INTRODUCTION
Pain remains a significant challenge in cancer treatment, affecting approximately two-thirds of patients undergoing chemotherapy. Despite advancements in pain management guidelines, their implementation in clinical practice remains suboptimal. [ 1 ] The effective management of pain is crucial, as unaddressed pain not only diminishes the quality of life but also exacerbates psychological distress and reduces treatment adherence. [ 2 ]
Cancer pain is complex and multifactorial, arising from direct tumour involvement, treatment-related side effects or a combination of nociceptive and neuropathic mechanisms. The subjective nature of pain and its variability among individuals make assessment and management particularly challenging. [ 3 ] Gender-specific differences in pain perception, influenced by hormonal and psychological factors, add another layer of complexity to this issue.
This study aims to evaluate the prevalence and severity of pain in chemotherapy patients, focusing on its management and the associated factors influencing pain perception. The primary goal is to assess the efficacy of pharmacological interventions in alleviating pain and improving patient outcomes. [ 4 ] By identifying patterns and gaps in current pain management practices, this study seeks to provide insights that could guide future clinical strategies and enhance patient care. [ 5 ] Local and regional pain relief in India faces significant challenges due to restricted access to speciality care, underutilization of palliative care and drug regulatory barriers to access to opioids, and this emphasises the requirement for local context-specific, scalable solutions.
The hypothesis underpinning this study is that individualised pain management tailored to the severity and type of pain significantly improves patient comfort and reduces reliance on high-potency opioids. [ 6 ] The study also addresses the deficiency in long-term follow-up data regarding pain management outcomes, aiming to fill this gap and provide a foundation for future research.
MATERIALS AND METHODS
Study design
This was an observational study designed to assess the pain experienced by patients undergoing chemotherapy. [ 7 ]
Study setting and duration
The study was conducted in the Department of Medical Oncology at Mahatma Gandhi Medical College and Research Institute, Puducherry, India. The duration of the study was 6 months, from January 2024 to June 2024.
Study population
The study population included patients receiving chemotherapy in the department of medical oncology. [ 8 ]
Inclusion criteria
Patients aged 18 years or older Patients newly diagnosed with cancer and undergoing chemotherapy.
Exclusion criteria
Paediatric patients (aged below 18 years) Pregnant or lactating women Patients who had already completed previous cycles of chemotherapy Patients with Cognitive disturbances.
Sample size
The study included a total of 104 patients undergoing chemotherapy who met the inclusion criteria. [ 9 ]
Cancer type distribution
The study included 104 patients diagnosed with various types of cancer. The distribution of cancer types among the patients was as illustrated in Figure 1 :
Breast cancer: 34 patients (32.69%) Lymphoma: 10 patients (9.62%) Ovarian cancer: 10 patients (9.62%) Colon cancer: 10 patients (9.62%) Cervical cancer: 6 patients (5.77%) Lung cancer: 5 patients (4.81%) Stomach cancer: 5 patients (4.81%) Endometrial cancer: 4 patients (3.85%) Multiple myeloma: 4 patients (3.85%) Prostate cancer: 3 patients (2.88%) Pancreatic cancer: 3 patients (2.88%) Renal cell carcinoma: 2 patients (1.92%) Others: 8 patients (7.68%).
These distributions reflect the common prevalence of different cancers, with breast cancer being the most frequently diagnosed among the study cohort.
Methodology
Patient recruitment
Patients admitted to the Department of Medical Oncology at Mahatma Gandhi Medical College and Research Institute were screened for eligibility. Eligibility was assessed through a detailed history, physical examination and diagnostic tests to confirm the diagnosis and cancer stage. [ 10 ] Patients were assessed for pain using numerical rating scale (NRS).
Pain assessment
Pain was evaluated using the numerical rating scale (NRS), a validated tool where patients rated their pain intensity on a scale of 0–10: [ 11 ]
0: No pain 1–3: Mild pain 4–6: Moderate pain 7–10: Severe pain.
Patients were assessed for pain before the initiation of chemotherapy and reassessed every 3 weeks for any change in pain intensity score using NRS. Patients were monitored throughout their completion of chemotherapy cycles. [ 12 ]
Supportive care
Pharmacological management: Pain relief was provided through a stepwise approach, including acetaminophen, non-steroidal anti-inflammatory drugs and opioids, depending on the pain severity. [ 13 ] Non-pharmacological measures: Patients received psychological counselling, education about managing side effects and dietary advice to optimise overall well-being.
Data collection
Data were systematically recorded, including: Patient demographics (age, sex and comorbidities) Chemotherapy regimen and cycle details Pain intensity scores using NRS Pharmacological and non-pharmacological interventions are used for pain management. [ 14 ]
Data analysis
Data were compiled using Microsoft Excel and analysed with Statistical Package for the Social Sciences (SPSS) software.
Descriptive statistics such as means, standard deviations and percentages were calculated Analytical tests, including Chi-square tests and t -tests, were performed, with a significance threshold set at P < 0.05. [ 15 ]
Ethical considerations
Approval for the study was obtained from the Institutional Ethics Committee (Ref. No: SAHS/IRB/PA/2024/23). Procedures adhered to the ethical standards outlined in the Declaration of Helsinki (revised 2000). [ 16 ] Written informed consent was secured from all participants. Patient confidentiality was maintained, and no identifying details were included in the study records. Participants were informed of their right to withdraw from the study at any point without consequences. [ 17 ]
RESULTS
Demographics
A total of 104 participants were included in the study, comprising 56 females (54%) and 48 males (46%). Participants’ ages ranged from 24 to 81 years, with the mean age being 53.2 ± 14.1 years as illustrated in Figure 2 . Females predominated in the age group of 45–55 years, whereas males were evenly distributed across all age ranges.
Pain scores
Pain intensity was categorised using the NRS: No pain: 21 participants (20%) Mild pain (1–3): 45 participants (43%) Moderate pain (4–6): 28 participants (27%) Severe pain (7–9): 10 participants (10%).
Females reported a higher prevalence of moderate-to-severe pain (38%) compared to males (26%) as illustrated in Figure 3 . Statistical analysis revealed a significant association between gender and pain intensity ( P = 0.031). Pain intensity scores using NRS is illustrated in Figure 4 .
Pain management outcomes
Pharmacological interventions were implemented as follows: Mild pain: Treated with tablet paracetamol (650 mg) administered orally; 41 of 47 participants (87.2%) reported adequate pain relief. Moderate pain: Managed with tablet ultracet and adjuvant analgesics (amitriptyline, gabapentin, duloxetine, etc.) therapies; 22 of 29 participants (75.9%) reported improvement. Severe pain: Started with T. Morphine 10 mg IR (1/2-1/2-1/2-1/2-1) every 6 th hourly and dose titrated based on patient pain relief. Adjuvant analgesics (amitriptyline, gabapentin, duloxetine, etc.) were added based on the patient’s needs. 10 of 10 participants (100%) experienced significant relief.
Non-pharmacological interventions
Supportive measures, including dietary counselling and psychological support, were provided to 71 participants (68%). Of these, 58 participants (81.7%) reported reduced emotional distress, enhancing the overall perception of pain relief.
Age-based analysis
Participants aged 45–64 years experienced the highest frequency of moderate-to-severe pain (57%). Those aged ≥65 years reported significantly lower pain scores, potentially due to differences in pain tolerance or reporting behaviour ( P = 0.045).
Statistical analysis
Descriptive statistics were used to summarise demographic data. Chi-square tests were applied to evaluate categorical variables, and t -tests analysed continuous variables. The results were significant at P < 0.05. SPSS software (Version 25.0) facilitated data analysis.
Key trends
Females reported higher pain scores than males across all age groups Moderate-to-severe pain was more prevalent during the early chemotherapy cycles Individualised pain management strategies effectively alleviated symptoms in 91% of participants.
DISCUSSION
This study highlights the significant burden of pain among patients undergoing chemotherapy, emphasising its intensity, gender-based variations and the effectiveness of management strategies. The findings demonstrate that individualised pain management approaches were highly effective, with 91% of participants achieving symptom relief. Gender differences in pain perception were evident, with females reporting higher pain scores than males, which may be attributed to biological, hormonal and psychological factors influencing pain sensitivity. In addition, the data reveal that patients [ 18 ] aged 45–64 years experienced the most severe pain, supporting the notion that pain perception and tolerance vary across different age groups. Elderly patients (>65 years) report lower pain during chemotherapy due to altered pain perception and psychosocial adaptation. Ageing is associated with changes in the nervous system that can reduce pain sensitivity or alter pain signalling, leading to underreporting or diminished perception of pain. Older adults often have better emotional coping mechanisms, acceptance of illness or different pain expectations based on life experience, which may influence how they perceive and report pain. These insights reinforce the need for targeted pain management strategies that consider demographic factors.
The study provides crucial insights into the importance of a holistic approach to pain management, integrating both pharmacological and non-pharmacological interventions to optimise patient outcomes. [ 19 ] The effectiveness of combined strategies suggests that a multimodal approach, incorporating medications along with psychological and supportive care, can significantly improve pain relief and overall well-being. This underscores the role of emotional, which includes breakthrough pain [ 20 ] and psychological support in enhancing treatment efficacy, as unmanaged pain can lead to increased distress, anxiety and reduced quality of life. The findings also highlight the necessity for healthcare providers to develop gender- and age-specific pain management [ 21 ] protocols to ensure personalised care that meets the unique needs of each patient. In the Indian context, non-pharmacologic pain management strategies such as yoga, mindfulness-based practices, music therapy and Ayurvedic therapies (e.g. Abhyanga and herbal remedies) are culturally acceptable and widely accessible. In addition, group therapy and community-based support programmes can provide psychosocial relief and improve coping in chronic pain patients. Oncology outpatient and inpatient services in India should incorporate routine pain assessments into chemotherapy treatment workflows, ensuring timely identification and management of pain. Integrating multidisciplinary approaches, including pharmacologic, psychosocial and culturally relevant non-pharmacologic interventions, can enhance patient comfort and treatment adherence.
CONCLUSION
Future research should focus on larger sample sizes and exploring innovative non-pharmacological therapies such as cognitive-behavioural interventions, mindfulness techniques and integrative medicine approaches. By addressing these aspects, future studies can further refine pain management strategies, contributing to improved clinical outcomes and more effective healthcare policies aimed at enhancing the quality of life for chemotherapy patients.
How to cite this article: Kaliyamurthi K, Alam S, Ali A, Branham F. Assessment and Treatment Outcomes of Pain in Cancer Patients Undergoing Chemotherapy – A Tertiary Care Centre Experience. Indian J Palliat Care. 2025;31:321-5. doi: 10.25259/IJPC_59_2025
Ethical approval:
The research/study was approved by the Institutional Ethics Committee, approval number SAHS/IRB/PA/2024/23 dated 24th January 2024.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript, and no images were manipulated using AI.
1. Bennett M Paice JA Wallace M Pain and Opioids in Cancer Care: Benefits, Risks, and Alternatives Am Soc Clin Oncol Educ Book 2017 37 705 13 10.1200/EDBK_180469 28561731
2. Fallon M Giusti R Aielli F Hoskin P Rolke R Sharma M et al Management of Cancer Pain in Adult Patients: ESMO Clinical Practice Guidelines Ann Oncol 2018 29 Suppl 4 iv166 91 10.1093/annonc/mdy152 30052758
3. Scarborough BM Smith CB Optimal Pain Management for Patients with Cancer in the Modern Era CA Cancer J Clin 2018 68 182 96 10.3322/caac.21453 29603142 PMC5980731
4. Arthur J Tanco K Park M Haider A Maligi C Dalal S et al Personalized Pain Goal as an Outcome Measure in Routine Cancer Pain Assessment J Pain Symptom Manage 2018 56 80 7 10.1016/j.jpainsymman.2018.03.004 29526610
5. Wang K Yee C Tam S Drost L Chan S Zaki P et al Prevalence of Pain in Patients with Breast Cancer Post-Treatment: A Systematic Review Breast 2018 42 113 27 10.1016/j.breast.2018.08.105 30243159
6. Portenoy RK Ahmed E Cancer Pain Syndromes Hematol Oncol Clin North Am 2018 32 371 86 10.1016/j.hoc.2018.01.002 29729775
7. Epstein JB Miaskowski C Oral Pain in the Cancer Patient J Natl Cancer Inst Monogr 2019 2019 Igz003 10.1093/jncimonographs/lgz003 31425595
8. Bouya S Balouchi A Maleknejad A Koochakzai M AlKhasawneh E Abdollahimohammad A Cancer Pain Management among Oncology Nurses: Knowledge, Attitude, Related Factors, and Clinical Recommendations: A Systematic Review J Cancer Educ 2019 34 839 46 10.1007/s13187-018-1433-6 30315497
9. Minello C George B Allano G Maindet C Burnod A Lemaire A Assessing Cancer Pain-the First Step toward Improving Patients' Quality of Life Support Care Cancer 2019 27 3095 104 10.1007/s00520-019-04825-x 31076899
10. Caraceni A Shkodra M Cancer Pain Assessment and Classification Cancers (Basel) 2019 11 510 10.3390/cancers11040510 30974857 PMC6521068
11. Paice JA Pain in Cancer Survivors: How to Manage Curr Treat Options Oncol 2019 20 48 10.1007/s11864-019-0647-0 31062182
12. Khan JS Ladha KS Abdallah F Clarke H Treating Persistent Pain after Breast Cancer Surgery Drugs 2020 80 23 31 10.1007/s40265-019-01227-5 31784873
13. Liang Q Zhang K Wang S Xu X Liu Y Cui S et al Acupuncture for Cancer Pain-An Adjuvant Therapy for Cancer Pain Relief Am J Chin Med 2020 48 1769 86 10.1142/S0192415X20500883 33300479
14. Pawasarat IM Schultz EM Frisby JC Mehta S Angelo MA Hardy SS et al The Efficacy of Medical Marijuana in the Treatment of Cancer-Related Pain J Palliat Med 2020 23 809 16 10.1089/jpm.2019.0374 32101075
15. Warth M Zöller J Köhler F Aguilar-Raab C Kessler J Ditzen B Psychosocial Interventions for Pain Management in Advanced Cancer Patients: A Systematic Review and Meta-Analysis Curr Oncol Rep 2020 22 3 10.1007/s11912-020-0870-7 31965361 PMC8035102
16. Nakash O Granek L Cohen M Ben David M Association between Cancer Stigma, Pain and Quality of Life in Breast Cancer Psychol Community Health 2020 8 275 87 10.5964/pch.v8i1.310
17. Zheng J He J Wang W Zhou H Cai S Zhu L et al The Impact of Pain and Opioids Use on Survival in Cancer Patients: Results from a Population-Based Cohort Study and a Meta-Analysis Medicine (Baltimore) 2020 99 e19306 10.1097/MD.0000000000019306 32118751 PMC7478583
18. Fisher HM Winger JG Miller SN Wright AN Plumb Vilardaga JC Majestic C et al Relationship between Social Support, Physical Symptoms, and Depression in Women with Breast Cancer and Pain Support Care Cancer 2021 29 5513 21 10.1007/s00520-021-06136-6 33723675 PMC8919209
19. Brozovic G Lesar N Janev D Bošnjak T Muhaxhiri B Cancer Pain and Therapy Acta Clin Croat 2022 61 Suppl 2 103 8 10.20471/acc.2022.61.s2.13 36824638 PMC9942478
20. Løhre ET Thronaes M Klepstad P Breakthrough Cancer Pain in 2020 Curr Opin Support Palliat Care 2020 14 94 9 10.1097/SPC.0000000000000494 32332210
21. Gress KL Charipova K Kaye AD Viswanath O Urits I An Overview of Current Recommendations and Options for the Management of Cancer Pain: A Comprehensive Review Oncol Ther 2020 8 251 9 10.1007/s40487-020-00128-y 32894414 PMC7683745