Pain and Hope in Patients With Cancer: A Role for Cognition

Abstract and Introduction

The importance of hope in determining the adjustment of patients with cancer to their illness has been recognized. Stressful events such as pain and disease metastasis may have an impact on patients' hope levels. This study had three purposes: 1) to examine the effect of disease status on hope levels among patients with cancer who have pain; (2) to compare the level of hope between patients with cancer who have pain and those do not; and (3) to determine which dimensions of pain are associated with hope. Patients (n = 226) with various cancer diagnoses completed the Herth Hope Index. Disease status was measured by one objective indicator (disease stage) and one subjective indicator (perceived treatment effect). The Perceived Meanings of Cancer Pain Inventory was used to measure the cognitive dimension of pain, whereas pain intensity and relief were used to represent the sensory dimension of pain. The patients' disease stage did not affect their level of hope, but their perception of treatment effect was associated with this factor. No difference in level of hope was found between patients with pain and those without pain. For those with pain, the cognitive dimension of pain (meaning ascribed to pain) was significantly correlated with hope, whereas sensory dimensions (pain intensity and relief) showed no such correlation. The study results support the role of cognition in promoting the psychological well-being of patients with cancer.

Hope has been identified as having therapeutic value for patients with cancer.^[1] Developing and maintaining hope can maximize psychological adjustment and fortify both psychological and physiologic defenses.^[2,3] Loss of hope may hinder patients' adjustment to their cancer diagnosis and treatment.^[3] In fact, a relation was demonstrated between hope and rates for both survival and disease recurrence in patients with cancer. Patients with cancer who had higher levels of hope tended to live longer or have longer disease-free periods.^[4,5,6] Previous studies also have suggested a positive correlation between hope and quality of life in patients with cancer.^[7,8]

Stressful stimuli, crises, and life-threatening situations have been identified as antecedents of hope.^[9] For patients with cancer, recurrence or metastasis can be viewed as a stressful stimulus or crisis. Yet many studies have failed to find a significant correlation between disease stage and hope. For example, Ballard et al^[10] studied 38 patients with cancer and found no difference in levels of hope between patients with a new diagnosis and those with recurrent disease. Herth's^[11] study of 172 ill adults in hospital, outpatient, and home settings found no difference in hope among patients, whether categorized in acute, chronic, or terminal phases of their illness. Similar findings were reported in a study of 55 patients with cancer recruited from the hospital, physician's office, patient support group, and hospice.^[12] No difference in the level of hope was found among patients in remission, under treatment, or in terminal phases of their illness. On the other hand, Huang^[13] reported that among Taiwanese patients with cancer who had pain (n = 84) from either inpatient or outpatient services, patients with stage II disease had significantly higher levels of hope than those with stage IV disease. The sample mean age in the aforementioned studies was quite similar, ranging from 50 to 56 years.

The presence of physical symptoms and pain might influence a patient's degree of hopelessness.^[14] A study of patients with breast cancer (n = 31) found that the participants experienced relatively low levels of hopelessness.^[15] However, two participants from that study who had moderate levels of hopelessness also experienced extreme fatigue and pain at the time of data collection. Owen,^[3] in her qualitative study exploring the meaning of hope in patients with cancer, interviewed six clinical nurse specialists to elicit their vivid descriptions of hopeful patients with cancer. Her analysis of the interview data identified six subthemes, and 'energy' was the only theme consistently expressed by each participant to describe hope or hopefulness. A person's energy may be drained by unrelieved pain. Therefore, it is conceivable that a relation between pain and hope or hopefulness may exist. However, little research has been devoted to the relation between pain and hope. Based on the interview responses of 30 terminally ill patients, Herth,^[16] identified uncontrolled pain as one of the factors that inhibits or interferes with attaining or maintaining hope. A strong negative correlation (r = -.73) was found between pain and hope, as measured by the Herth Hope Index,^[11] in a study of 84 Taiwanese patients with cancer,^[13] indicating that higher pain intensity scores are associated with lower levels of hope.

Pain is well recognized as a multidimensional phenomenon with physiologic, sensory, affective, cognitive, behavioral, and sociocultural aspects.^[17,18] The sensory aspect of pain refers to sensations of pain such as its intensity, location, and quality (eg, sharp, throbbing). The cognitive dimension of pain refers to beliefs about pain, meanings ascribed to pain, and other thoughts related to pain.^[19] However, it is not known which aspect of pain is associated with level of hope. The purposes of the present study were 1) to examine the effect of disease status on the level of hope in patients with cancer; 2) to compare the level of hope between patients with cancer who have pain and those who do not; and 3) to determine which aspects of pain are associated with hope among patients with pain.

The conceptual framework for this study was based on the 'self-regulation model of coping with health threats' proposed by Leventhal et al.^[20] In this model, the key concept is illness representation, the way people conceptualize or interpret health and illness. This lay-person mental representation of illness, which may conflict with that of the medical establishment, influences how people cope with their health problems.^[20,21] The components of illness representation include people's beliefs about the symptoms, diagnostic labels, cause, cure, timeline, and consequences of their illness.^[21,22] In the current study, the subjective interpretation of illness, including perceived treatment effects and the meaning of pain, and the objective indicators of illness, such as disease stage and pain intensity, were examined for their association with hope in patients who have cancer. It was expected that subjective the patient's cognitive interpretation of illness would have more impact on hope than objective indicators.

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