Age-Related Patterns in Cancer Pain and Its Psychosocial Impact: Investigating the Role of Variability in Physical and Mental Health Quality of Life.

Objective: Age-related patterns in cancer pain remain equivocal. Most studies ignore heterogeneity across multiple domains of well-being, and the potential role of physical (PH) and mental health (MH) quality of life (QOL) in these age-related patterns is unknown. We investigated the relationships between age and cancer pain intensity, qualities, and interference, and physical and psychosocial adaptation and the interaction between age and PH and MH QOL on pain and adaptation to cancer pain. Design: In this cross-sectional study, 244 patients with advanced cancer and pain completed measures of pain, QOL, physical function, and psychosocial well-being. Pearson's correlations and ANOVAs assessed relationships between age and demographic and clinical factors, pain, and physical and psychosocial measures. Regression models tested the role of age and its interaction with PH and MH QOL on pain and physical and psychosocial adaptation. Results: Older age was associated with a lower likelihood of receiving an opioid prescription, greater likelihood of having comorbidities, and worse functional status. When we did not account for these factors, age was not associated with pain and most adaptation indices. When we did account for these factors and PH QOL, older age was associated with lower non-neuropathic and neuropathic pain and several indices of psychosocial adaptation. Most interestingly, older age was associated with lower non-neuropathic pain among those with high, but not low, MH QOL. Conclusions: This study addresses knowledge gaps about factors underlying age-related patterns in cancer pain. Impaired MH QOL may be a proxy for age-related patterns in cancer pain. Summary: This study investigated age-related patterns in the experience of cancer pain and the role of quality of life in resilience and vulnerability to pain and adaptation to pain. Older age is associated with lower non-neuropathic pain among those with high, but not low, mental health quality of life, suggesting that impaired mental health quality of life is an important indicator of vulnerability to multidimensional pain outcomes.

Depression and hopelessness in patients with acute leukemia: the psychological impact of an acute and life-threatening disorder.

OBJECTIVE: Acute leukemia (AL) is a life-threatening cancer associated with substantial morbidity and mortality, particularly in older adults. Given that there has been little research on the psychological impact of such malignancies with acute onset, we assessed the prevalence and correlates of depression and hopelessness in patients with AL. METHODS: Three hundred forty-one participants were recruited within 1 month of diagnosis or relapse and completed the Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), Memorial Symptom Assessment Scale, and other psychosocial measures. Multivariate regression analyses identified correlates of depression and hopelessness. RESULTS: 17.8% reported clinically significant depressive symptoms (BDI-II ≥ 15), 40.4% of which were in the moderate-severe range (BDI-II ≥ 20). 8.5% reported significant symptoms of hopelessness (BHS ≥ 8). Depression was associated with greater physical symptom burden (adjusted R(2) = 48.4%), while hopelessness was associated with older age and lower self-esteem (adjusted R(2) = 45.4%). Both were associated with poorer spiritual well-being. CONCLUSIONS: Clinically significant depressive symptoms were common early in the course of AL and related to physical symptom burden. Hopelessness was less common and associated with older age and lower self-esteem. The results suggest that whereas depression in AL may be related to disease burden, the preservation of hope may be linked to individual resilience, life stage, and realistic prognosis.Copyright © 2015 John Wiley & Sons, Ltd.

How do healthcare workers judge pain in older palliative care patients with delirium near the end of life?

OBJECTIVE: Pain and delirium are commonly reported in older people with advanced cancer. However, assessing pain in this population is challenging, and there is currently no validated assessment tool for this task. The present retrospective cohort study was conducted to understand how healthcare workers (HCWs; nurses and physicians) determine that older cancer patients with delirium are in pain. METHOD: We reviewed the medical records of consecutive palliative care inpatients, 65 years of age and above (N = 113), in order to identify patient-based cues used by HCWs to make pain judgments and to examine how the cues differ by delirium subtype and outcome. RESULTS: We found that HCWs routinely make judgments about pain in older patients with delirium using a repertoire of strategies that includes patient self-report and observations of spontaneous and evoked behavior. Using these strategies, HCWs judged pain to be highly prevalent in this inpatient palliative care setting. SIGNIFICANCE OF RESULTS: These novel findings will inform the development of valid and reliable tools to assess pain in older cancer patients with delirium.

Finding new bearings: a qualitative study on the transition from inpatient to ambulatory care of patients with acute myeloid leukemia.

PURPOSE: Treatment of adult acute myeloid leukemia (AML) is intensive, with induction treatment initiated in an inpatient setting and subsequent consolidation therapy often conducted in an outpatient setting. The purpose of the present qualitative paper is to provide insight into the experience of patients in the transition from inpatient to ambulatory care. METHODS: Participants were 35 AML patients who were interviewed about their experience of the illness and treatment. Utilizing the grounded theory method, we describe the adjustment of participants to the transition to ambulatory care. RESULTS: As outpatients, participants described adjusting to the intensity of ambulatory treatment and to the need to assume greater responsibility for their care. They also expressed a growing desire to understand their long-term care plan, compared to their preference to focus on the present prior to discharge, and they were struggling to construct a new sense of identity. CONCLUSIONS: AML patients are now leaving acute care settings sicker and earlier. Considering their perceptions can inform interventions to facilitate adjustment during the transition to outpatient care.

Traumatic stress in acute leukemia.

OBJECTIVE: Acute leukemia is a condition with an acute onset that is associated with considerable morbidity and mortality. However, the psychological impact of this life-threatening condition and its intensive treatment has not been systematically examined. In the present study, we investigate the prevalence and correlates of post-traumatic stress symptoms in this population. METHODS: Patients with acute myeloid, lymphocytic, and promyelocytic leukemia who were newly diagnosed, recently relapsed, or treatment failures were recruited at a comprehensive cancer center in Toronto, Canada. Participants completed the Stanford Acute Stress Reaction Questionnaire, Memorial Symptom Assessment Scale, CARES Medical Interaction Subscale, and other psychosocial measures. A multivariate regression analysis was used to assess independent predictors of post-traumatic stress symptoms. RESULTS: Of the 205 participants, 58% were male, mean age was 50.1 ± 15.4 years, 86% were recently diagnosed, and 94% were receiving active treatment. The mean Stanford Acute Stress Reaction Questionnaire score was 30.2 ± 22.5, with 27 of 200 (14%) patients meeting criteria for acute stress disorder and 36 (18%) for subsyndromal acute stress disorder. Post-traumatic stress symptoms were associated with more physical symptoms, physical symptom distress, attachment anxiety, and perceived difficulty communicating with health-care providers, and poorer spiritual well-being (all p < 0.05). CONCLUSIONS: The present study demonstrates that clinically significant symptoms of traumatic stress are common in acute leukemia and are linked to the degree of physical suffering, to satisfaction with relationships with health-care providers, and with individual psychological characteristics. Longitudinal study is needed to determine the natural history, but these findings suggest that intervention may be indicated to alleviate or prevent traumatic stress in this population.

Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy Diagnostic Criteria for Acute Needle Pain.

Needle procedures are among the most common causes of pain and distress for individuals seeking health care. While needle pain is especially problematic for children needle pain and associated fear also has significant impact on adults and can lead to avoidance of appropriate medical care. Currently there is not a standard definition of needle pain. A taxonomy, or classification system, for acute needle pain would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including needle pain. To accomplish this, a working group of experts in needle pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific needle pain. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of needle associated fear, are proposed to define the types of acute needle pain. PERSPECTIVE: This article presents a taxonomy for acute needle pain. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients undergoing needle procedures.

Managing Cancer and Living Meaningfully (CALM): a qualitative study of a brief individual psychotherapy for individuals with advanced cancer.

BACKGROUND: Although psychosocial care has been regarded as central to palliative and supportive care, there have been few empirically tested approaches to individual intervention. AIM: The subjective experience of advanced cancer patients receiving a new manualized brief individual psychotherapy, referred to as Managing Cancer and Living Meaningfully (CALM), was examined prior to the initiation of a randomized controlled trial testing the effectiveness of this intervention. DESIGN: Semi-structured interviews were conducted with patients who had a diagnosis of advanced cancer, and who underwent the intervention. SETTING/PARTICIPANTS: Patients were recruited from a large urban regional cancer center in Toronto, Canada. The 10 interviewees included seven women and three men. All had completed between three to six CALM sessions prior to the interview. RESULTS: The CALM intervention was associated with profound and unique patient-identified benefits and no patient-identified risks or concerns. Five interrelated benefits of the intervention were identified: (1) a safe place to process the experience of advanced cancer; (2) permission to talk about death and dying; (3) assistance in managing the illness and navigating the healthcare system; (4) resolution of relational strain; and (5) an opportunity to 'be seen as a whole person' within the healthcare system. These benefits were regarded by participants as unique in their cancer journey. CONCLUSIONS: Findings from a qualitative study suggest that the CALM intervention provides substantial benefits for patients with advanced cancer prior to the end of life. Findings informed the development of a randomized controlled trial to evaluate the effectiveness of this intervention.

Psychometric validation of the cardiac rehabilitation barriers scale.

OBJECTIVE: The purpose of this study was to investigate the factor structure and psychometric properties of the Cardiac Rehabilitation Barriers Scale (CRBS). DESIGN, SETTING, AND PARTICIPANTS: In total, 2636 cardiac inpatients from 11 hospitals completed a survey. One year later, participants completed a follow-up survey, which included the CRBS. A subsample of patients also completed a third survey which included the CRBS, the Cardiac Rehabilitation Enrolment Obstacles scale, and the Beliefs About Cardiac Rehabilitation scale three weeks later. The CRBS asked participants to rate 21 cardiac rehabilitation barriers on a five-point Likert scale regardless of cardiac rehabilitation referral or enrolment. RESULTS: Maximum likelihood factor analysis with oblique rotation resulted in a four-factor solution: perceived need/healthcare factors (eigenvalue = 6.13, Cronbach's α = .89), logistical factors (eigenvalue = 5.83, Cronbach's α = .88), work/time conflicts (eigenvalue = 3.78, Cronbach's α = .71), and comorbidities/functional status (eigenvalue = 4.85, Cronbach's α = .83). Mean total perceived barriers were significantly greater among non-enrollees than cardiac rehabilitation enrollees (P < .001). Convergent validity with the Beliefs About Cardiac Rehabilitation and Cardiac Rehabilitation Enrolment Obstacles scales was also demonstrated. Test-retest reliability of the CRBS was acceptable (intraclass correlation coefficient = .64). CONCLUSION: The CRBS consists of four subscales and has sound psychometric properties. The extent to which identified barriers can be addressed to facilitate greater cardiac rehabilitation utilization warrants future study.

Measuring death-related anxiety in advanced cancer: preliminary psychometrics of the Death and Dying Distress Scale.

The alleviation of distress associated with death and dying is a central goal of palliative care, despite the lack of routine measurement of this outcome. In this study, we introduce the Death and Dying Distress Scale (DADDS), a new, brief measure we have developed to assess death-related anxiety in advanced cancer and other palliative populations. We describe its preliminary psychometrics based on a sample of 33 patients with advanced or metastatic cancer. The DADDS broadly captures distress about the loss of time and opportunity, the process of death and dying, and its impact on others. The initial version of the scale has a one-factor structure and good internal reliability. Dying and death-related distress was positively associated with depression and negatively associated with spiritual, emotional, physical, and functional well-being, providing early evidence of construct validity. This distress was relatively common, with 45% of the sample scoring in the upper reaches of the scale, suggesting that the DADDS may be a relevant outcome for palliative intervention. We conclude by presenting a revised 15-item version of the scale for further study in advanced cancer and other palliative populations.

Age and gender differences in symptom intensity and symptom clusters among patients with metastatic cancer.

BACKGROUND: Few studies have explored demographic variations in symptom patterns. Our goals were to examine age and gender differences in symptom intensity and symptom clusters among outpatients with advanced cancer. METHODS: Symptom scores by the Edmonton Symptom Assessment System (ESAS) were collected for patients attending the Oncology Palliative Care Clinics at Princess Margaret Hospital from 2005 to 2007. Symptom intensity was compared between individuals aged ≤ 60 and > 60 years and between males and females. Principal component analysis (PCA) was performed to determine inter-relationships of the nine ESAS symptoms and to compare symptom clusters within age and gender subgroups. RESULTS: From a total of 1,358 patients, 49.8% were male and 50.2% were female. The median age was 64 (range 19 to 99): 39.6% were ≤ 60 and 60.4% were >60. The most common primary cancer sites were gastrointestinal (27%), lung (15%), and breast (11%). Younger patients reported worse pain (4.9 vs. 4.5, p = 0.02) and better appetite (4.7 vs. 5.3, p = 0.002) than older patients. Females reported poorer scores than males for nausea (2.6 vs. 2.2, p = 0.02). Analyses of symptom clusters revealed that fatigue and drowsiness were included in the cluster of pain, nausea, and appetite in younger but not older patients. In men, pain clustered together with depression and anxiety; for women, physical and psychological symptoms formed separate clusters. CONCLUSIONS: In patients with advanced cancers, symptom patterns differ according to age and gender. Palliative interventions tailored for symptoms that are more prominent in specific patient subgroups may offer greater therapeutic benefit.

Patterns of depression in cancer patients: an indirect test of gender-specific vulnerabilities to depression.

BACKGROUND: Higher rates of depression in women compared to men have been attributed to intrinsic biological or psychological vulnerabilities, to their disproportionate exposure to stressful events and circumstances, or to the combined contributions of these factors. PURPOSE: This study aimed to determine if there is a gender disparity in depression rates in patients with advanced cancer, a circumstance associated with multiple stressors and a high prevalence of depression. METHOD: Data were collected from 569 patients, assessing demographic characteristics, depressive symptoms, physical symptoms, and social support. RESULTS: Clinically significant symptoms of depression (BDI-II scores ≥16) were reported by more than 20% of the sample, with no significant gender differences in depression. There were no significant gender differences in potentially confounding factors such as social support or physical symptom burden. CONCLUSION: The results indicated that men and women may be equally likely to develop depression when faced with a highly stressful circumstance.

Factor structure of the Beck Hopelessness Scale in individuals with advanced cancer.

OBJECTIVE: Although the Beck Hopelessness Scale is often used with the seriously ill, its factor structure has been given relatively little consideration in this context. METHODS: The factor structure of this scale was examined in a sample of 406 ambulatory patients with advanced lung or gastrointestinal cancer, using a sequential exploratory-confirmatory factor analysis procedure. RESULTS: A two-factor model was consistent with the data: The first factor reflected a negative outlook and was labeled 'negative expectations'; the second factor identified a sense of resignation and was labeled 'loss of motivation.' CONCLUSIONS: Implications regarding scoring of the scale in this population are discussed, as are implications of the two-factor structure for our understanding of hopelessness in individuals with advanced cancer.

Health Care Professionals' Reports of Cancer Pain Cues Among Older People With Delirium: A Qualitative-Quantitative Content Analysis.

CONTEXT: Health care professionals (HCPs) currently judge pain presence and intensity in patients with delirium despite the lack of a valid, standardized assessment protocol. However, little is known about how they make these judgments. This information is essential to develop a valid and reliable assessment tool. OBJECTIVES: To identify pain cues that HCPs report to judge pain in patients with delirium and to examine whether the pain cues differed based on patient cognitive status and delirium subtype. METHODS: Mixed qualitative-quantitative design. Doctors and nurses were recruited. All participants provided written informed consent, and before the recorded interview, demographic information was collected; then participants were asked to describe their practices and beliefs regarding pain assessment and management with older patients who are cognitively intact and patients with delirium. Interviews were transcribed verbatim and coded for pain cues. Coded data were imported into SPSS software (IBM SPSS Statistics Version 24; IBM Corporation, Armonk, NY) to conduct bivariate analyses. RESULTS: The pain cue self-report was stated more often for intact than for delirium patients (χ2 [1; N = 106] = 22.56; P < 0.001). HCPs stated yelling (χ2 [2; N = 159] = 11.14; P = 0.004), when describing pain in hyperactive than in hypoactive and mixed delirium patients; and significantly more HCPs stated grimace (χ2 [2; N = 159] = 6.88; P = 0.03), when describing pain in hypoactive than hyperactive and mixed patients. CONCLUSION: This study outlines how HCPs conduct pain assessment in patients who are delirious and, also, identifies pain behavior profiles for the subtypes of delirium.

Measuring attachment security in patients with advanced cancer: psychometric properties of a modified and brief Experiences in Close Relationships scale.

OBJECTIVE: Attachment security has been identified as an important buffer of distress in patients with cancer and other medical illnesses but current measures have not been adapted for this population who may be older, in long-term stable relationships, and suffering from considerable disease burden. This study reports on (1) the psychometric properties of a modified 36-item Experiences in Close Relationships scale (ECR), adapted for this population; and (2) the validity of a brief 16-item version of our modified scale. METHODS: A modified ECR (ECR-M36) was constructed by rephrasing relevant items to refer more generally to people with whom one feels close, instead of specifically in relation to one's romantic partner(s). Patients with metastatic gastrointestinal (GI) and lung cancer completed the ECR-M36 and other scales tapping self-esteem, social support, and depressive symptoms on two occasions within a period of 4-6 months. Based on factor analyses of the ECR-M36, 16 items were selected to form a brief measure (ECR-M16). RESULTS: Factor analyses of both ECR forms revealed a higher-order factor structure in which four first-order factors (Worrying about Relationships, Frustration about Unavailability, Discomfort with Closeness, Turning Away from Others) loaded onto two second-order factors tapping Attachment Anxiety and Avoidance. Both ECR forms were reliable and valid. CONCLUSION: The ECR-M36 and ECR-M16 are good measures of attachment orientations for use with medically ill, older populations.

Pathways to distress: the multiple determinants of depression, hopelessness, and the desire for hastened death in metastatic cancer patients.

We tested a model in which psychosocial and disease-related variables act as multiple protective and risk factors for psychological distress in patients with metastatic cancer. We hypothesized that depression and hopelessness constitute common pathways of distress, which mediate the effects of psychosocial and disease-related factors on the desire for hastened death. This model was tested on a cross-sectional sample of 406 patients with metastatic gastrointestinal or lung cancer recruited at outpatient clinics of a Toronto cancer hospital, using structural equation modeling. The results supported the model. High disease burden, insecure attachment, low self-esteem, and younger age were risk factors for depression. Low spiritual well-being was a risk factor for hopelessness. Depression and hopelessness were found to be mutually reinforcing, but distinct constructs. Both depression and hopelessness independently predicted the desire for hastened death, and mediated the effects of psychosocial and disease-related variables on this outcome. The identified risk factors support a holistic approach to palliative care in patients with metastatic cancer, which attends to physical, psychological, and spiritual factors to prevent and treat distress in patients with advanced disease.

Age-related patterns in adaptation to cancer pain: a mixed-method study.

OBJECTIVE: Although older people make up the majority of cancer patients, little is known about aging and cancer pain. The objective of this study was to explore age-related patterns in adaptation to chronic cancer-related pain in younger and older patients. DESIGN: A mixed-method study combining quantitative measures with individual semi-structured interviews. Quantitative measures included the Brief Pain Inventory, Pain Management Index, Charlson Comorbidity Index, and Karnofsky Performance Status. SETTING: Two outpatient clinics (Palliative Care and Cancer Pain service) in an academic cancer hospital. PARTICIPANTS: Fifteen younger (average age: 48.9 +/- 4.9 years old) and 17 older (average age: 72.4 +/- 9.2 years old) people with cancer-related pain. RESULTS: Two age-related adaptation outcomes emerged from the interviews: "Waiting to live" and "Living despite pain." Younger patients were more likely than older patients to be "Waiting to live." They felt that complete pain relief was necessary before their lives could move forward and reported feeling out of control, angry, and unable to accept their pain. Marital strain was common. "Living despite pain" was more frequent among older than younger patients. These patients accepted pain as an inevitable part of cancer, pursued life goals, and modified activities to maximize engagement. Marital growth was common. CONCLUSION: Older and younger cancer patients described different adaptations to cancer pain despite reporting comparable pain intensity and interference. Older patients adapted by employing accommodative strategies. Younger patients were less likely to use these strategies and struggled with accepting the losses associated with cancer pain. These findings may guide future research into age-related patterns in cancer pain and the development of psychosocial interventions tailored to patients' life stage challenges.

Correlates of postoperative pain and intravenous patient-controlled analgesia use in younger and older surgical patients.

OBJECTIVE: Age-related patterns in postoperative pain are unclear with reports of no age differences and less pain with age. The objective of this study was to identify correlates of pain and intravenous patient-controlled analgesia (i.v. PCA) morphine use in younger and older patients. DESIGN: 24 hours after surgery, patients completed measures of pain intensity and pain qualities. Surgical factors, i.v. PCA morphine intake, anticholinergic load, polypharmacy, physical status, previous chronic and postoperative pain, and PCA experience were measured. SETTING: Two academic general hospitals. PATIENTS. Two hundred forty-six general surgery patients ranging in age from 18 to 82 years old. RESULTS: In older patients, higher pain scores were associated with female gender and previous experience of postoperative PCA. In younger patients, higher pain scores were associated with female gender, previous surgery without PCA, and greater morphine intake. Lower pain was associated with being male, and no previous surgical experience in older patients, and lower morphine intake in younger patients. Morphine intake was higher in patients who were younger, had better physical status, higher anticholinergic load, and experience with PCA. Among younger patients, increased morphine use also was associated with surgical procedure and duration. Higher pain scores were more strongly associated with morphine use among younger than older patients. CONCLUSIONS: The correlates of postoperative pain and morphine use may differ with age, and the same factor may have different effects across age groups. Research is needed into the mechanisms of these age-specific profiles.

Pain, aging and dementia: Towards a biopsychosocial model.

Dementia is a progressive disease associated with irreversible impairment and loss of cognitive abilities. About half of older people with dementia experience pain. In this paper, we propose that pain in older people with dementia can be conceptualized as the final result of the interaction of three heterogeneous phenomena, pain, aging, and dementia, which are created and influenced by the interactions of predisposing, lifelong, and current biopsychosocial factors. We review pain assessment in people with dementia using both self-report and observational/behavioral measures. We then review the biological/sensory, psychological (cognitive and affective) and social dimensions of pain in dementia. The available data suggest that dementia does not impact pain threshold or tolerance. To date, there is little research on the social dimension of pain in dementia. Changes in the affective domain in response to experimental pain have been contradictory with evidence supporting both increased and decreased unpleasantness and emotional responsiveness in people with dementia compared to healthy controls. Clinically, depression is a significant burden for older people with dementia and chronic pain. The relationship between pain and other neuropsychiatric symptoms is controversial, and there is insufficient evidence on which to base conclusions. Some of the most important dementia-related changes may arise in the cognitive domain, including impairments of semantic and episodic memory for pain, executive function, and pain anticipation. Changes in brain activation and interconnectivity support many of these conclusions. Despite methodological limitations, we conclude there are compelling preliminary data to support a biopsychosocial framework of pain and dementia. Future research directions, especially the need for improved assessment tools, are highlighted.

Do Correlates of Pain-Related Stoicism and Cautiousness Differ in Younger and Older People With Advanced Cancer?

Age differences are not evident in pain-related stoicism and cautiousness in people with cancer pain. Little is known about the factors associated with these pain-related attitudes or age-related patterns in these associations. The present cross-sectional study investigated the biopsychosocial correlates of the attitudes in younger and older patients with advanced cancer. Pain-related stoicism (fortitude, concealment, superiority) and cautiousness (self-doubt, reluctance) were assessed using the Pain Attitudes Questionnaire-Revised (PAQ-R). Participants, 155 younger (younger than 60 years old) and 114 older (60 years old or older) patients with advanced cancer completed the PAQ-R and measures of sociodemographic and medical characteristics, pain intensity, cognitive-affective pain-related responses, physical functioning, psychological distress and well-being, and psychosocial functioning. Backwards regression analyses identified correlates for each PAQ-R factor separately for younger and older patients. Activity engagement was a frequent correlate, but its relationship with concealment was the only association common to both age groups. Younger and older patients exhibited different avoidance-related constructs suggesting relational challenges in the former group (avoidant attachment) and intrapersonal fear in the latter (cognitive avoidance). Medical correlates also showed age differences: younger patients showed symptom-focused correlates, whereas older patients showed aging-related correlates. Findings support a biopsychosocial framework of cancer-pain adaptation incorporating a lifespan-developmental perspective. PERSPECTIVE: To our knowledge, this article is the first to identify biopsychosocial correlates of stoic and cautious attitudes toward cancer pain in younger and older patients with advanced cancer. Findings highlight possible age-related motivations for greater pain-related stoicism or cautiousness and can potentially inform interventions addressing challenges in cancer-pain adaptation in advanced cancer.

The desire for hastened death in patients with metastatic cancer.

A substantial minority of patients in palliative care settings report a high desire for hastened death (DHD), in association with physical and emotional distress, low social support, and impaired spiritual well being. To clarify to what extent DHD emerges in association with suffering prior to the end of life, we determined its prevalence and correlates in ambulatory patients with metastatic cancer, the majority of whom had an expected survival of >6 months. We hypothesized that DHD in this sample would be directly linked to physical and psychological distress, and inversely related to perceived social support, self-esteem, and spiritual well being. Three hundred twenty-six outpatients completed the Schedule of Attitudes Toward Hastened Death (SAHD), Brief Pain Inventory, Memorial Symptom Assessment Scale, Beck Depression Inventory-II (BDI-II), Beck Hopelessness Scale (BHS), Medical Outcomes Study Social Support Survey, FACIT-Spiritual Well-Being Scale, Rosenberg Self-Esteem Scale, and Karnofsky Performance Status. Over 50% of participants reported pain, >20% reported elevated levels of depression (BDI-II> or =15) and hopelessness (BHS> or =8), but <2% had a high DHD (SAHD> or =10). DHD was correlated positively with hopelessness, depression, and physical distress, and negatively with physical functioning, spiritual well being, social support, and self-esteem; it was not associated with treatment status or proximity to death. Over 34% of the variance in predicting SAHD scores was accounted for by hopelessness, depression, and functional status. The relative absence of a strong DHD in this sample suggests that the will to live tends to be preserved in cancer patients prior to the end of life, in spite of significant emotional and physical suffering.