomy. This is in line with the study by Shorofi et al. (2021)[25] that patients who have undergone mastectomy may experience depressive disorder. This underscores the importance of early identification and management of depressive symptoms.

Finally, it can be said that various studies conducted on different patients who experienced pain acutely or chronically have shown that their results were consistent with the results of our study, and all of this can be a reason to confirm our work. In this regard, no study was found that showed an inverse relationship between PC and levels of anxiety and depression. This could be because the nature of pain and the subjective concept of pain are associated with depression, and anxiety is considered a reactive response to pain.

Implications for practice and future research

The findings of this study, which investigates the relationship between PC with anxiety and depression in BCS, can have significant implications for clinical practice and future research. These findings highlight how crucial it is for healthcare providers, especially nurses and oncologists, to regularly evaluate psychological distress and PC in BCS. Early detection of PC can serve as a vital intervention point since it is a modifiable risk factor for anxiety and depression. Implementing evidence-based treatments in patient care plans, including mindfulness-based stress reduction (MBSR) or cognitive-behavioral therapy (CBT), might mitigate PC and enhance emotional health. Furthermore, patient education initiatives that focus on the relationship between mental health and PC can enable survivors to embrace flexible coping mechanisms, thereby improving their quality of life.

From a research standpoint, this study emphasizes the necessity of longitudinal studies to gain a deeper understanding of the causal connections between depression and anxiety, with PC across time. Future research should also examine the efficacy of tailored therapies for particular populations, such as younger patients, patients with more advanced stages of the disease, or people with a lower level of education. To gain a more thorough knowledge of these interactions, it may be helpful to investigate how social support, cultural factors, and comorbidities influence PC and psychological outcomes. To enhance the comprehensive care of BCS, researchers can help design focused, evidence-based methods by filling in these gaps.

Strengths and limitations

This study covers a gap in the literature by concentrating on the emotional and psychological difficulties in BCS who are frequently afflicted by mental health problems and psychological distress. Furthermore, the study’s use of validated measures of PC, anxiety, and depression improves the validity and reliability of the findings. The focus on a specific population also allows for a more nuanced understanding of the unique challenges faced by this group. However, the study is not without limitations. Its cross-sectional design is one of its main limitations and prevents determining a causal link between PC, anxiety, and depression. Another limitation is the possibility of sampling bias since the study might not accurately reflect the variation of socioeconomic status, cultural background, and cancer stage among BCS.

Conclusion

The results of this study showed that there is a positive relationship between anxiety and depression with PC due to cancer. In other words, the more a BCS has PC, the more levels of anxiety and depression will be experienced due to the presence of pain, diagnosis, and treatment of cancer. In addition, factors related to the disease (duration of the disease, stage of the disease, treatment, etc.) and factors such as age in combination with PC are effective on the level of anxiety and depression due to the disease. These findings underscore the importance of addressing PC in mental health care for BCS and suggest the need for integrated pain and psychological interventions to improve quality of life in this population. From a health policy perspective, this study advocates for routine screening, multidisciplinary care, culturally sensitive interventions, patient education, and policy advocacy to ensure comprehensive and equitable care for BCS.

Data availability statement

The datasets generated and analyzed during the current study are not publicly available due to patient confidentiality and hospital policy but are available from the corresponding author upon reasonable request.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

This research was supported by grant No IR. IUMS. REC. 1403.453 from Iran University of Medical Sciences.