Cancer is the second leading cause of death worldwide, along cancer continuum, cancer patients might be suffer from pain which is varies, subjective symptoms and also unpleasant feeling arises from a tumor compressing or infiltrating nearby body parts, might be from treatments and/or diagnostic procedures, interferes with a person's Quality Of Life (QOL) and general functioning [1].

Every year, more than 10 million cancer cases are diagnosed worldwide, however, malignant cancer is often associated with pain, each day about 4 million cancer patients suffer from pain, 50% of them do not receive proper treatment and pain management medications to their pain severity levels and one-third survive with severe pain, 40% report moderate to severe pain [2], International Association for the Study of Pain, estimated pain at the time of cancer diagnosis to be approximately 50% increasing to 75% at advanced stages, it could be acute or chronic, breakthrough and/or persistent and breakthrough pain [3]. 

Despite of advanced technology and increasing the awareness on pain assessment and management, it continues to be a prevalent symptom for cancer patients [4], cancer pain prevalence rate in Asia was 59.1%, Europe was 40.3 and 39.1% in North America, it was higher when compared Asia to Europe and it revealed comparable between Europe and North America, which mean that opioid availability is not only the main reason for the high prevalence rates, studies conducted at Middle East regions, reported that cancer pain management remained unmet patient's need; and inadequate pain control was correlated with poor satisfaction with daily living activities and QOL [5].

Jordan is a small country located in the center of the Middle East, Syria to the north, Iraq to the east, Saudi Arabia to the southeast and Palestine to the west [6]‏. The total population is approximately 9.903.798 million, of which fifty one and half percent are male, Arabic is the official language, Jordan has a well-developed health care system in comparison with other countries in the region, 70% of all residents are eligible for free cancer treatment regardless of their medical insurance status, When an individual is diagnosed with cancer, it is perceived as potentially life threatening, decrease in functional status and changes in lifestyle which affect treatment regimen, health care system in Jordan consists of two main sectors: the public/semipublic sector and the private sector [7].

According to the International Agency for Research on Cancer in Jordan, 10.898 new cancer cases were diagnosed in 2018; the most frequent cancers include breast, lung, colorectal, bladder and leukemia [8], cancer affects Jordanian populations relatively young ages, resulting in long periods of ill-health, great loss of productivity and premature deaths, the burden of cancer continues to increase because of the ageing and growth of the population alongside increasing levels of cancer-causing behaviors such as smoking, sedentary lifestyle and unhealthy dietary habits [9].

Management of cancer pain severity by strategies and interventions must be implemented early to prevent the development of chronic persistent pain that might lead to a significant decrease in QOL and manage total pain in all aspects as biopsychosocial approach as needed along cancer continuum. 

According to the WHO, quality of life QOL is a personal perception of their role and position in life according to the person culture and value systems that they live and in relation to the person's goals, standards, expectations and concerns. It is a wide concept affected by bio-psychosocial approach i.e. person's physical health, psychological state, social relationships, personal beliefs and their relationship to the environment [7].

QOL is a major concern for cancer patients, cancer pain impairs and affects QOL, management the severity of cancer pain improves distress and QOL, many factors could be influence cancer pain severity such as demographic data, cultural beliefs, past experiences, clinical characteristics such as cancer type and type of treatment…etc. [10]. 

Studies show a significant association between the pain severity, cancer type, treatment, demographic variables (age, income, marital status and education) were significantly to QOL [11], the main issues of long-term cancer survivors are in the areas of QOL that includes social/emotional support, spiritual/philosophical view of life, health habits and body image concerns [12].

In order to identify and estimate severity of pain and QOL among cancer patients who 's treated in primary health care hospitals; this study were conducted, many factors might be identified which influence the discrepancies of pain severity and QOL among Jordanian cancer patients, the importance to conduct this research study appears due to the high incidence rate of newly cancer cases and high prevalence of cancer pain rates worldwide, 40% of cancer patients report moderate to severe pain [2] and few recent studies conducted in Arab Middle East region especially in Jordan that investigated the impact of cancer pain severity on QOL.

To strength and support this study it was guided by theoretical framework, which explains the path and directions of this research and grounds it firmly in theoretical constructs to make research findings acceptable and more meaningful, to ensures generalizability and enhance the empiricism and rigor of a research [13].

Purpose

To assess risk factor for cancer pain severity on quality of life among cancer patients in military cancer center in Jordan.

A descriptive, cross-sectional design was conducted after brief pain inventory and EORTC QLQ C-30 (version 3.0) questionnaires were online disseminated. 

Approximately 375 questionnaires were disseminated.

Variables under the Study

Cancer Pain Severity: Cancer pain results from tissue damage due to the cancer itself, or due to conventional treatment (chemotherapy, radiotherapy and surgery) may cause by the tumor pressing on bones, nerves or other organs in the body, no scoring algorithm, but "worst pain" or the mathematical mean of the four severity items that includes worst pain in last 24 hours, least pain in last 24 hours, pain on average and pain right now can be used as measures of pain severity.

Operationally, the Brief Pain Inventory (BPI) of pain is used in this study. 

Quality of Life (QOL)

According to The World Health Organization QOL is an individual's perception of their role in life in which they live depending on person's culture and value systems and in relation to their goals, standards, expectations and concerns [7,14]. It is a subjective multidimensional term for the quality in different domains in life. It is a standard level for emotional, physical, material and social well-being that consists of the expectations, guided by values, goals and socio-cultural, of an individual or society for a good life satisfaction, QOL is the well-being of person and societies, outlining positive and negative features of life, observe life satisfaction from physical health, family, employment education, safety, wealth and security to religious beliefs, freedom and the environment [15,16].

Operationally, European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 (EORTC QLQ C-30 (version 3.0)) questionnaire is used to measure QOL.

Instruments

The study instruments included three parts. The first part contained patients' demographic sheet developed by the researcher and had items: age, gender, education level, income, cancer type, stage, opioid use, Tobacco consumption, type of hospital, occupation. 

The second instrument for pain severity that were assessed using the Brief Pain Inventory (BPI), BPI assessment tool use with cancer patients; which consider valid and reliable tool and widely used in oncology settings and research [17], it provides information on the severity of pain that interferes with function, consists of pain score and 7 functional items on a scale of 0-10 with 0 indicating no pain and 10 indicating extreme pain and maximal interference.

The third instrument to assess the quality of life European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core-30 EORTC QLQ C-30 (version 3.0) questionnaire was used; it composed of 16 domains, 30 questions and four scales that corresponding to the patient health state during the last week. All subscales have a score range from 0-100 points. A higher score represented better function and a higher QOL.

Ethical Consideration 

The ethical approval to conduct this study was obtained from Royal Medical Services institution review board and the voluntary participations to fill the questionnaires were considered approval to participate and also participants’ privacy, anonymity and confidentiality were reserved by ensuring that their participation in the study is voluntary and can withdraw at any time and no form of personal identification by using coding approach and preserved the information in computer with a researcher's password.

Data Collection Procedure

The investigator disseminated online questionnaires (Brief Pain Inventory Instrument (BPI) and EORTC QLQ C-30 (version 3.0)) through social-media (WhatsApp and Facebook groups). 

Eligible participants were invited to participate in the study to complete the questionnaires after carefully read the instructions given in the cover letter and mentioned that filling the questioners and returned consider a participant approval, noting that there no risks or benefits or bias to participants from taking part in the study.

Response rate was 80 and 300 eligible participants were recruited (the inclusion criteria included adult cancer patients aged above 18 years, have cancer on treatment).

Data Analysis

Data analyses were performed using Statistical Package for the Social Sciences (SPSS version-23). Descriptive statistics analysis, frequencies, percentages and means were used to represent the data in connection with the socio-demographic profile, clinical characteristics of patients and also t test, ANOVA and ANCOVA to evaluate the effect of demographic characteristics and cancer pain severity.

Logistic regression was used to evaluate the impact cancer pain severity on quality of life with. 

Distribution of demographic, disease and treatment variables (n = 300) in cancer patients at military cancer center in Jordan.

P value will considered less than 0.05 in all statistical analyses, α = 0.05 and confidence interval (CI) = 95%.

Demographic and Disease Characteristics

A total of 300 patients with cancer participated in the study and completed the questionnaires. Of the 300 cancer patients, 179 (59.7%) were females and 121 (40.3) were males. The mean age of the study subjects was 53.9 years. About 137 (45.6%) patients had income lower than 500 JD/month. Breast cancers were most common among the patients accounting for 115 (38.4%) followed by gastrointestinal cancers 65 (21.6%). One hundred (33.3%) patients were presented with stage 3 cancers, while 45 (15%) patients had stage 1 (Table 1 and 2).

Table 1: Distribution of Demographic, Disease and Treatment Variables (n = 300)

*Others include renal cell carcinoma, soft tissue Sarcoma. **JD: Jordanian Dinar 

Table 2: Distributions of Total Mean Scores of Pain Severity for Demographic Characteristics in Jordan

*GI: Gastrointestinal ** JD: Jordanian Dinar

Logistic regression analysis revealed that patient age (OR = 2.219, 95% CI: 1.113–15.005, p = 0.034), female patient (OR = 2.303, 95% CI: 1.207-15.343, p = 0.024), gastrointestinal malignancy (OR = 3.613, 95%CI: 1.082-20.579, p = 0.031), advanced stage (OR = 2.512, 95% CI: 1.102-16.021, p = 0.023), education level ( OR = 1.583, 95% CI: 1.965-9.385, p = 0.044), income (OR = 1.783, 95%CI: 1.112-11.216, p = 0.01) and smoking (OR = 3.812, 95%CI: 1.009-22.821, p = 0.004) were all identified as significant independent risk factor for degree of pain severity Table 3.

Table 3: Logistic Regression Analysis of Risk Factor Related to Pain Severity Score

Overall Jordanian cancer patients had moderate-high mean total scores for pain severity and low mean total scores for quality of life.

Supportive interventions for cancer patients that address wider aspects of patient wellbeing were needed in governmental hospital, as well as policies that address financial and other barriers to timely treatment.

There is an association of demographics data and pain e.g. gender, type of cancer and treatment modalities, income, level of education…etc, female patients and those living in rural areas were at a higher risk of having pain than urban areas due to inadequacy of treatment and/or cultural beliefs, young people had better quality of life than old people. 

Increase severity of pain and decrease QOL in cases of metastasis e.g. bone cancer especially in Stage III and Stage IV i.e. terminal ill, colorectal cancer correlate with low severity pain compared with another type of cancer and reduction in QOL if the patient has stoma, advanced breast cancer patients had lower QOL due to changed body image.

RMS and Public hospitals owned and funded by military and government, respectively, it provides medical care for free to patients, covering expenses by military and government reimbursement [18]. 

Private hospital owned by individuals and/or organization, profit and non-profit companies, provide specialized medical care for patients and funded by patients or by insurers [18], furthermore, the influence on quality-of-life of cancer patient's indicators, self-efficacy and cancer patient agreement is beneficial to lead the practice and the treatment process [19].

RMS and specialized hospitals in Jordan have strategies to improve pain management that includes active pain management team, palliative and home care program using valid guidelines in clinical practice for chronic and acute pain management in cancer patients and conducting informal and formal pain management education courses to improve health care provider's knowledge and practices inside the hospital and conducting oncology nursing training courses in other Jordanian oncology centers [20].

A study at Al-Bashir Hospital reported that breast cancer patients, with bone metastasis and complain of skeletal-related events, suffer from bone pain, pathological fracture, spinal cord compression and functional impairment which impacts negatively on their quality of life [21], in another study conducted on 189 participants , the proportion of patients with colorectal cancer presentation and delay in diagnosis was 33.9 and 68.1 respectively and the main reasons for delay in the diagnosis were misdiagnosis by physicians (38.4%), lack of knowledge of cancer symptoms (58.5%) and the patient refused to visit a doctor (3.1%) [22].

There is an inverse relationship between pain severity and QOL and level of pain severity is high and low QOL in cancer patients at governmental hospital compared to RMS and specialized hospital.

Governmental hospital need a structured training and teaching program in pain medicine that is affiliated by the Medical Council and include pain management in the undergraduate and postgraduate medical curriculum and health care system in governmental hospital need to re-think and prioritize cancer care and put polices and action plans in place to cover and overcome some of the challenges surrounding the delivery of optimal cancer pain management, use available resource-stratified guidelines for supportive care and test efficient and cost-effective models for cancer care to control cancer pain severity which is high in governmental hospital rather than specialized hospital and its highly recommended that palliative care model needs to be implemented in governmental hospital so patients with illnesses such as cancer can improve their quality of life and die with dignity and comfort.

In general cancer pain severity could controlled if considered as a part of medical practice and decisions are not restricted; controlled opioid in governmental hospital as necessary for the public health as legitimate professional practice and not considered as a last treatment and Physical dependence or analgesic tolerance are not mistaken for addiction. 

Limitation and Implication 

This study could be utilized on oncology settings and in planning for cancer patient's care and promote, develop and establish polices, guidelines and standers that concern in pain management to enhance QOL.

Strengths of this study include sufficient large sample size that empowered the study and it includes all types of cancer-related pain, all cancer stages and types, aged above 18 suffering from pain, treated on oncology words that received patients from low to high socio-economic status and suitable strong parametric data analysis; therefore the result of this study were generalized for Jordan population.

Study limitation include that patients complaining of severe pain were more likely to refuse participation than those without pain or those in mild to moderate pain.

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