© 2004 by Oxford University Press
2004 © Oxford University Press
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ARTICLE |
Gender Differences in Pain, Fatigue, and Depression in Patients With Cancer
Correspondence to: Christine Miaskowski, RN, PhD, FAAN, Department of Physiological Nursing, University of California, 2 Koret Way, Box 0610-N631Y, San Francisco, CA 94143-0610 (e-mail: chris.miaskowski{at}nursing.ucsf.edu)
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ABSTRACT |
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 Top Abstract IntroductionGender Differences in Cancer...Gender Differences in Cancer...Gender Differences in Cancer...ConclusionsReferences |
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A quick review of virtually any research topic documents the pervasiveness of sex and gender bias throughout all of science. A large portion of both animal and human research has been, and continues to be, done primarily with male subjects. This gender bias influences research results and often leads to inappropriate and questionable generalizations of research findings, usually from studies done with male participants to females. Needless to say, this bias exists in symptom management research on pain, fatigue, and depression in patients with cancer. This article reviews the evidence from the studies on gender differences in pain, fatigue, and depression in patients with cancer. It should be noted that research studies on gender differences in cancer-related pain, fatigue, and depression are minimal in number, are restricted to studies of the differences in prevalence rates and severity scores, and for the most part have yielded inconsistent results. Additional investigations are warranted to determine whether the gender differences in prevalence rates and severity of these symptoms represent clinically meaningful differences. If these gender differences are substantiated, these findings will guide the design of studies to elucidate the underlying mechanisms for these differences, as well as the development and testing of gender specific interventions to treat cancer-related pain, fatigue, and depression.
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INTRODUCTION |
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TopAbstractIntroductionGender Differences in Cancer...Gender Differences in Cancer...Gender Differences in Cancer...ConclusionsReferences |
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A quick review of virtually any research topic documents the pervasiveness of sex and gender bias throughout all of science. A large proportion of both animal and human research has been, and continues to be, done primarily with male participants. As noted by Sechzer and colleagues (1), this bias toward the inclusion of only males or the preponderance of males in research studies influences and often leads to inappropriate and questionable generalization of these findings, usually from males to females. These authors note that the effect of this bias on women's health has not been completely evaluated. Equally important is the fact that even with the National Institutes of Health requirement for the inclusion of women in clinical trials, Sechzer and colleagues found that in clinical research on lung cancer treatment, studies with male participants predominated in the literature. The authors cited that in a review of all of the papers published in the Journal of Clinical Oncology and in Cancer in 1994 on lung cancer treatment, 77% of the study participants were male.
As a follow-up to their literature review, Sechzer and colleagues conducted an informal survey of scientists and asked them whether they would be willing to include women in clinical trials (1). The authors report in their article that they were told, "Oh, I have no problem about including women in my studies and would be happy to do so, but female subjects are very difficult to find," or "It will really cost an enormous amount of money to recruit women for my studies, and that would decrease the amount of research I could conduct." They also heard concerns that a woman's menstrual cycle would interfere with the problem being studied (p. 43).
Of note, this same bias occurs in symptom management research on pain, fatigue, and depression in patients with cancer. The purpose of this article is to summarize the limited amount of research on gender differences in pain, fatigue, and depression in patients with cancer and to make recommendations for future research. It should be noted that no studies could be found on gender differences in pain, fatigue, and depression in children with cancer.
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GENDER DIFFERENCES IN CANCER-RELATED PAIN |
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TopAbstractIntroductionGender Differences in Cancer...Gender Differences in Cancer...Gender Differences in Cancer...ConclusionsReferences |
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Recent information on acute pain management indicates that there may be gender differences in pain sensitivity and tolerance, as well as in analgesic effectiveness [for reviews, see (2–4)], and that certain chronic pain problems occur more commonly in women (5). Although chronic pain is experienced by approximately 50% of oncology outpatients (6–7) and by 80% to 90% of patients with metastatic cancer (8), little is known about gender differences in the prevalence or severity of chronic cancer pain.
Only two published studies (9,10) and two unpublished studies (Miaskowski et al.) have provided data on gender differences associated with cancer pain. The results of these studies are summarized in Table 1. In a prospective study of cancer pain in 1308 outpatients with metastatic cancer (9), female oncology patients were found to be at greater risk for inadequate prescription of analgesics and were significantly more likely to experience inadequate pain management than male patients.
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Although Cleeland and colleagues (9) evaluated gender differences in analgesic prescriptions for cancer patients, they did not report on gender differences in pain intensity scores. A retrospective study by Turk and Okifuji (10) evaluated the pain intensity scores of cancer patients (n = 143) who were experiencing chronic pain for gender differences. Using the McGill Pain Questionnaire and the Multidimensional Pain Inventory, no significant gender differences were found in pain intensity scores reported by these patients.
In a recently completed randomized clinical trial that tested the effectiveness of a psychoeducational intervention (PRO-SELF Pain Control Program) compared with standard care in improving cancer pain management (11–13), we evaluated a sample of oncology outpatients who were experiencing pain from bone metastasis for gender differences in baseline pain. One hundred thirty-three women and 65 men were enrolled in this randomized clinical trial. All patients were experiencing pain from bone metastasis. At baseline, no gender differences were found in any of the pain intensity measures (i.e., pain right now, average pain, worst pain, least pain) that were evaluated using 0-10 numeric rating scales.
An examination of unpublished data from a descriptive, cross-sectional study of oncology outpatients who were receiving active treatment for their cancer (n = 117) revealed that 50 patients (42.7%) were experiencing cancer pain. No gender differences were found in any of the pain intensity measures (i.e., pain right now, average pain, worst pain, least pain) that were evaluated using 0-10 numeric rating scales.
Only one published (10) and two unpublished studies (Miaskowski et al.) have provided data on gender differences in pain severity in patients with chronic cancer pain. The findings from these three studies indicate that men and women report similar levels of pain intensity when they experience chronic cancer pain. Additional research is warranted to determine whether this finding persists with different types of chronic cancer pain as well as with acute cancer-related pain.
The finding of a gender bias in the treatment of cancer pain (9) requires additional investigation. If this gender bias of undertreatment of women, which has been reported in another study of chronic pain (14), is found in future research, it has tremendous clinical implications for the effective management of cancer-related pain as well as for additional research on the reasons why this bias exists.
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GENDER DIFFERENCES IN CANCER-RELATED FATIGUE |
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TopAbstractIntroductionGender Differences in Cancer...Gender Differences in Cancer...Gender Differences in Cancer...ConclusionsReferences |
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Fatigue is a common symptom experienced by patients with cancer as well as by cancer survivors (15–19). However, only eight published (20–27) and two unpublished studies (Miaskowski et al.) have evaluated for gender differences in cancer-related fatigue. Findings from these 10 studies are summarized in Table 2.
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Two studies (21,27) evaluated the prevalence of fatigue in two different patient populations (i.e., patients with lung cancer who were receiving radiation therapy and inpatients and outpatients referred for palliative care) and found no gender differences in the prevalence of fatigue. The remaining eight descriptive, cross-sectional studies evaluated for gender differences in fatigue severity. In three of the studies that evaluated oncology outpatients who were receiving chemotherapy or radiation therapy (22,25,26), women reported higher fatigue severity scores than men. Similar findings were reported in one study that evaluated for gender differences in fatigue severity in patients following allogeneic bone marrow transplantation (24). In the one unpublished study (Miaskowski et al.) that evaluated for gender differences in fatigue severity in oncology outpatients who were receiving active treatment, no differences were found. Likewise, in the studies that evaluated for gender differences in fatigue severity in patients admitted to a palliative care unit (23) or in patients with chronic pain from bone metastasis, no differences were found. In addition, in the one study that evaluated patients who were off treatment for at least 6 months (20), no differences in fatigue severity were found between men and women.
Given the high prevalence of fatigue in the cancer patient population, as well as across the disease trajectory, the number of studies that have evaluated for gender differences in the prevalence and severity of fatigue is extremely small. To date, the heterogeneous nature of the patient populations in these studies makes it difficult to draw any conclusions about whether gender differences in the prevalence and severity of cancer-related fatigue exist, what the reasons are for these differences, or the effect of these differences on patients' lives.
An important consideration that should be noted as this area of research moves forward is that one study done in a primary care setting found that women reported higher fatigue severity scores than men (28). In addition, a number of investigators have noted that women, in general, report higher rates of symptoms than men (29–30).
Therefore, although additional research is warranted on gender differences in fatigue, both in adults and children with cancer, these types of studies may have to include appropriate comparison groups to draw definitive conclusions given the high levels of fatigue that are reported in the general population. Additional research areas related to gender differences in cancer-related fatigue include the need to systematically investigate for changes in the prevalence and severity of fatigue across the disease trajectory, the need for longitudinal studies of gender differences in fatigue severity across different treatment regimens, the need to investigate how gender role functioning might influence the development of cancer-related fatigue, and the need to evaluate for gender differences in the effectiveness of interventions to manage cancer-related fatigue.
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GENDER DIFFERENCES IN CANCER-RELATED DEPRESSION |
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TopAbstractIntroductionGender Differences in Cancer...Gender Differences in Cancer...Gender Differences in Cancer...ConclusionsReferences |
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Like pain and fatigue, depression is frequently underdiagnosed in patients with cancer, and therefore it is frequently undertreated (31–34). In addition, data from epidemiologic studies of depression consistently report a higher prevalence rate of depressive symptoms among women compared with men (35–37). However, only seven published (25,27,38–42) and two unpublished studies (Miaskowski et al.) from our group were identified that evaluated for gender differences in the prevalence or severity of depression in patients with cancer. The findings from these nine studies are summarized in Table 3.
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Five of the nine studies evaluated for gender differences in the prevalence of depression (27,38–40,42). One study evaluated a cross-sectional sample of inpatients and outpatients who were receiving cancer treatment (38), two studies evaluated patients who were receiving palliative care (27,39), one longitudinal study evaluated patients with lung cancer (42), and one longitudinal study evaluated patients with head and neck cancer (40). Three of the five prevalence studies found no gender differences in depression rates (27,38–39). The other two studies (40,42) reported higher prevalence rates of depression in women.
Only two published studies (25,41) and two unpublished studies from our own group evaluated for gender differences in the severity of depressive symptoms. Given and colleagues (41) evaluated for gender differences in the severity of depression in oncology outpatients who were 50 years of age or older and who were receiving active treatment for cancer. They found an interaction between age and gender on the level of depression measured using the Center for Epidemiological Studies-Depression scale (CES-D). For men, as age increased by 1 year, depression decreased by 0.33 units; whereas for women, as age increased by 1 year, depression increased by 0.16 units.
In a descriptive, cross-sectional study of oncology outpatients who were receiving chemotherapy, Redeker and colleagues (25) found no gender differences in the severity of depression using the Profile of Mood States. Likewise, in our study of oncology outpatients who were experiencing pain from bone metastasis (Miaskowski et al.), no gender differences in the severity of depression were found at baseline using the Profile of Mood States. In addition, in our cross-sectional study of oncology outpatients who were receiving active treatment for their cancer (Miaskowski et al.), no gender differences were found in the severity of depressive symptoms measured using the CES-D.
Because of the limited amount of evidence, it is impossible to draw definitive conclusions regarding gender differences in the prevalence or severity of depression in patients with cancer. As stated previously, findings from population-based studies indicate that the prevalence rates for depression are higher in women (35–37). However, these findings need to be placed within the context that women are more likely to express their feelings and report more symptoms than men (30).
Another factor that needs to be considered in this area of scientific inquiry is whether the gender differences that were reported in previous studies are an artifact of the measurement procedures. In an excellent paper, Stommel and colleagues (43) reported findings from a confirmatory factor analysis that identified two items on the CES-D that produced biased responses when comparisons were done of men's and women's responses to these items. Specifically, men, who otherwise had the same level of depressive symptoms as women, were less likely to have "crying spells." In contrast, the gender bias in response to the item "talked less" was in the opposite direction; namely, men with depressive symptoms were more likely to reduce their verbal communication compared with women with the same level of depressive symptoms. The authors recommended that these items be removed from any analysis of gender differences in depressive symptoms using the CES-D.
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CONCLUSIONS |
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TopAbstractIntroductionGender Differences in Cancer...Gender Differences in Cancer...Gender Differences in Cancer...ConclusionsReferences |
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Research studies on gender differences in cancer-related pain, fatigue, and depression are minimal in number, are restricted to studies of differences in prevalence rates and severity scores, and have for the most part yielded conflicting results. Additional investigations are warranted to determine whether the gender differences in prevalence rates and severity of these symptoms represent clinically meaningful differences. If these gender differences are substantiated, these findings will guide the design of studies to elucidate the underlying mechanisms for these differences, as well as the development and testing of gender-specific interventions to treat cancer-related pain, fatigue, and depression.
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REFERENCES |
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TopAbstractIntroductionGender Differences in Cancer...Gender Differences in Cancer...Gender Differences in Cancer...ConclusionsReferences |
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1 Sechzer JA, Rabinowitz VC, Denmark FL, McGinn MF, Weeks BM, Wilkens CL. Sex and gender bias in animal research and in clinical studies of cancer, cardiovascular disease, and depression. Ann N Y Acad Sci 1994;736:21–48.[CrossRef][ISI][Medline]
2 Fillingim R, Maixner W. Gender differences in responses to noxious stimuli. Pain Forum 1995;4:209–21.
3 Miaskowski C, Gear RW, Levine JD. Sex-related differences in analgesic responses. In: Fillingim RB, editor. Sex, gender and pain: progress in pain research and management. Seattle (WA): IASP Press; 2000 . p. 209 –30.
4 Miaskowski C, Levine JD. Does opioid analgesia show a gender preference for females? Pain Forum 1999;8:34–44.
5 Unruh AM. Gender variations in clinical pain experience. Pain 1996;65:123–67.[CrossRef][ISI][Medline]
6 Portenoy RK, Kornblith AB, Wong G, Vlamis V, Lepore JM, Loseth DB, et al. Pain in ovarian cancer patients. Prevalence, characteristics, and associated symptoms. Cancer 1994;74:907–15.[CrossRef][ISI][Medline]
7 Caraceni A, Portenoy RK. An international survey of cancer pain characteristics and syndromes. IASP Task Force on Cancer Pain. Pain 1999;82:263–74.[CrossRef][ISI][Medline]
8 Grond S, Zech D, Diefenbach C, Bischoff A. Prevalence and pattern of symptoms in patients with cancer pain: a prospective evaluation of 1635 cancer patients referred to a pain clinic. J Pain Symptom Manage 1994;9:372–82.[CrossRef][ISI][Medline]
9 Cleeland CS, Gonin R, Hatfield AK, Edmonson JH, Blum RH, Stewart JA, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994;330:592–6.
10 Turk DC, Okifuji A. Does sex make a difference in the prescription of treatments and the adaptation to chronic pain by cancer and non-cancer patients? Pain 1999;82:139–48.[CrossRef][ISI][Medline]
11 Miaskowski C, Dodd MJ, West C, Paul SM, Tripathy D, Koo P, et al. Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol 2001;19:4275–9.
12 Schumacher KL, Koresawa S, West C, Hawkins C, Johnson C, Wais E, et al. Putting cancer pain management regimens into practice at home. J Pain Symptom Manage 2002;23:369–82.[CrossRef][ISI][Medline]
13 Schumacher KL, West C, Dodd, M, Paul SM, Tripathy D, Koo P, et al. Pain management autobiographies and reluctance to use opioids for cancer pain management. Cancer Nurs 2002;25:125–33.[CrossRef][ISI][Medline]
14 Breitbart W, Rosenfeld BD, Passik SD, McDonald MV, Thaler H, Portenoy RK. The undertreatment of pain in ambulatory AIDS patients. Pain 1996;65:243–9.[CrossRef][ISI][Medline]
15 Berglund G, Bolund C, Forander T, Rutqvist LE, Sjoden P. Late effects of adjuvant chemotherapy and postoperative radiotherapy on quality of life among breast cancer patients. Eur J Cancer 1991;27:1075–81.
16 Bjordal K, Kaasa S, Mastekaasa A. Quality of life in patients treated for head and neck cancer: a follow-up study of 7 to 11 years after radiotherapy. Int J Radiat Oncol Biol Phys 1994;28:847–56.[ISI][Medline]
17 Bush NE, Haberman M, Donaldson G, Sullivan KM. Quality of life of 125 adults surviving 6-18 years after bone marrow transplantation. Soc Sci Med 1995;40:479–90.
18 Norum J, Wist EA. Quality of life in survivors of Hodgkin's disease. Qual Life Res 1996;5:367–74.[CrossRef][ISI][Medline]
19 Walker BL, Nail LM, Larsen L, Magill J, Schwartz A. Concerns, affect, and cognitive disruption following completion of radiation treatment for localized breast or prostate cancer. Oncol Nurs Forum 1996;23:1181–87.[Medline]
20 Servaes P, van der Werf S, Prins J, Verhagen S, Bleijenberg G. Fatigue in disease-free cancer patients compared with fatigue in patients with chronic fatigue syndrome. Support Care Cancer 2001;9:11–7.[CrossRef][ISI][Medline]
21 Hickok JT, Morrow GR, McDonald S, Bellg AJ. Frequency and correlates of fatigue in lung cancer patients receiving radiation therapy: implications for management. J Pain Symptom Manage 1996;11:370–77.[CrossRef][ISI][Medline]
22 Akechi T, Kugaya A, Okamura H, Yamawaki S, Uchitomi Y. Fatigue and its associated factors in ambulatory cancer patients: a preliminary study. J Pain Symptom Manage 1999;17:42–8.[CrossRef][ISI][Medline]
23 Stone P, Hardy J, Broadley K, Tookman AJ, Kurowska A, A'Hern R. Fatigue in advanced cancer: a prospective controlled cross-sectional study. Br J Cancer 1999;79:1479–86.[CrossRef][ISI][Medline]
24 Heinonen H, Volin L, Uutela A, Zevon M, Barrick C, Ruutu T. Gender associated differences in the quality of life after allogeneic BMT. Bone Marrow Transplant 2001;28:503–9.[CrossRef][ISI][Medline]
25 Redeker NS, Lev EL, Ruggiero J. Insomnia, fatigue, anxiety, depression, and quality of life of cancer patients undergoing chemotherapy. Sch Inq Nurs Pract 2000;14:275–90.[Medline]
26 Pater JL, Zee B, Palmer M, Johnston D, Osoba D. Fatigue in patients with cancer: results with the National Cancer Institute of Canada Clinical Trials Group studies employing the EORTC QLQ-C30. Support Care Cancer 1997;5:410–13.[CrossRef][ISI][Medline]
27 Walsh D, Donnelly S, Rybicki L. The symptoms of advanced cancer: relationship to age, gender, and performance status in 1000 patients. Support Care Cancer 2000;8:175–9.[CrossRef][ISI][Medline]
28 Kroenke K, Wood RD, Mangelsdorff AD, Meier NJ, Powell JB. Chronic fatigue in primary care. Prevalence, patient characteristics, and outcome. JAMA 1988;260:929–34.[Abstract]
29 Van Wijk CM, Kolk AM. Sex differences in physical symptoms: the contribution of symptom perception theory. Soc Sci Med 1997;45:231–46.
30 Verbrugge LM. Gender and health: an update on hypotheses and evidence. J Health Soc Behav 1985;26:156–82.[CrossRef][ISI][Medline]
31 Maguire P. Improving the detection of psychiatric problems in cancer patients. Soc Sci Med 1985;20:819–23.
32 Mermelstein HT, Lesko L. Depression in patients with cancer. Psycho-Oncology 1992;1:199–215.
33 Bottomley A. Depression in cancer patients: a literature review. Eur J Cancer Care 1998;7:181–91.
34 Valente SM, Saunders JM. Diagnosis and treatment of major depression among people with cancer. Cancer Nurs 1997;20:168–77.[CrossRef][ISI][Medline]
35 Murrell SA, Himmelfarb, S. Wright K. Prevalence of depression and its correlated in older adults. Am J Epidemiol 1983;117:173–85.
36 Devins GM, Orme CM. Center for epidemiological studies depression scale. In: Kayser DJ, Sweetland RC, editors. Test critiques. Vol. 2. Kansas City (KS): Test Corporation of America; 1986 . p. 144 –60.
37 Ensel WM. Sex, marital status, and depression: the role of life events and social support. In: Lin N, Denn A, Ensel WH, editors. Social support, life events, and depression. New York (NY): Academic Press; 1986 . p. 231 –47.
38 Aass N, Fossa SD, Dahl AA, Moe TJ. Prevalence of anxiety and depression in cancer patients seen at the Norwegian Radium Hospital. Eur J Cancer 1997;33:1597–1604.
39 Ciaramella A, Poli P. Assessment of depression among cancer patients: the role of pain, cancer type, and treatment. Psycho-Oncology 2001;10:156–65.[CrossRef][Medline]
40 de Leeuw JRJ, de Graeff A, Ros WJG, Blijham GH, Hordijk G-J, Winnubst JAM. Prediction of depression 6 months to 3 years after treatment of head and neck cancer. Head Neck 2001;23:892–98.[CrossRef][ISI][Medline]
41 Given CW, Given BA, Stommel M. The impact of age, treatment, and symptoms on physical and mental health of cancer patients. Cancer 1994;74:2128–38.[CrossRef][ISI][Medline]
42 Hopwood P, Stephens RJ, the British Medical Research Council Lung Cancer Working Party. Depression in patients with lung cancer: prevalence and risk factors derived from quality of life data. J Clin Oncol 2000;18:893–903.
43 Stommel M, Given BA, Given CW, Kalaian HA, Schulz R, McCorkle R. Gender bias in the measurement properties of the Center for Epidemiologic Studies Depression Scale (CES-D). Psychiatry Res 1993;49:239–50.[CrossRef][ISI][Medline]
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