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. Author manuscript; available in PMC: 2022 May 20.
Published in final edited form as: Pain Manag Nurs. 2020 Jun 5;21(5):410–415. doi: 10.1016/j.pmn.2020.03.006

Factors Associated with Depression in African American Patients Being Treated for Cancer Pain

Youjeong Kang *, Salimah H Meghani †, Deborah W Bruner ‡, Katherine A Yeager ‡
PMCID: PMC9122263  NIHMSID: NIHMS1641294  PMID: 32513560

Abstract

Background:

Among cancer patients in the United States, African American cancer patients have the highest mortality rate and shortest survival rate. Although depression is known as a predictor of mortality in cancer and a potential barrier to health care utilization, research on depression in African American patients is limited. Cancer pain can interfere with an individual’s ability to cope with depression.

Aims:

To identify factors that are associated with a positive screening of depressive symptoms assessed by the PHQ-8 in African American patients treated for cancer pain.

Design:

Secondary data analysis of a cross-sectional study of opioid adherence.

Setting:

Medical oncology, palliative care, and radiation oncology clinics in Atlanta, Georgia.

Participants/Subjects:

African American patients with cancer pain in the parent study.

Methods:

Independent samples t-test was used to assess variable correlations with and without depressive symptoms. Adjusted logistic regression was conducted to identify factors that were associated with presence of depressive symptoms.

Results:

Mean patient age was 55.6 years, and nearly 38% had a PHQ-8 score of >10 indicating presence of moderate to severe depressive symptoms. Participants with depressive symptoms had significantly higher means for anxiety and pain interference with mood than those without depressive symptoms. Factors that were significantly associated with depressive symptoms were anxiety, pain interfering with mood, and lack of involvement with a religious congregation.

Conclusions:

The findings of this study help to identify African American cancer patients at risk for depression and demonstrates the need for increased screening for depression in this underserved population.

Among cancer patients of all races and ethnicities in the United States, African American cancer patients have the highest mortality rate and shortest survival rate (American Cancer Society, 2020). Although depression is known as a predictor of mortality in cancer and a potential barrier to health care use, research on depression in African American patients is limited (Agarwal, Hamilton, Moore, & Crandell, 2010; Cheruvu & Oancea, 2016; Onitilo, Nietert, & Egede, 2006; Zhang & Cooper, 2010; Zhang, Gary, & Zhu, 2015). Because African American patients receive cancer diagnoses at later stages and face more economic and cultural barriers in getting access to care (Esnaola & Ford, 2012; American Cancer Society, 2020), the burden of depression can amplify the hardships and treatment disparities African American patients face while living with cancer. Few studies have specifically examined the prevalence and associated factors of depression among African American patients with cancer. According to two available studies, the prevalence of depression in African American patients with cancer ranges 12%–27% (Agarwal et al., 2010; Hamilton et al., 2013).

Cancer pain has been consistently linked to increased depression in African American patients with cancer and the general cancer patient population (Agarwal, Hamilton, Moore, & Crandell, 2010; Hamilton et al., 2013; Kroenke et al., 2010; Zaza & Baine, 2002). Cancer pain can interfere with an individual’s ability to cope with depression (Deandrea, et al., 2008). Although at least 40% of all people with cancer are undertreated for pain, almost two thirds of African American patients do not receive proper analgesic treatments for cancer pain (Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997; Deandrea, Montanari, Moja, & Apolone, 2008).

The purpose of this secondary data analysis is to identify factors that are associated with a positive screening of depressive symptoms assessed by the Patient Health Questionnaire-8 (PHQ-8) in African American patients treated for cancer pain. The bioecological model was used to examine how an individual is influenced not only by the circumstances of their disease, background, and socioeconomic status but also by their community, such as their participation in a religious congregation (Bronfenbrenner, 1994; Logsdon, et al., 2008). Examining factors associated with depressive symptoms in African American patients treated for cancer pain will enable the identification of at-risk individuals and encourage increased screening for depression in this underserved population. The aims of this study were (1) to explore the association between depressive symptoms and other symptoms of cancer in African American patients, and (2) to compare the differences in sociodemographic factors and symptoms including pain between patients with and without depressive symptoms based on PHQ-8 score.

Methods

Design

This study is a secondary analysis of baseline data from a parent study focusing on predictors of opioid adherence in African American patients being treated for cancer pain (NIH/NINR: 1K01NR014673; Yeager et al., 2019). The original study obtained institutional review board approval, and all patients gave informed consent.

Sample and Setting

African American patients in the parent study (N = 121) were recruited from medical oncology, palliative care, and radiation oncology clinics in Atlanta, Georgia. To be eligible for the original study, patients had to be ≥ 21 years of age, have a cancer diagnosis, live within the 10-county Atlanta metropolitan area, have resided in the United States for ≥ 10 years, and have resided at their current residence for ≥6 months. In addition, participants had to have a current prescription for an extended-release opioid for pain treatment. For the purpose of this study, participants (N = 111) were selected if they completed the PHQ-8, the Edmonton Symptom Assessment Scale (ESAS), the Brief Pain Inventory short form (BPI-SF), and the organized religious participation questions.

Measures

Research staff administered a series of self-report instruments and gave participants a $15 gift card for a local store at the conclusion of the interview. Results presented here are from the baseline visit of the parent study. The baseline visit took approximately 60 minutes and was conducted at a private location at a clinic or at the participant’s home.

The dependent variable, presence of depressive symptoms, was determined by using the PHQ-8, which has a reliability of .86 (Razykov, et al., 2012). Participants answered the eight-item survey by indicating if the statement described them not at all (0 points) to nearly every day (3 points), resulting in a possible total score ranging 0 to 24. A single cutoff score of ≥ 10 has been validated and has an 88% sensitivity and 88% specificity for the diagnostic algorithm of depression (Kroenke et al., 2009; Kroenke, Spitzer, & Williams, 2001).

Primary independent variables of interest included symptoms, pain, and involvement with a religious congregation. The ESAS measures cancer patient symptoms including tiredness, nausea, depression, shortness of breath, dyspnea, drowsiness, sleep, wellbeing, appetite, pain, and anxiety. For the parent study, constipation was also assessed as part of the ESAS. ESAS has been validated across the general cancer patient population (Chang, Hwang, & Feuerman, 2000). Respondents rate the severity of each symptom from 0 (none) to 10 (worst possible). Scores may be reported as a sum of all responses or as single items (Chang, Hwang, & Feuerman, 2000).

The BPI-SF was used to measure cancer pain within the past 24 hours. The BPI-SF has been validated for use in patients with cancer around the world (Kumar, 2011) and includes pain severity, pain interference, and pain relief questions (Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997). Worst, least, average, and current pain severity were assessed on a scale of 0 (no pain) to 10 (pain as bad as you can imagine). The pain severity subscale is the average of these four scores, and a higher average score indicates pain of greater severity. Pain interference is rated on a scale of 0 (does not interfere) to 10 (completely interferes; Cleeland, Gonin, Baez, Loehrer, & Pandya, 1997) The pain interference score, an average of seven items, measures the degree to which pain hinders mood, the performance of general activities, and personal relationships over the past 24 hours. Participants were also asked to report the percentage of pain relief they had achieved using medications plus nonmedical treatments on a scale from 0% (no relief) to 100% (complete relief).

Participation in a religious congregation was assessed by using two questions. One question asked if the participant belonged to a religious congregation or organization. A religious organization was defined as a formal public religious institution, such as a church, synagogue, temple, mosque, or ashram. Involvement was defined as attending worship services or other activities (e.g., choir practice, youth groups, or volunteer activities) organized by the religious institution. The second question asked how often the participant attended religious services, with nine categorical responses ranging from “never,” “about once or twice a year,” and “two to three times a month” to “every week.”

A demographic form was used to collect the following information for each patient: age, sex, individual income, education level, marital status, history of smoking and alcohol intake, and religion-related information (i.e., affiliation). Through a chart review, clinical characteristics were collected including cancer types, comorbidities, antidepressant prescriptions, and type of opioid used.

Data Analysis

Data were analyzed using IBM SPSS Statistics 24 (Armonk, NY, USA). Significance was set at .05. Descriptive methods were used to describe sociodemographic and clinical characteristics. Differences between participants without depressive symptoms (PHQ-8 score <10) and those with depressive symptoms (PHQ-8 score ≥ 10) were compared by independent samples t test. Bivariate logistic regression analyses were conducted to select variables at the alpha level of 0.2 for inclusion in the stepwise logistic regression model. For the final model, we conducted an adjusted logistic regression analysis again using a 0.2 cutoff for inclusion of symptom subscales from the bivariate logistic regression.

Results

Mean age of participants was 55.6 ± 10.2 years, 60% were women, and nearly 70% were not married; about 70% were involved with a religious congregation (Table 1). Among clinical characteristics, the highest prevalence of cancer type among patients was multiple myeloma (Table 2). Nearly 57% of participants had metastasis present, and 38% of participants had a PHQ-8 score of ≥ 10 (patients with depressive symptoms; Table 2).

Table 1.

Sociodemographic Characteristics (N = 111)

Variable Mean ± SD or Count (%)
Age (years) 55.6 ± 10.2
Sex
 Female 67 (60.4)
 Male 44 (39.6)
Marital status
 Married 36 (32.4)
 Not married 75 (67.6)
Employment
 Work outside the home 20 (18)
 Do not work outside home 91 (82)
Education
 Bachelor’s degree or higher 11 (9.9)
 College or some college 48 (43.2)
 High school degree or less 52 (46.9)
Medical insurance
 Public 81 (73)
 Private 21 (19)
 Public and private 9 (8)
Belongs to a religious congregation
 No 34 (30.6)
 Yes 77 (69.4)
Frequency of attendance at religious services
 Never to several times per year 48 (43.2)
 About 1–3 per month 25 (22.5)
 Nearly every week 13 (11.8)
 Every week to several times a week 25 (22.5)
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SD = standard deviation.

Table 2.

Clinical Characteristics (N = 111)

Variable Mean ± SD or Count (%)
Opioids
 Methadone 4 (3.8)
 MS Contin 72 (64.7)
 Oxycodone 35 (31.5)
Cancer diagnosis
 Breast 18 (16.2)
 Cervical 3 (2.7)
 Colon, rectal, prostate, anal 16 (14.4)
 Liver 1 (0.9)
 Lung 16 (14.4)
 Lymphoma 3 (2.7)
 Multiple myeloma 30 (27.0)
 Pancreatic 10 (9.0)
 Other 14 (12.6)
Chemo last month (n = 109)
 No 40 (33.7)
 Yes 69 (66.3)
Presence of metastasis (n = 104)
 No 45 (43.3)
 Yes 59 (56.7)
Years of diagnosis 3.3 ± 3.8
Total number of prescribed medications 7.28 ± 3.93
Number of years of regular use of nicotine (n = 109) 13.46 ± 18.84
Number of years of regular use of alcohol (n = 109) 13.34 ± 15.62
Prescribed antidepressants
 No 79 (71)
 Yes 43 (39)
PHQ-8
 Total PHQ-8 score mean 8.39 ± 5.28
 <10 69 (62.2)
 ≥10 42 (37.8)
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PHQ8 = Patient Health Questionnaire-8.

The Patient Health Questionnaire-8 (PHQ8) measures depressive symptoms and ranges from 0 to 22 (22 indicative of more depressive symptoms). In this data analysis, a score of 10 or above was considered positive for the presence of depression.

Table 3 shows the mean differences in demographic variables, religious congregation involvement, record of prescribed antidepressants, symptoms, pain severity, and pain interference between participants in those with and without depressive symptoms. There was significant difference in religious congregation participation (p = .004) and in the number of years of regular use of nicotine (p = .030). The number of years of regular use of alcohol (p = .046) and having an antidepressant prescribed were marginally different between the two groups (p = .048). Among symptoms, total symptom scores, and individual severity of anxiety, nausea and shortness of breath were significantly different for those with and without depressive symptoms. Pain severity scores in the past 24 hours were not significantly different between those with and without depressive symptoms, including worst pain, average pain, least pain, and current pain. In contrast, pain interference with enjoyment of life, general activities, mood, sleep, and work were significantly different between those with and without depressive symptoms. Overall, the means of all symptom scores, pain levels, and pain interference scores were higher in the group with depressive symptoms than in the group without depressive symptoms. Report of pain relief was significantly different between the groups; those without depressive symptoms reported better pain relief.

Table 3.

Comparison of Mean PHQ Scores Between Nondepressive and Depressive Groups

Participants without Depressive Symptoms
PHQ-8 < 10 (n = 68)
Mean ± SD or Count (%)		 Participants with Depressive Symptoms
PHQ-8 ≥ 10 (n = 43)
Mean ± SD or Count (%)		 p Value
Age 56.57 (10.63) 53.91 (8.61) .140
Sex .986
 Male 27 (39.7) 17 (39.5)
 Female 41 (60.3) 26 (60.5)
Marital status .220
 Married 25 (36.8) 11 (25.6)
 Not married 43 (63.2) 32 (74.4)
Religious congregation Participation .004
 No 14 (20.6) 20 (46.5)
 Yes 54 (79.4) 23 (53.5)
Number of years of regular use of nicotine 5.84 ± 15.37 2.79 ± 8.26 .030
Number of years of regular use of alcohol 1.79 ± 5.5 0.67 ± 2.41 .046
Prescribed antidepressant .048
 No 53 (77.9) 26 (60.5)
 Yes 15 (22.1) 17 (39.5)
Symptoms
 Total symptom 19.76 ± 11.33 45.84 ± 15.52 .044
 Anxiety 0.65 ± 1.46 4.33 ± 2.74 <.001
 Appetite 3.22 ± 3.36 5.51 ± 3.49 .855
 Constipation 2.62 ± 3.13 3.77 ± 3.61 .079
 Drowsiness 2.34 ± 2.92 4.72 ± 3.31 .359
 Nausea 0.78 ± 2.08 2.53 ± 3.51 <.001
 Shortness of breath 0.90 ± 1.94 2.51 ± 2.87 <.001
 Tiredness 3.75 ± 3.18 6.35 ± 2.93 .634
 Lack of feeling of well-being 2.71 ± 2.74 4.98 ± 2.64 .505
BPI Pain level
 Pain severity 4.06 ± 2.33 5.55 ± 2.18 .494
 Pain worst 5.84 ± 2.95 7.19 ± 2.41 .099
 Pain least 2.56 ± 2.52 3.86 ± 2.78 .775
 Pain average 4.53 ± 2.51 5.95 ± 2.02 .286
 Pain now 2.76 ± 3.14 4.60 ± 3.27 .940
BPI Pain Interference
 Total pain interference 4.06 ± 2.33 5.54 ± 2.18 .286
 Enjoyment of life 4.03 ± 3.70 7.16 ± 2.98 .019
 General activity 4.62 ± 3.52 7.21 ± 2.57 .006
 Mood 2.69 ± 3.26 7.16 ± 2.73 .014
 Relationships 2.32 ± 3.44 6.09 ± 2.98 .158
 Sleep 4.63 ± 4.04 7.23 ± 3.32 .008
 Walking 4.51 ± 3.87 6.23 ± 3.64 .205
 Work 4.60 ± 3.58 7.05 ± 3.02 .032
Pain relief 73.68 ± 30.02 66.05 ± 22.48 .048
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BPI = Brief Pain Inventory; PHQ8 = Patient Health Questionnaire-8.

Pain severity was computed using worst, least, average, and current pain. SD: standard deviation. The Patient Health Questionnaire-8 (PHQ8) measures depressive symptoms and ranges from 0 to 22 (22 indicative of more depressive symptoms). In this data analysis, a score of 10 or above was considered positive for the presence of depressive symptoms.

From the adjusted logistic regression model (see Table 4), three factors associated with depressive symptoms that were identified were anxiety, pain interfering with mood, and involvement with a religious congregation. For each 1-point increase in the anxiety score, the patients were 1.90 times more likely to have depressive symptoms. For each 1-point increase in pain interfering with mood, the patients were 1.49 times more likely to have depressive symptoms. The odds of having depressive symptoms in patients who did not belong to a religious congregation were 7.27 times greater than the odds of having depressive symptoms in those who did belong to a religious congregation.

Table 4.

Factors that Are Associated With Depressive Symptoms

Factors Odds Ratio 95% Confidence Interval
Anxiety 1.90 1.35, 2.35
Pain interferes with mood 1.49 1.21, 1.83
Belong to a religious congregation 7.27 1.54, 34.33
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Adjusted logistic regression was conducted. Significance level was p value < .05.

Discussion

Significant proportions of cancer patients experience pain; nearly 40% have pain after curative treatment, 55% during cancer-directed treatment, and 66% in advanced metastatic or terminal disease (van den Beuken-van Everdingen, Hochstenbach, Joosten, Tjan-Heijnen, & Janssen, 2016). At the same time, many individuals with cancer also experience depression. Patients with cancer are at risk for depression at the time of diagnosis and throughout their treatment (Linden, et al., 2012; Lo et al., 2010; Pasquini & Biondi, 2007). This study supports and extends previous research on the intersection of depressive symptoms and pain in cancer patients. In this unique sample of patients currently being treated with an extended-release opioid, our findings show that 40% of African American participants were experiencing depressive symptoms, a much higher percentage than in the general cancer patient population (15%–25%; Lo et al., 2010; Pasquini & Biondi, 2007) or African American cancer patients (12%–27%; Agarwal et al., 2010; Hamilton et al., 2013). The cancer patient experience that includes both pain and depression is important not only because of the impact both symptoms have on day-to-day functioning and quality of life, but also because patients with cancer and depression have three times the odds of being nonadherent to curative treatment regimens than those without depression (DiMatteo, Lepper, & Croghan, 2000) and are at increased risk of death (Pinquart & Duberstein, 2010).

Identifying factors associated with depression in African American patients receiving treatment for cancer pain is helpful in guiding assessments and interventions to improve their quality of life. Gender and age have been shown to be related to depression (Agarwal et al., 2010; Hamilton et al., 2013; Linden et al., 2012; Pasquini & Biondi, 2007; Traeger et al., 2014), but were not in the current study, possibly because our sample was relatively young, with a mean age of 55.6 ± 10.2 years. In contrast, Agarwal’s study of older African American cancer patients (mean age of 63.5, SD=7.9), which examined predictors of depression, found that younger-aged cancer patients were more at risk of depression than were older patients (Agarwal et al., 2010).

Although demographic factors were not different between those with depressive symptoms and those without depressive symptoms in the current sample, involvement with a religious congregation was a significant factor. Participants who were involved in a religious congregation were less likely to experience depressive symptoms than were those without a religious congregation. African American cancer survivors, especially those with depression, may withdraw from traditional sources of social support for fear of being ostracized (Hamilton & Sandelowski, 2004). Additionally, counterproductive beliefs about pain (pain is an expected part of life; grin and bear it; pain is God’s will; people who succumb to pain are weak) may also influence social interactions (Mossey, 2011). More often, research has demonstrated that religious participation of African Americans is associated with improved quality of life and lower psychological distress related to illness (Levin, Chatters, & Taylor, 2005). Religious support from a congregation was negatively associated with depression in a national sample of African American individuals, even if they physically attend church only a few times per year (Chatters, Taylor, Woodward, & Nicklett, 2015). In general, a majority of African American individuals attend church once a week and are likely to seek the help of pastoral counselors in coping with illness, which might be protective for depression (Holt et al., 2009; Reese et al., 2012; Umezawa et al., 2012). Future research involving more sensitive tools is needed to examine the significance of religious support for mitigating symptoms of depression in African American patients with cancer. Nonetheless, the role of religious engagement and the symptom experience remains an important consideration when caring for African American cancer patients.

These study findings support other research that found positive relationships between symptoms and depression in cancer patients (Lo et al., 2010; Traeger et al., 2014; Zaza & Baine, 2002), specifically in African American patients. In our sample, pain interference in regard to mood was significantly associated with depression, but measures of pain severity were not. The relationship between pain interference and depressive symptoms demonstrates the toll that pain plays in their day-to-day lives. Reports of higher levels of pain relief from medications and complementary agents were related to not having depressive symptoms, a finding that emphasizes the need to adequately treat pain. Relief from pain most likely influences many more factors than pain severity, including greater functional ability and social interactions, which in turn may decrease mood disorders and the resultant poor quality of life.

Previous studies have shown that in addition to pain, symptoms such as fatigue, anxiety, low appetite, and shortness of breath can increase the risk for depression in African American patients and the general cancer patient population (Ell et al., 2005; Hamilton et al., 2013; Kurtz, et al., 2002). Our finding that anxiety was associated with depressive symptoms is consistent with this evidence. This result indicates that anxiety might serve as a critical indicator for health care providers detecting early signs of developing depressive symptoms.

The presence of burdensome symptoms tends to be more influential on depression than stage of disease or type of treatment (Agarwal et al., 2010; Lo et al., 2010). Treatment approaches to pain and depression in cancer patients warrant special consideration. Despite the availability of effective treatments, many African American patients with cancer still report clinically significant pain and emotional distress (Kadan-Lottick et al., 2005; Sheppard et al., 2013). Unfortunately, symptoms of depression, such as fatigue and impaired cognition, can lower a person’s ability and motivation to engage in pain management programs and adhere to treatment regimens. Meta-analytic findings indicate that depressed individuals are three times more likely to be nonadherent to general treatment guidelines than nondepressed individuals (DiMatteo, Lepper, & Croghan, 2000). Likewise, pain can impair a person’s ability to take part in activities known to decrease depression, such as social interaction. Nonpharmacologic treatment approaches that provide relief for both pain and depression should be promoted, including exercise and cognitive behavioral therapy (Brammer, 2018).

Depression and pain often coexist with serious outcomes, including the risk of suicide. In a study of risk factors of cancer-related suicide, depression, medical comorbidities, and pain were common suicide risk factors identified (Aboumrad et al., 2018). Suicide rates have been reported to be higher in oncology patients compared to the general population (Bjorkenstam et al., 2005), with 31.4 suicides per 100,000 cancer patients reported (Misono et al., 2008).

Our results should be interpreted in the context of potential limitations, including the use of a convenience sample that represents participants in one metropolitan area. Results from this data analysis might thus have limited general applicability. Depressive symptoms in this study were defined on the basis of PHQ-8 score, not an interview with a mental health provider, which is the gold standard for diagnosing depression. Additionally, the effectiveness of the antidepressant medication when prescribed was not assessed; more information about dosage and length of time on the medication would have been useful in the analysis. Future research looking at the impact of chronic pain on depression over time could help explain the relationship between these clinical factors.

Implications

Implications for clinicians based on the findings of this study are, first, the need for adequate assessment of pain and depression in cancer patients. However, African American patients may be reluctant to use the word “depression” and are more likely to report physical symptoms when experiencing distress (Zhang et al., 2015; Zhang et al., 2015). The Distress Thermometer, a single-item distress screening scale, is used to assess psychological distress in people affected by cancer, and may be easier to integrate into a busy clinical setting and be more acceptable to patients. The Distress Thermometer, endorsed by the National Comprehensive Cancer Network, has demonstrated acceptable validity compared to longer measures (Cutillo et al., 2017; Jacobsen et al., 2005) and has been found to perform well in a range of languages (Gunnarsdottir et al., 2012; Ozalp et al., 2007; Shim et al., 2008) and across a number of cancer types (Bevans et al., 2011; Craike, Livingston, & Warne, 2011; Hegel et al., 2008; Roerink et al., 2013), and in community settings (Tuinman et al., 2008) as well as research settings (Hawkes et al., 2010). Additionally, an assessment of how pain interferes with daily activities is key to understanding the pain experience and may be at least as important as assessing pain severity. Specifically the items that measure pain interference from the BPI (general activity, mood, walking ability, work, relations with others, sleep, and enjoyment of life) can be assessed and then used to inform the treatment plan. For example, if a patient reports that pain interferes with their sleep, an intervention plan can address how to improve both sleep and pain.

Conclusions

This study shows that African American cancer patients experiencing high levels of anxiety and pain interfering with mood and lack of membership in a religious congregation were likely to have a PHQ-8 score indicative of depressive symptoms. Participants who belonged to a religious congregation experienced fewer depressive symptoms than those without a regular religious congregation. Because depression negatively affects patient outcomes, including treatment adherence, functioning, and quality of life, clinicians caring for cancer patients must assess and ameliorate risk factors of depression as well as provide treatment on an ongoing basis. Specifically, identifying factors associated with depressive symptoms in African American patients treated for cancer pain will enable the identification of at-risk individuals and encourage increased screening for depressive symptoms in this underserved population.

Acknowledgments

The authors thank all participants who participated in this study. They also thank Allysa Rueschenberg, M.S.N., R.N., for her contributions to the earlier phase of the project. This work was supported by the National Institutes of Health/National Institute of Nursing Research (1K01NR014673; PI: K. Yeager).

Footnotes

None of the authors declare any conflicts of interest relevant to the current work.

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