Abstract
This survey study uses data from the National Health Interview Survey to investigate the prevalence of, and socioeconomic risk factors for, chronic pain and high-impact chronic pain among cancer survivors in the United States.
The population of cancer survivors in the United States is growing rapidly.1 In 2016, the number of survivors was 15.5 million; with the aging of the population and advances in early detection and treatment methods, this number is expected to reach 26.1 million by 2040.1 Chronic pain is one of the most common long-term effects of cancer treatment and has been linked with an impaired quality of life, lower adherence to treatment, and higher health care costs.2 Nevertheless, there is a paucity of information regarding the prevalence of, and risk factors for, the development of chronic pain among cancer survivors. A better understanding of the epidemiology of pain in cancer survivors can help inform future health care educational priorities and policies. Accordingly, the objective of this study was to investigate the prevalence of chronic pain and high-impact chronic pain (HICP, chronic pain with major activity restriction) among cancer survivors in the United States by using data from the National Health Interview Survey (2016-2017).
Methods
We identified 4526 adult cancer survivors from 59 770 participants in the 2016-2017 National Health Interview Survey (https://www.cdc.gov/nchs/nhis/), a national cross-sectional survey of the civilian, noninstitutionalized US population. The survey collects information related to chronic pain (pain on most days or every day in the past 6 months) and HICP (chronic pain limiting life or work activities on most days or every day in the past 6 months), with definitions consistent with those proposed by the National Pain Strategy Population Research Workgroup,3 and which have been used in a report by the Centers for Disease Control and Prevention on the national estimates of chronic pain.4 Institutional review board approval and the need for patient informed consent were exempted by the Program for the Protection of Human Subjects at the Icahn School of Medicine at Mount Sinai, given that the data were deidentified and from a publicly available database. Chronic pain prevalence was calculated and stratified by sociodemographic characteristics and cancer type. Respondents with only nonmelanoma skin cancer and those reporting a cancer diagnosis before age 18 years were excluded from the analyses. To account for the complex design of the National Health Interview Survey, all estimates were weighted using SAS statistical software, version 9.4 (SAS Institute Inc) and SAS callable SUDAAN. All statistical significance testing was 2-sided at P < .05.
Results
Overall, of the identified 4526 cancer survivors, 1648 (34.6%, 95% CI, 32.7%-36.5%) reported having chronic pain and 768 (16.1%, 95% CI, 14.8%-17.5%) having HICP, representing approximately 5.39 million and 2.51 million cancer survivors, respectively, in the US population. No significant differences in the prevalence of chronic pain or HICP were found for age, sex, marital status, or region groups. A higher prevalence of chronic pain and HICP was reported among survivors with less than a high school education (adjusted prevalence, 39.2% for chronic pain and 18.5% for HICP), low household income (44.6% and 22.8%, respectively), public insurance (for those aged 18-64 years) (43.6% and 27.1%, respectively), or no paid employment (38.5% and 20.4%, respectively) (Table).
Table. Characteristics and Prevalence of Chronic Pain and High-Impact Chronic Pain Among US Cancer Survivors 18 Years or Older, National Health Interview Survey, 2016-2017.
| Characteristic | Sample, No. (Weighted %) (n = 4526) | Chronic Pain (n = 1648)a,b | High-Impact Chronic Pain (n = 768)b,c | ||
|---|---|---|---|---|---|
| Adjusted Prevalence (%) 95% CId | P Valuee | Adjusted Prevalence (%) 95% CId | P Valuee | ||
| Educational level | |||||
| <High school | 688 (14.8) | 39.2 (34.8-43.8) | .04 | 18.5 (15.3-22.1) | .15 |
| Graduated high school/GED | 1069 (23.2) | 32.5 (29.1-36.0) | 14.5 (12.2-17.1) | ||
| >High school | 2769 (62.1) | 34.4 (32.1-36.7) | 16.1 (14.4-17.9) | ||
| Race | |||||
| Hispanic | 269 (7.5) | 26.6 (21.4-32.5) | .02 | 12.6 (9.0-17.4) | .21 |
| Non-Hispanic white | 3726 (79.9) | 35.8 (33.8-38.0) | 16.8 (15.3-18.5) | ||
| Non-Hispanic black | 362 (8.2) | 33.0 (27.7-38.8) | 12.9 (9.7-16.9) | ||
| Non-Hispanic Asian | 126 (3.7) | 28.5 (18.7-40.9) | 18.8 (10.4-31.4) | ||
| Non-Hispanic otherf | 43 (0.7) | 47.2 (29.1-66.1) | 16.7 (9.0-28.9) | ||
| Insurance | |||||
| Any private (<65 y) | 1184 (31.3) | 28.1 (22.6-34.2) | <.001 | 18.1 (12.7-25.0) | .001 |
| Other coverage (<65 y) | 497 (11.8) | 43.6 (35.4-52.1) | 27.1 (20.0-35.6) | ||
| Uninsured (<65 y) | 139 (3.4) | 35.3 (30.4-40.4) | 13.3 (10.8-16.3) | ||
| Medicare with any private (≥65 y) | 1418 (27.9) | 37.7 (31.5-44.2) | 12.7 (9.8-16.3) | ||
| Public only (≥65 y) | 1288 (25.6) | 35.3 (30.4-40.4) | 13.3 (10.8-16.3) | ||
| Paid employment | |||||
| Yes | 3203 (67.4) | 26.7 (23.4-30.3) | <.001 | 6.8 (5.2-9.0) | <.001 |
| No | 1323 (32.6) | 38.5 (35.9-41.1) | 20.4 (18.5-22.4) | ||
| Poverty status (FPL) | |||||
| <100% | 450 (8.1) | 44.6 (38.1-51.2) | <.001 | 22.8 (18.3-27.9) | <.001 |
| 100%-199% | 788 (14.9) | 38.9 (34.5-43.4) | 20.2 (16.8-24.0) | ||
| 200%-399% | 1314 (28.5) | 36.7 (33.6-39.9) | 17.4 (15.0-20.1) | ||
| ≥400% | 1606 (40.0) | 29.6 (26.6-32.8) | 11.0 (9.0-13.3) | ||
| Unknown | 368 (8.4) | 33.6 (27.5-40.2) | 15.9 (11.7-21.2) | ||
| Time since diagnosis, y | |||||
| 0-1 | 662 (14.8) | 36.4 (31.9-41.2) | .80 | 15.4 (12.5-19.0) | .65 |
| 2-5 | 1035 (24.5) | 32.9 (29.4-36.7) | 17.1 (14.3-20.2) | ||
| 6-10 | 950 (21.4) | 35.3 (31.9-38.9) | 17.3 (14.6-20.4) | ||
| 11-15 | 632 (14.0) | 34.6 (30.4-39.1) | 14.5 (11.6-17.9) | ||
| ≥16 | 1247 (25.3) | 34.8 (31.3-38.5) | 15.6 (13.3-18.2) | ||
Abbreviations: FPL, federal poverty level; GED, general equivalency diploma.
Weighted number of survivors, 5 392 634 (95% CI, 4 981 252-5 804 015); weighted prevalence, 34.6% (95% CI, 32.7%-36.5%).
Chronic pain is measured by “pain on most days or every day in the past 6 months”; high-impact chronic pain is measured by “chronic pain limiting life or work activities on most days or every day in the past 6 months.”
Weighted number of survivors, 2 512 006 (95% CI, 2 263 616-2 760 395); weighted prevalence, 16.1% (95% CI, 14.8%-17.5%).
The adjusted prevalence values for chronic pain and high-impact chronic pain were estimated with 2 separate multivariable logistic models that included age, sex, educational level, race, insurance, paid employment, poverty status, region, year of survey, time since cancer diagnosis, and cancer type as covariates. Only statistically significant results are presented.
P values were obtained from Wald F tests in multivariable logistic regression models.
Non-Hispanic other includes non-Hispanic American Indian and Alaska Native only, non-Hispanic Native Hawaiian and Pacific Islander only, and non-Hispanic multiple race.
The adjusted prevalence of chronic pain was the highest among survivors of bone (54.0%), kidney (52.3%), throat-pharynx (47.9%), and uterine (44.5%) cancers. The time since diagnosis was not significantly associated with the prevalence of either chronic pain or HICP (Table).
Discussion
We found the prevalence of chronic pain and HICP among cancer survivors to be almost double that in the general US population.4 Chronic pain and HICP were more prevalent in survivors who were unemployed and who had low socioeconomic status, inadequate insurance, and had some specific types of cancer. Because socioeconomic status and employment are associated with insurance coverage and access to care in the United States,5 the patterns of chronic pain that we observed in cancer survivors may be explained by barriers to cancer care and pain management as well as by the type and extent of cancer treatment received. In contrast to the general perception of higher prevalence of pain in women than in men,6 we did not find a statistically significant difference by sex among cancer survivors. This could be owing to insufficient statistical power from the limited sample size, or that the cancer-induced pain in both sex groups may have diluted the relative difference.
Limitations of this study include the potential recall error of self-reported data, limited statistical power for survivors of less common cancers, and no information on cancer treatment, pain management, or the etiology of pain.
In conclusion, the prevalence of chronic pain and HICP is high among cancer survivors compared with that in the general US population, thereby suggesting the presence of important unmet needs in the large and growing cancer survivorship community.
References
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