Assessment of Pain, Acceptance of Illness, Adjustment to Life and Strategies of Coping with the Illness in Patients with Pancreatic Cancer

*Urszula Religioni, Aleksandra Czerw, Anna M. Badowska-Kozakiewicz, Michał Budzik and Andrzej Deptała*

#### **Abstract**

Pancreatic cancer is the fourth most common cancer causing death in the world. The prognosis of patients with pancreatic cancer is relatively low, which may be reflected in the patients' lack of acceptance of the illness and passive attitudes towards the illness. The aim of the study was to evaluate the strategy of coping with pain and its control, acceptance of the illness and adjustment to life with cancer in patients suffering from pancreatic cancer. Forty-six patients with pancreatic cancer were included in the study. They were treated as outpatients at the Center of Oncology at Maria Skłodowska-Curie's Institute in Warsaw between 2017 and 2018. The questionnaire included four psychometric tests: BPCQ, CSQ, AIS and MiniMAC. In the BPCQ test the highest average test result was obtained by "internal factors" (M = 16.85; SD = 5.64). The most frequently chosen strategies for coping with pain are praying/hoping (M = 22.33; SD = 7.85). The average illness acceptance score was 23.13 (SD = 7.84). The most common methods of psychological adjustment to cancer for the studied group are the strategies of positive reevaluation (M = 20.07, SD = 3.67). Patients with pancreatic cancer have a low level of acceptance of their illness.

**Keywords:** pancreatic cancer, pain control, coping with pain, acceptance of illness

#### **1. Introduction**

According to data available in the National Cancer Registry, the number of pancreatic cancers in Poland in 2016 was over 3,486 (standardized ratio 5.5/ 100,000). In 2016, pancreatic cancer in the illness mortality structure in Poland took eighth place in men (2.1%) and eleventh in women (2.1%). Most pancreatic cancers are diagnosed in Poland after the age of 50 [1, 2].

In Poland, pancreatic cancer occurs less frequently than in most European Union countries. Pancreatic cancer is much more common in developed countries (North

America, Central and Northern Europe, Australia) than in African or Indian countries. The American statistical data from 2018 provided the number of 56,770 new cases, including 29,940 in men and 26,830 in women (fourth place in the mortality structure in men and women) [3].

Pancreatic cancer is the fourth most common cancer causing death in the world [4]. In Poland, it is the sixth most common cause of deaths for men (4.3% in the mortality structure) and five women (5.6% in the mortality structure) due to cancer. In 2016, a total of 4,908 Poles died due to pancreatic cancer (standardized ratio 6.2/100,000), and this ratio is comparable to the average of the European Union countries and other countries in the world. The 5-year survival rate in patients with pancreatic cancer in Poland is 9.0% [1, 2].

Risk factors for pancreatic cancer include genetic factors, smoking, obesity, diet rich in red meat and animal fats, and chronic pancreatitis. Surgical treatment is the only method that allows complete cure of pancreatic cancer, provided there is no metastasis at the time of diagnosis, however, due to significant illness severity, only 15–20% of patients can be optimally treated surgically [5].

Due to the very low survival rate of patients with pancreatic cancer (on average 3–7 months from diagnosis and 10–15% one year), it is important that the treatment of patients takes into account the achievement of the highest quality of life [6, 7]. The subjectively assessed quality of life of patients with cancer largely depends on the acceptance of cancer and coping with pain and illness. In the case of pancreatic cancer, patients, having knowledge that survival with this type of illness is very low, may have a tendency to choose destructive behaviors in coping with the illness, which may affect the quality of life they assess, increase pain, and affect the effects of treatment.

The aim of the study was to assess the level of acceptance of the illness, strategies for coping with pain, locating pain control, as well as adapting to life with cancer in patients with pancreatic cancer. The study looked for relationships between socioeconomic factors (sex, age, education, professional status, income, place of residence) and treatment with chemotherapy, and results obtained in psychometric tests.

#### **2. Material and methods**

The study was conducted between 2017 and mid-2018 among 46 patients diagnosed with pancreatic cancer in stage II-IV according to the AJCC 2017, 8th ed. The outpatients were treated with chemotherapy with gemcitabine at the Center of Oncology at Maria Sklodowska-Curie's Institute in Warsaw. The study tool was a questionnaire with metric questions and four psychometric tests:


The PAPI (Paper and Pencil Interview) technique was used in the study. All patients included in the study gave consented to carry it out.

*Assessment of Pain, Acceptance of Illness, Adjustment to Life and Strategies of Coping… DOI: http://dx.doi.org/10.5772/intechopen.97325*

The study findings were then statistically analyzed with the use of Student's t-test for independent samples, one-way analysis of variance and Pearson's r correlation (in the case of age variable). The adopted statistical significance was at p < 0.05.

The scores of the tests were correlated with socioeconomic characteristics of the respondents: sex, age, education, professional status, place of residence, net income-per-household-member, and with chemotherapy treatment in the past year.

#### **3. Results**

The study involved patients aged 30–84 years (M = 60.46, SD = 12.28), including 24 (52.2%) women aged 43–84 (M = 63.71, SD = 12.08) and 22 (47.8%) men aged 30–74 (M = 56.91, SD = 11.74).

Among the studied group of patients, 16 (34.8%) have primary/vocational education, 14 (30.4%) have secondary, and 16 (34.8%) have higher education. Over half of the patients - 26 (56.5%) live in towns with a population of up to 100,000, and 20 (43.5%) live in cities with a population of over 100,000. Half of the patients have a monthly net income of up to PLN 1,500 (23 patients, 50.0%), thereby 50% patients indicated that they achieved income over PLN 1,500.00. There were 20 people (43.5%) working in the examined group, and 26 patients (56.5%) were pensioners (56.5%).

In 23 patients (50.0%) metastases were diagnosed. Among the studied group of patients, 25 (54.3%) were undergoing chemotherapy treatment, 15 (32.6%) were undergoing radiotherapy and 10 subjects (21.7%) were undergoing targeted treatment.

#### **3.1 Pain control**

In the assessment of pain control in patients with pancreatic cancer S. Skevington's BPCQ (The Beliefs about Pain Control Questionnaire), consisting of 13 statements, was used. In accordance with the assumptions of the BPCQ, the statements used in the questionnaire constitute a part of three factors that measure the strength of individual beliefs about controlling pain personally (internal factors), influence of physicians (other forces), or by random events [8].

In the case of patients with pancreatic cancer, the highest average score in the BPCQ questionnaire was obtained by "internal factors" (M = 16.85; SD = 5.64), and the lowest – "random events" (M = 14.85; SD = 4.11) (**Table 1**), which means that patients believe that these factors contribute to pain control.

Socio-economic variables that differentiate results in patients with pancreatic cancer are gender and net income per household member. In the case of gender, there was a statistically significant difference in the internal locus of pain control (p = 0.024). The mean value obtained in the group of women (M = 18.63) was higher than in the group of men (M = 14.91).

The level of income in the studied group of patients influenced the difference in the locus of pain control in random events (p = 0.027). The mean value of the severity of the locus of pain control in random events was higher in the group of people with higher income above PLN 1,500 (M = 16.17) than in those in the case of whom in the household the income per family member does not exceed PLN 1,500 (M = 13.52).

Other variables (age, education, place of residence, professional status and chemotherapy) did not affect the results of the pain control questionnaire.

#### **3.2 Pain coping strategies**

The Pain Coping Strategies Questionnaire developed by A.K. Rosenstiel and F.J. Keefe (CSQ) is used to examine people who complain about pain. The questionnaire consists of 42 statements and is intended to assess the pain coping strategies that patients use, as well as to verify the effectiveness of these strategies in reducing or managing pain. The ways of dealing with pain assessed in the questionnaire reflect six cognitive and one behavioral strategy, which in turn constitute a part of three factors: cognitive coping, distracting and taking substitute actions, and catastrophizing and seeking hope [9].

In the BPCQ the highest average score for respondents suffering from pancreatic cancer was obtained by praying/hoping (M = 22.33; SD = 7.85), then declaring coping (M = 19.83; SD = 8.06) and increased behavioral activity (M = 19.67; SD = 8.59). According to patients, these factors have the greatest impact on the fight against cancer. The smallest values are visible in the case of re-evaluation of pain (M = 13.35; SD = 9.24) and ignoring sensations (M = 14.93; SD = 9.36) (**Figure 1**).

The assessment that was particularly differentiated by the socio-economic variables under study is praying/hoping. The results in this assessment are differentiated by gender, age, occupational status and the fact that patients have undergone chemotherapeutic treatment in the last year.

In the case of gender, it was noticed that the average value of the praying/hoping assessment was significantly higher in the group of women than men (p = 0.030), and the average values of this assessment were 24.71 for women and 19.73 for men respectively.

In the assessment of praying/hoping, statistically significant positive correlations were obtained in the case of the age of the respondents (r = 0.367). In addition, the age of patients positively correlated with the assessment of increased behavioral activity (r = 0.387).

The average value of the praying/hoping dimension was also higher in the group of pensioners than in the group of working patients (p = 0.044), amounting to 24.48 for pensioners and 19.75 for working people.

Patients who have not been subjected to chemotherapy in the last year also had a higher average value of praying/hoping in the BPCQ (M = 25.52) than patients who were subjected to chemotherapy (M = 19.64) (p = 0.010).

Patients' education, place of residence and income per family member did not affect the pain coping strategies adopted by patients.

**Figure 1.** *Results of the CSQ for patients with pancreatic cancer.*

*Assessment of Pain, Acceptance of Illness, Adjustment to Life and Strategies of Coping… DOI: http://dx.doi.org/10.5772/intechopen.97325*

#### **3.3 Acceptance of illness**

The Approval Illness Scale (AIS) consists of eight statements, based on which the results obtainable for each respondent in the level of acceptance of the illness are within the range from 8 to 40. The higher the score, the better adjustment to the illness and the lesser the sense of mental discomfort. The lower the score, the greater the severity of negative emotions associated with the illness, and thus its lower acceptance [10].

The mean score (disease acceptance level) obtained by patients suffering from pancreatic cancer in the AIS scale was 23.13 with a standard deviation of 7.84. None of the socio-economic variables studied determines differences in the level of illness acceptance between groups.

The average value of acceptance of the illness in the group of women was 22.54 and was close to the average value obtained in the group of men, which was 23.77. The average value of acceptance of the illness in the group of people with primary or vocational education was 22.08, in the group of people with secondary education was 23.43, and in the group of people with higher education was 23.13.

The average disease acceptance was similar in the group of people living in towns with a population of up to 100,000, and in towns with a population above 100,000 (23.1 and 23.15, respectively).Income also did not differentiate the obtained results. The average value of acceptance of the illness in the group of people with net income of up to PLN 1,500 per person in the family was 23.61 and was also close to the average value obtained in the group of people who achieved income above PLN 1,500 (M = 22.65).

The average value of acceptance of the illness in the working group was 24.85, and in the group of pensioners - 21.52, but these differences were also not statistically significant.

The average value of acceptance of the illness in the group of patients who underwent the chemotherapeutic treatment last year was 22.84 and similarly to other variables it was close to the average value obtained in the group of people who did not undergo chemotherapy treatment which was 23.48.

#### **3.4 Mental adjustment to the illness**

The Mini-Mac (Mental Adjustment to Cancer) questionnaire measures four methods of mental adjustment to the illness: anxiety, fighting spirit, helplessness hopelessness and positive reevaluation. According to the assumptions of the questionnaire, anxiety and helplessness-hopelessness are part of a passive (destructive) style of coping with the illness, and the other two dimensions refer to the active (constructive) style of coping with the illness [11].

Respondents suffering from pancreatic cancer obtained the highest result of the Mini-Mac test in terms of positive re-evaluation (M = 20.07, SD = 3.67) and fighting spirit (M = 19.80, SD = 3.89) and these are the main disease adaptation methods used by patients, and the lowest - in terms of helplessness-hopelessness (M = 15.87, SD = 4.56) (**Table 2**).

The strategy of positive re-evaluation was differentiated by the gender of patients (p = 0.002). The average value of positive re-evaluation obtained in the group of women was higher than in the group of men (respectively M = 21.63 and M = 18.36). Similarly, the average in positive re-evaluation was dependent on the age of patients - the higher the age, the higher the values obtained by patients in this assessment (r = 0.550). The age of the patients also positively correlated with fighting spirit (r = 0.429).

The average value of positive re-evaluation was statistically significantly lower in the group of patients with higher education (M = 17.50) than in the group with

basic or vocational education (M = 21.00) and in the group of people with secondary education (M = 21.93) (p = 0.001).

Income also conditioned the value of positive re-evaluation (p = 0.004). The average value of positive re-evaluation was higher in the group of people with lower income up to PLN 1,500 per person in the family (M = 21.57) in comparison with people whose income per family member exceeded PLN 1,500 (M = 18.57).

Positive re-evaluation was also conditioned by the professional status of patients (p = 0.001). The average value of this assessment was higher in the group of pensioners (M = 21.83) than in the group of working patients (M = 17.70).

### **4. Discussion**

Chronic illness forces patients to make many changes in their life to be able to adapt to the new situation. In this area, accepting the losses caused by the illness seems to be the most difficult for patients, coping with the limitations and measuring the risks that may arise in connection with cancer [12].

Pancreatic cancer is usually diagnosed at an advanced stage, which results from the fact that the patient feels the symptoms only when the illness is fully developed and the metastases are already distant. At the same time, late diagnosis of the illness is associated with rapidly developing, difficult to treat symptoms, which in the case of pancreatic cancer include quick destruction of the body, lack of appetite, pain, pruritus, nausea and vomiting, deep vein thrombosis. Many patients with pancreatic cancer do not survive the first year after the diagnosis, and with severe pain and high severity of cancer symptoms it seems reasonable to implement palliative care in the first months after the diagnosis [13]. Furthermore, patients themselves are aware that the survival rate with pancreatic cancer is one of the lowest of all cancers, which is additionally a stress factor for patients.

A study to assess the level of stress and depression among patients with various cancers indicates that patients with pancreatic cancer are most affected by anxiety and are characterized by the highest rate of depression [14, 15]. Similar results are indicated by Clark K.L. et al. [16].

Many studies indicate that subjective feelings, attitudes and behaviors influence pain. Pain as a physical and psychological phenomenon is felt with the participation of consciousness, therefore the state of the psyche and psychological factors play a fundamental role in experiencing pain, especially chronic pain. Particularly important element affecting the experience of pain is the control locus (locus of control is the degree to which people believe they control the situations they experience in lives; control can be internal or external) which also directly affects the behavior of the patient in a situation of pain [17–19].

Our study, including 46 patients with pancreatic cancer, indicates that patients control pain mainly through internal factors (M = 16.85, SD = 5.64). A similar result is obtained by patients with cancer of the digestive system - colorectal cancer (N = 238; M = 17.36; SD = 5.48) [20]. Studies conducted by Basińska M.A. et al. also using the BPCQ questionnaire in patients with colorectal cancer and lung cancer indicate that in both groups the patients attribute the greatest role in the control of pain to the influence of physicians (for patients with lung cancer M = 17.08, SD 4.97, and for patients with colorectal cancer M = 16.98, SD = 4.32) (**Table 3**). Patients attribute the lowest role of pain control to random events (for patients with lung cancer M = 15.18, SD = 3.80, and for patients with colorectal cancer M = 15.00, SD = 3.46), and these values are very similar to the sense of control through internal factors. The study conducted by Basińska M.A. et al. at the *Assessment of Pain, Acceptance of Illness, Adjustment to Life and Strategies of Coping… DOI: http://dx.doi.org/10.5772/intechopen.97325*

same time, indicated that patients with external control locus use methods of passively struggling with the illness and vice versa - patients with high internal control locus are characterized by high activity and better psychological well-being. The external health control locus is associated with chronic negative emotions such as depression, anxiety or hostility, as well as an increase in pain symptoms in patients [17].

According to our study, the most common way to cope with pain in the case of patients with pancreatic cancer is praying/hoping (M = 22.33, SD = 7.85), typical primarily for women, the elderly, and pensioners. These groups obtained by far the highest values in the assessment of praying/hoping. Patients with colorectal cancer in the study conducted by Czerw A. et al. most often use coping strategies and increased behavioral activity [20] also typical for prostate cancer [21], lung cancer [22] and breast cancer [23] (**Figure 2**). Interestingly, among patients with colorectal cancer, it was noticed that the strategy of praying/hoping is particularly often chosen by women and the group of pensioners [20], as in the case of patients with pancreatic cancer according to our study.

The strategies of praying/hoping and declaring coping typical for patients with pancreatic cancer are the most commonly used in the group of patients chronically ill with back pain in the studies conducted by A.K. Rosenstiel and F.J. Keefe. Similarly, the most rarely used strategy for patients was the re-evaluation of pain [9], and this assessment was also poorly assessed by patients in our study. Although, Religioni U. et al. [24] in the study conducted on cancer patients indicates that socio-economic variables, which most often differentiate the selection of strategies for coping with cancer pain, are education and income, in the case of patients with pancreatic cancer, this relationship was not noticed.

However, it should be noted that many studies indicate that the strategies of catastrophizing or praying/hoping significantly affect the severity of pain symptoms in chronic illnesses and deterioration of the general health condition [25, 26].

The level of acceptance of the illness among patients with pancreatic cancer in our study was 23.13 (SD = 7.84). The acceptance of the illness in the studied group is lower than in the group of patients with other cancers (among patients with breast cancer the average disease acceptance score in the AIS test was 28.46, among patients with lung cancer M = 23.17, among patients with cancer of the large intestine M = 27.74, among prostate cancer patients M = 30.39) [27]. Similarly,

Kapela I. et al. indicate that among patients with colorectal cancer, the level of acceptance of the disease according to the AIS scale reaches values slightly higher than the average (M = 28.4) and close to the values obtained in the studies conducted by Religioni U. et al. [28].

Significantly lower results in the AIS test were obtained by Kozak G. Among the oncological patients subject to palliative care, the highest level of acceptance of the illness was observed in women with cancer of the reproductive organs (M = 21.93, SD = 6.00) compared to patients with colorectal cancer (M = 16.58, SD = 7.42), gastric cancer (M = 16.87, SD = 5.59) and pancreatic cancer (M = 18.23, SD = 9.13) [29]. The level of acceptance of the illness in patients with various cancers, including pancreatic cancer, examined by Kołpa M. et al. was on average M = 25.35; SD = 9.25. This study indicates that age diversifies the level of adjustment to the illness, but other variables, such as education or gender, do not affect the results [30]. In the study of patients with pancreatic cancer none of the variables affected the level of acceptance of the illness.

The study conducted on other groups of patients indicates that such patients get higher results in the AIS test than patients with pancreatic cancer, e.g. patients with diabetes M = 25.76; SD = 10.34, patients with cardiovascular disease M = 27.78; SD = 9.86, patients with diseases of the nervous system M = 27.02; SD = 8.92 [12].

Among the available studies only few groups achieve lower values in the AIS test compared to patients with pancreatic cancer in our study: men after myocardial infarction (M = 22.14), men with chronic pain (M = 18.44), men with back pain (M = 20.51) [31].

The level of disease acceptance among patients with various types of cancer is presented in **Table 4**.

Pancreatic cancer is a specific type of cancer. The coping process is dynamic and involves various strategies, the use of which depends on the duration of the illness [32]. Among the methods of coping with cancer by patients with pancreatic cancer, positive re-evaluation (M = 20.07, SD = 3.67) and fighting spirit (M = 19,8; SD = 3,89) dominate. In patients with colorectal cancer in the study conducted by Kapela I. et al. the constructive style dominates as well, with a predominance of fighting spirit (M = 23.9) and positive re-evaluation (M = 22.5) [28]. Similar results were obtained by Czerw A. et al. among patients with colorectal cancer (fighting spirit M = 23.42, positive re-evaluation M = 22.31) [20].

The average results for anxiety and hopelessness/hopelessness in our study were respectively M = 18.30;SD = 4.72 and M = 15.87; SD = 4.56, which is a much higher result than in the case of other most common cancers (lung, breast, colon and prostate cancer) [33]. Similar, although higher results for these assessments are indicated by Kozak G. In his studies, men with prostate cancer have the highest intensity of anxiety among all cancer patients. Anxiety is also significantly higher in the case of patients with stomach cancer (M = 22.84; SD = 5.52), pancreas cancer (M = 22.43; SD = 6.30) and colorectal cancer (M = 21.72; SD = 6.55) in comparison to women with cancer of the reproductive organs (M = 18.34; SD = 4.26). In the case of these patients, the highest level of fighting spirit is observed (M = 23.95; SD = 4.35). In the studies conducted by Kozak G. a significantly higher level of fighting spirit was observed in patients with stomach cancer (M = 19.62; SD = 5.82) and colorectal cancer (M = 19.37; SD = 5.32) in comparison to patients with pancreatic cancer M = 15.43; SD = 5.01) or prostate cancer (M = 15.68; SD = 5.06). Patients with stomach cancer (M = 20.98; SD = 5.68), pancreatic cancer (M = 21.22; SD = 5.10) and colorectal cancer (M = 19.16; SD = 7.41) are characterized by greater severity of helplessness/hopelessness compared to women with cancer of the reproductive organs (M = 13.70; SD = 5.36) (**Table 5**) [29].

#### *Assessment of Pain, Acceptance of Illness, Adjustment to Life and Strategies of Coping… DOI: http://dx.doi.org/10.5772/intechopen.97325*

The analysis of the level of acceptance of the illness in relation to the adopted way of adjustment to the illness indicated that the higher the level of acceptance on the AIS scale, the higher the level of fighting spirit and the level on the scale of the constructive style (Mini-MAC) [30]. In this context, the implementation of activities aimed at helping to accept the disease is particularly important. These actions should be taken by medical personnel. Health policy programs can also play an important role in this respect. These programs may include specialist trainings for medical personnel as well as implementation of activities directed directly to patients [34].

Similarly, in the study conducted on 220 patients with various cancers: stomach cancer, cancer of reproductive organs, pancreatic cancer, colorectal cancer and prostate cancer, similar dependencies were indicated – the higher the acceptance of the illness, the higher the intensity of fighting spirit and the lower the intensity of anxiety and helplessness/hopelessness [29]. In the study conducted on patients with colorectal patients, education significantly affects the results obtained in terms of anxiety, helplessness/hopelessness and the destructive style [28]. In our study conducted on patients with pancreatic cancer, education positively correlated with the strategy of positive re-evaluation. Among patients with pancreatic cancer in the study conducted by Kozak G., it was also observed that the older the patients, the lower the intensity of anxiety and helplessness/hopelessness [29]. A similar relationship in this group of patients was also described by Juczyński Z., although our study does not confirm this dependency. Numerous studies indicate that a typical method to cope with the illness among patients with pancreatic cancer is the application of defense mechanisms – repression and denial. According to Bahnson C. et al., repression and denial play a key role in the development of cancer, including pancreatic cancer [35, 36].

As authors, we are aware of the imitations of our research. First of all, we know that our sample of patients is small. The study took place in an outpatient clinic, and we recruited as many patients as possible. However, we know that extending the study to include hospitalized patients would bring more accurate results. We believe that this is the direction of further research. Additionally, despite identifying the benefits of some psychological strategies, we recognize that our research only shows the course of action. It is not possible to force a patient to adopt any disease strategy. This attitude must result from their internal needs and beliefs. However, the skillful help of a psychologist can help patients fight the disease so that the patient experiences the highest possible quality of life.
