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Abstract

Cancer-related pain has a significant impact on quality of life for patients with cancer. In populations without cancer, there are documented pain inequities associated with minoritized racial and/or ethnic groups, women, and low socioeconomic status. However, our understanding of pain inequities specifically among patients with cancer remains incomplete. We narratively synthesized published quantitative research on cancer-related pain inequities in the US in the past decade. A search identified 17 English-language articles examining pain for patients with various cancer types at different treatment stages. Our review revealed mixed findings comparing cancer-related pain by racial group (e.g., Black vs White) and sex (male vs female), but consistent findings indicating that people with lower (vs higher) socioeconomic status and younger (vs older) patients report more cancer-related pain. Research on cancer pain among sexual and gender minorities remains scant. Key research gaps include a need for more research that incorporates an intersectional perspective by exploring intersecting subgroups and measuring social and structural processes that drive pain inequities. These findings underscore an important need for researchers to use an intersectional approach to cancer pain to help elucidate key populations at-risk for exacerbated cancer-related pain and identify ways to mitigate social and structural processes that drive these inequities.

Plain Language Summary

There are known differences in pain experiences among people from different racial or ethnic groups, sex (male or female) or gender (men or women), and socioeconomic groups such as low income people. However, we don't fully understand these differences among cancer patients yet. This review looks at the past 10 years of research on how cancer-related pain may differ for people from different sociodemographic groups. We collected information from 17 studies in the US that looked at how pain from different types of cancer and different stages of treatment may differ for people from these different groups. We found mixed results when comparing pain between racial groups and sex and/or gender groups, but consistently found that people with lower incomes and younger patients reported more pain. There's not much research on how cancer pain affects sexual and gender minorities (LGBTQ+ people). Our review suggests that we need an intersectional approach to best understand cancer-related pain in order to best address how structural discrimination influences pain. Researchers should use an intersectional perspective, which will help us find out who's most at risk of severe cancer pain and find ways to help them better.

Keywords

cancer pain cancer inequity health disparity intersectionality pain disparity

Introduction

Pain is a persistent, debilitating symptom of cancer^1,2 coming from the cancer itself or its treatments.² Approximately 38% of patients with cancer experience moderate-severe cancer-related pain³ (hereafter “cancer pain”) and an estimated 47% of cancer survivors suffer from chronic pain after curative treatment.⁴ Pain is a complex phenomenon influenced by biological (e.g., sensation), psychological (e.g., emotional, attributional), and social processes (e.g., social support).⁵ Cancer pain contributes to diminished quality of life and is often undertreated,^6,7 but is particularly undertreated among historically marginalized groups in the US due to interpersonal and structural discrimination, which includes policies, practices, and cultural norms within institutions and societies that maintain inequities.^8,9 For example, among Black patients there are inequities in palliative care referrals and medication prescribing compared to White patients.^8,10-12 For people without cancer, pain is not equitably experienced; for example there are inequities in pain experience based on sex (females report more pain than males),^13,14 racial and/or ethnic group (Black adults report more pain than White adults), ^15-17 and socioeconomic status (people with lower incomes report greater pain than those with higher incomes).¹⁸ Despite such research, there is a less comprehensive view of pain inequities during and after cancer treatment.

Our objective was to summarize the recent research on cancer-related pain inequities in the US, identify gaps in the inequities literature, and consider such gaps through an intersectional lens. Intersectionality incorporates how multiple interlocking power structures (e.g., racism, classism, and sexism) would influence cancer-related pain.^19-22 Thus, research with an intersectional approach considers people at multiple social positions (measured by demographics, e.g., their “race,” class, sex, and gender) simultaneously, within the context of structural oppression (e.g., discriminatory policies and laws).^19-22 We discuss how such an approach may advance new knowledge about inequities in cancer pain.

Reviewing Recent Research on Inequities Among Patients with Cancer-Related Pain

We focused our review on published research between January 2013 and December 2023 with US patients that reported on cancer-related pain inequities quantitatively: presence vs absence, pain severity, and/or pain interference. KA, ML, and EB searched for articles in Google Scholar, MEDLine, and PubMed between September 2023 and December 2023, with supplemental searches in February 2024. Keywords included “cancer pain,” “cancer-related pain,” “inequity,” “disparity,” and words related to social positions (“race,” “gender,” “sex,” “LGBT”). Included studies focused on inequities/disparities in pain for patients with cancer, and were identified through title review. We identified 17 articles that reported on historically marginalized groups’ cancer-related pain, summarized in Table 1. Importantly, because pain is a complex subjective experience comprised of biological, psychological, and social processes, patients’ self-report is the best to assess pain.^2,23 We therefore interpret results with the understanding that self-reported pain represents the patients’ pain experience.

Table 1.

Details of 17 Studies Included in Our Review. When Available, We Reported Multivariate Model Results. Terminology for “Race,” Ethnicity, Sex, and/or Gender are Reported Here as They Were in the Published Articles.

	Social Positions or Demographic Social Determinants Examined as Pain Predictors		Types of Cancer	Methodology & Participants	Method of Pain Assessment	Summary of Results
Article	Main Position for Analysis	Covariates And/Or Secondary Positions	Types of Cancer	Methodology & Participants	Method of Pain Assessment	Summary of Results
Ahmed et al. 2017³⁵	Gender and/or sex (terms used interchangeably; male/female)	N/A	All inclusive	Meta-analysis	NRS, VAS, ESAS, BPI	No male/female difference in pain
Ahmed et al. 2017³⁵	Gender and/or sex (terms used interchangeably; male/female)	N/A	All inclusive	13 studies on cancer-related pain	NRS, VAS, ESAS, BPI	No male/female difference in pain
Baker et al.²⁷ 2016	“Race” and/or ethnicity	SES (education, income) Gender and/or sex (“male/female”) Age	Breast (17%) Hematologic (13%) Lung (11%) Not reported/other (59%)	Cross-sectional survey N = 150 patients from the southeastern US 18% Non-hispanic Black, 82% non-hispanic White 43% male, 57% female Age ≥55 M = 65.4	BPI	“Race:” Black (vs White) patients reported more sleep interference and marginally (p < .10) higher psychosocial interference from cancer-related pain SES: Higher education predicted significantly lower sleep interference from cancer-related pain; income did not significantly predict any pain interference Sex: Women reported marginally lower walking ability from pain than men (p < .10) Age did not significantly predict any pain interference
Booker et al.²⁴ 2020	“Race” and/or ethnicity	N/A	GI (30%) Ear, nose, and throat (27%) Musculoskeletal (9%) Genitourinary (8%) Lymphatic (6%) Unspecified neoplasms (3%) Endocrine and brain (2%) Missing data (16%)	Case-control comparison by “race” 32 African American and 32 “Caucasian” American adults receiving hospice care for cancer pain in the midwestern US. 63% female; 38% male ≥65 years old M = 78.41	NRS; maximum and average across 2 weeks	No difference in mean pain intensity or maximum pain intensity between African- and “Caucasian”-American patients. However, there were treatment inequities in terms of receiving comprehensive pain management ≤24 hours of admission to hospice
Canick et al.³² 2022	“Race” and/or ethnicity	Age, sex (“male/female”)	Head & neck cancer	Retrospective cohort N = 25 572 90.58% White, 5.47% Black/African American, 1.3% American Indian/Alaska native, 1.81% Asian, 0.67% multiple “races,” 0.17% Hawaiian/Pacific islander 75.19% male, 24.81% female Age <65 43.02% Age ≥65 56.98%	Modified patient reported outcomes version of the common terminology criteria for adverse events (PRO-CTCAE)	“Race:” No significant differences in odds of reporting pain between White and “non-White” patients. Mean resolution time for pain incidents was significantly longer for White vs “non-White” patients Age: Patients under the age of 65 were significantly more likely to report pain than those over the age of 65 Sex: No significant differences in pain reporting for male and female patients
Cox-martin et al.³⁶ 2020	Sex (“male/female”)	SES (employment) Only examined within each sex: Age, education, “race” and/or ethnicity	Breast was most common (32.26%); no others defined in the article	Cross-sectional cohort of working-age cancer survivors who completed treatment (age 25-64); N = 485 from midwestern states 66.2% women/female, 33.75% men/male	Item assessing presence of pain: “Do you currently have physical pain caused by your cancer or cancer treatment?” yes/no	Sex: Female survivors were more likely to report chronic cancer-related pain than male survivors SES: Employed survivors were more likely to report that their chronic cancer-related pain was controlled compared to unemployed survivors Among men: Reports of chronic cancer-related pain did not significantly relate to employment status or education. The proportion of Black men who reported chronic cancer-related pain was higher than those who did not. Whereas the proportion of White men who reported cancer-related chronic pain was lower than those who did not report pain. “Other” race did not differ for men. Younger men were more likely to report chronic cancer-related pain than older Among women: The proportion of unemployed (vs Employed) women was higher for those with chronic cancer-related pain. Among women, education, age, and racial and/or ethnic group did not relate to reports of chronic cancer-related pain
Fukui et al.³⁰ 2021	“Race” and/or ethnicity	Age	Breast cancer, all stages and treatments	Cross-sectional survey N = 237 breast cancer patients from Hawaii center consortium 74% Asian, 12.4% White, 9.8% Native Hawaiian; Age M = 60.69	MPQ	“Race:” Chinese and Japanese patients reported significantly lower pain severity than white patients, though not different from native Hawaiian, Filipino, mixed asian, and asian Korean patients Age: Older patients reported lower pain severity than younger patients
Ham et al.³¹ 2017	SES (income)	“Race”; White vs “non-White” Gender and/or sex (“male/female”)	Breast (45.2%) GI (9.6%) Female reproductive (8.1%) Head and neck (6.7%) Lung (6.3%) Hematologic (2.9%) Lymph node (2.3%) Prostate (2.1%) Combined (8.8%) Others (7.2%) Stage 0-IV	Cross-sectional survey N = 443 patients with cancer from the Internet, cancer clinics, or cancer support groups across the United States 21.9% Hispanic, 31.0% White, 22.5% African American, 24.6% Asian 20.2% male; 79.4% female Age M = 51.92	MPQ-SF	“Race:” both Black and Asian patients reported lower pain severity than White and Hispanic patients SES: Participants reporting “sufficient” income report lower pain severity than “insufficient.” unemployed participants reported higher pain severity than employed participants; no significant differences based on education Education x Income intersection: Participants reporting higher education (> high school) had lower pain severity with higher income. Participants with ≤ high school, no significant relationship between income and pain Gender and/or sex: No male/female differences in pain severity “Race” x income intersection: For White participants, higher income predicted lower pain severity. For “non-White” participants, the relationship between income and pain severity was not significant
Hudson et al.²⁹ 2022	“Race” and/or ethnicity	N/A	Breast (11.4%), dermatologic (3.14%), gastrointestinal (20.4%), genitourinary (8.3%), gynecologic (6.7%), head and neck (3.8%), hematologic (18.7%), lung and bronchus (14.3%), prostate (5.4%), other (7.6%), unknown (0.32%)	Cross-sectional survey of patients with cancer reporting to the emergency department N = 924 87.0% Non-Hispanic White, 13.0% non-Hispanic Black Age M = 62.9 51.5% male, 48.5% female	NRS; categorized as none (0), mild (1-4), moderate (5-6), or severe (7-10)	“Race:” Black patients were twice as likely than White patients to report severe pain
Joseph et al.³³ 2022	“Race” and/or ethnicity	SES (education) Sex and/or gender (“male/female”)	Genitourinary (17.9%) GI (17.2%) Breast (11.5%) Head and neck (14.5%) Lung (27.8%) Other (11.3%)	Cross-sectional survey N = 1339 patients with cancer from Seattle and Chicago 64.5% non-Hispanic White, 28.3% non-Hispanic Black, 7.2% Hispanic 45.4% female; 54.6% male	Modified MPQ	“Race” and/or ethnicity: Black (vs White) patients did not report significantly different levels of worst pain severity, though Hispanic patients reported higher worst pain severity compared to white patients Sex and/or gender: Male and female patients did not significantly differ in reports of worst pain severity SES: Education did not significantly relate to worst pain severity
Kano et al.³⁷ 2022	Sexual/Gender minority (SGM)	N/A	Breast (50%) Colorectal (12.5%) Lung (9.4%) Non-hodgkin lymphoma (6.3%) Pancreatic (9.4%) Ovarian (9.4%) Other (3.3%)	Cross-sectional survey N = 34 English-speaking patients with cancer 55.88% SGM (Age M = 66.8; 94.4% White) 44.12% Heterosexual/Cisgender (Age M = 68.8; 93.3% White)	PROMIS	SGM patients with cancer reported lower pain intensity than patients who were both heterosexual and cisgender. The two groups were similar in levels of pain interference
Krok-schoen & Baker²⁵ 2016	Gender and/or sex (“women/men”)	Only examined within each gender/sex group: SES (education) “Race” Age	Men: Hemotological (17%), lung (14%), prostate (14%), other/Not reported (45%) Women: Breast (30%), lung (20%), hematological (22%), other/Not reported (28%)	Cross-sectional survey N = 150 from a national cancer institute-designated comprehensive cancer center in Florida Age ≥55 57.33% Women (Age M = 64.67; 79% non-Hispanic White, 21% non-Hispanic Black) 42.66% Men (Age M = 66.33; 86% non-Hispanic White, 14% non-Hispanic Black)	BPI	Gender and/or sex: No significant difference in worst pain, least pain, average pain, current pain, total pain (composite score), or pain interference Among women: Younger age related to higher least and current pain severity. Racial and/or ethnic group, and education did not significantly predict pain severity in any domain. Among men: Higher education predicted lower total, worst, and average pain severity. Age and racial and/or ethnic group did not significantly predict pain severity in any domain.
Mack et al.³⁴ 2018	“Race” and/or ethnicity	N/A	Various	Cross-sectional data from the minimum DataSet; all Medicare/Medicaid-certified nursing facilities. N = 342 920 Age ≥50 11.61% Non-hispanic Black, 88.39% non-Hispanic White	Self-report and staff-assessed for those unable to self-report Assessed via chart documentation	“Race:” compared to White patients, Black patients were less likely to have documented (self- or staff-reported) pain. Pain frequency and severity were similar for Black and White patients who did report pain.
Martinez et al.²⁶ 2014	“Race” and/or ethnicity	Wealth (amount of savings) Education Sex and/or gender (“male/female”) Age	Colorectal cancer (56%) lung cancer (44%)	Cross-sectional survey N = 5761 69.1% White, 13.5% Black, 6.9% Hispanic/Latino, 5.5% Asian/Pacific Islander, 2.9% Multiracial, 2.1% Other 53.6% male; 46.4% female 20.9% patients aged 18-54, 26.9% aged 55-64, 29.5% aged 65-74, 22.7% aged 77 or older; 63.5%; 17.1% less than high school diploma, 58.3% high school diploma/some college, 24.6% college graduate	BPI	“Race” and/or ethnicity: “Multiracial” participants had a higher likelihood of reporting pain than non-Hispanic White patients. Both Black and “Multiracial” patients reported higher severity of cancer pain than White patients Gender and/or sex: No sex differences in odds of reporting cancer-related pain. Female patients reported higher pain severity than male patients Age: Higher age was related to significantly lower likelihood of reporting pain and pain severity SES: Higher education was related to lower likelihood of reporting pain and lower pain severity. No relationship between wealth and reporting pain, but higher wealth was related to lower pain severity
Yang et al.³⁸ 2023	Sexual/Gender minority (SGM)	N/A	Various	Cross-sectional survey N = 51,503 patients from Florida 2.7% self-identified SGM, 97.3% non-SGM Of SGM: 78.4% lesbian/gay/homosexual, 18.9% bisexual, 1.7% something else, 1.1% straight/heterosexual	Physical component summary subscale from the short form health survey	SGM patients reported higher levels of pain interference than cis-heterosexual participants. Patients reporting they are lesbian/gay (regardless of gender identity) reported higher pain interference than bisexual and heterosexual patients.
Young choi et al.²⁸ 2022	Structural-level SES	“Race,” individual-level SES (employment, insurance status) Age	Early-stage (I-III) hormone receptor-positive breast cancer	1191 women treated at a large cancer center in Memphis, Tennessee between 2007-2015 42.8% Black, 53.2% White. Age <65 (66.4%) Age ≥65 (33.6%) Medicaid (24.3%), insurance (44.7%)	NRS	SES: Structural-level poverty and blight significantly predicted likelihood of reporting pain and pain interference. Employment did not significantly relate to likelihood of reporting pain, but unemployed participants reported significantly higher pain than employed participants. Participants using medicaid had significantly higher likelihood of reporting pain, but no difference with pain intensity than commercial insurance “Race” and/or ethnicity: Black and White patients did not significantly differ in likelihood of reporting pain, but Black patients reported significantly higher pain intensity than White patients Age: Age did not significantly relate to likelihood of reporting pain, but higher age did relate to lower reported pain intensity

BPI = brief pain inventory, ESAS = European symptom assessment scale, MPQ = McGill pain questionnaire (SF = Short Form), NRS = numerical rating scale, VAS = visual analog scale.

All studies except one (a case-control study)²⁴ reported cross-sectional data. Most studies measured pain via the Brief Pain Inventory (BPI; n = 3),^25-27 Numerical Rating Scale (NRS; n = 3),^24,28,29 or McGill-Pain Questionnaire (MPQ; n = 2)^30,31 vs other methods. The studies included patients with a variety of cancer types, at a variety of stages; only three examined one cancer type exclusively (breast n = 2,^28,30 or head and neck n = 1³²). Eight articles focused on racial and/or ethnic groups,^{24,26,27,29,30,32-34} followed by sex and/or gender (male/female and/or men/women; n = 3),^25,35,36 socioeconomic status (SES; n = 2),^28,31 and sexual/gender minority status (SGM or LGBTQ + identity; n = 2)^37,38 However, approximately half of articles (n = 8; 47.06%) reported multiple sociodemographic predictors (e.g., age ^26-28,30,32) in their analyses,^{26-28,30-33,36} and those findings were also included in our review (Figure 1).

Figure 1.

Chart depicting the number of reviewed articles by social position (demographic indicators). We reviewed 15 articles in total, however multiple articles included more than one social position in analyses.

Racial And/Or Ethnic Group Inequities

Consistent with conceptions that “race” is a political and social construct that reinforces notions of inherent biological differences (a racist myth), we reference “race” in quotations.^39,40 Of the 8 studies that focused on racial and/or ethnic group, 4 demonstrated higher cancer pain for Black (n = 3),^26,27,29 “Multiracial” (n = 1),²⁶ and Hispanic (n = 1)³³ patients relative to White patients. In a nationally representative cohort of White, Black, Hispanic/Latino, Asian or Pacific Islander, and “multiracial” patients with colorectal and lung cancer, “multiracial” participants (who self-reported more than one “race”) had a higher likelihood of reporting any pain on the BPI than non-Hispanic White patients.²⁶ Both Black and “multiracial” patients reported higher severity of cancer pain on the BPI than White patients.²⁶

One study of patients with cancer reporting to the emergency department illustrated that Black patients were more likely than White to report severe pain on the NRS.²⁹ In a convenience sample of only Black and White patients age 55 and older experiencing cancer pain, Black patients (vs White) reported more sleep and psychosocial interference from cancer-related pain on the BPI, though no differences in other pain interference sub-domains.²⁷ Yet another study illustrated that though Black breast cancer patients did not have higher likelihood of reporting pain, they did report higher pain severity than White patients.²⁸

Several studies found null/mixed effects. A retrospective cohort from a national dataset found no differences in pain events recorded in the medical record between White and “non-White” patients with cancer.³² Another study with palliative care patients with cancer in Seattle and Chicago did not find that Black patients reported higher worst pain severity compared to White patients, though Hispanic patients did report higher worst pain severity on the MPQ compared to White patients.³³ The authors discussed, but did not measure, how stereotyping and cultural conceptions of pain may drive such inequities.³³

A study focused on Black and White patients with cancer who were in Medicare/Medicaid-certified nursing facilities, and found that Black patients were less likely to have pain documented in their chart compared to White patients.³⁴ The authors contextualized this finding with other evidence of under-documentation of Black patients’ pain, proposing this finding actually represents pain under-reporting.³⁴ Another matched cohort study examined the efficacy of evidence-based practices for cancer-related pain control for 32 African-American and 32 “Caucasian”-American (White) older adults with cancer pain receiving in-home hospice care.²⁴ The study found no significant differences in post-intervention pain intensity on the NRS between African-American and “Caucasian” participants. However, African-American patients were less likely to receive pain assessment within 24 hours of admittance. Demonstrating that although reported pain was similar, pain treatment processes were still inequitable, again potentially pointing to under-reporting.²⁴ This could translate into masking potential inequities in pain experience, and leaves open questions about long-term impacts of inequitable documentation of pain for patients with cancer with in-home hospice.

One study surveyed 237 English-speaking patients with breast cancer in Hawaii, a unique cultural context of high ethnic diversity with no racial and/or ethnic majority group.⁴¹ The sample was majority Asian (74%) and the authors further stratified based on ethnic background, finding that Chinese and Japanese patients reported significantly less pain on the MPQ than White patients, though not different from Native Hawaiian, Filipino, mixed Asian, and Asian Korean patients.³⁰ These results demonstrate how the social context matters, and that disaggregating “Asian” patients based on country of origin reveals important distinctions in pain experience. Two studies also included “race” and/or ethnicity secondarily in their analyses. One reported that Black and Asian participants in a convenience sample reported lower pain intensity on the MPQ than White participants.³¹ Yet another study illustrated that though Black breast cancer patients did not have higher likelihood of reporting pain than White patients, Black patients did report higher pain severity than White patients.²⁸

In sum, the reviewed research demonstrates that there are likely racialized inequities in the cancer pain experience, and these effects may depend on whether researchers are measuring cancer pain incidence vs severity, which groups and how such groups are examined, and the cultural context (e.g., Hawaii vs the Pacific Northwest vs the Southern US). Some studies discussed, but did not examine pain underreporting or under-assessment as mechanisms. More research is needed to better understand potential racialized inequities in cancer-related pain, specific to cultural context and with attention to treatment inequities.

Sex and/or Gender Inequities in Cancer Pain

Three articles focused on gender and/or sex differences in cancer pain.^25,35,36 Notably, these studies did not differentiate between the conceptually distinct terms gender and sex. Sex is a biological classification focusing primarily on male vs female, whereas gender is an expressed identity which may or may not align with “typical” (Western) correspondence with sex.⁴² In the context of extant research on non-cancer pain that consistently finds women report higher pain sensitivity and more pain than men,¹³ it was surprising that a 2017 meta-analysis of 13 studies indicated no reliable male/female difference in pain severity for patients with cancer.³⁵

One study examined cancer-related pain for older Black and White patients with cancer in Florida, and, overall, found no difference in pain measured via the BPI between men and women.²⁵ Interestingly, higher education was protective against pain among men, but this relationship was not found for women,²⁵ which could reflect that education does not construe health benefits for women at the same rates as men.⁴³ The authors also found that for women (but not men), higher age predicted worse cancer-related pain.²⁵ Thus, researchers could examine whether older women with cancer experience worse pain compared to men. Though the study included Black and White patients with cancer, they did not examine potential racialized inequities. Furthermore, the researchers did not examine how pain may differ at intersections of racial group, gender, or education; in other words, they did not examine people marginalized based on racial group, gender, and/or education, simultaneously.

One study did find that overall, working-age cancer survivors (who completed primary treatment) who were women/female were more likely to report chronic cancer-related pain than men/male participants.³⁶ The authors also examined how other demographics may predict cancer-related pain differently for men vs women. Among women, a lower proportion of survivors who were employed had chronic cancer-related pain compared to those who were unemployed. Age, racial and/or ethnic group, and education did not significantly relate to chronic cancer-related pain status for women. Among men, a higher proportion of Black survivors reported cancer-related chronic pain (vs not) whereas fewer White survivors reported cancer-related chronic pain (vs not). A higher proportion of younger male survivors also reported chronic cancer-related pain (vs not). However, for men, education and employment did not significantly relate to presence/absence of pain. These findings demonstrate that further intersections of gender with “race” and age should be explored. Notably, these analyses were descriptive and did not control for the other demographic positions.

Five articles we reviewed included sex and/or gender as a covariate in their multivariate analyses.^26,27,31-33 No male/female (man/woman) differences in pain were found in a convenience sample of patients with cancer,³¹ a retrospective cohort of head and neck cancer patients,³² a sample of Black and White patients with cancer,²⁷ or a sample of Black, White, and Hispanic palliative care patients with cancer in Seattle and Chicago.³³ Yet in the nationally representative sample of patients with colorectal and lung cancer, researchers found no sex differences in odds of reporting cancer-related pain on the BPI, but compared to male patients with cancer pain, female patients reported higher pain severity.²⁶ Thus, the reviewed research does not reliably demonstrate gender and/or sex inequities in cancer-related pain. Given considerable evidence in non-cancer pain which does demonstrate sex and/or gender differences in pain sensitivity,¹³ and findings that age, “race,” and/or SES may moderate the relationship between gender and/or sex and pain,^25,36 further research is warranted.

Sexual and Gender Minority Pain Inequities

Research on people outside of the cisgender binary (Trans and non-binary people; “gender minorities”) and sexual minorities (e.g., bi/pansexual, lesbian, gay people) is extremely limited in cancer research.⁴⁴ “Sexual and gender minorities” are often conflated as one group (SGM; or LGBTQ+) due to the paucity of information on SGM people in medical records, and relative inattention to SGM status in medical research outside of HIV.⁴⁵ 2 studies published <12 months prior to our search assessed cancer-related pain among SGM patients with cancer.^37,38 In one small mixed-methods study (n = 34), SGM patients with cancer in New Mexico reported lower pain intensity measured via PROMIS relative to the patients who identified as both heterosexual and cisgender (cis-heterosexual).³⁷ This finding is valuable given the dearth of SGM cancer research, but limited in generalizability due to its small sample size.

In a separate, larger study with 1387 SGM (vs 51 503 cis-heterosexual) patients with cancer in Florida, SGM patients did report higher levels of pain interference on the short-form health survey than cis-heterosexual participants.³⁸ Researchers also further disaggregated analyses based on sexual identity, finding that lesbian/gay patients with cancer reported higher pain than bisexual and heterosexual patients, regardless of gender.³⁸ However, trans (vs cisgender) patients and intersections of sexual and gender identity (e.g., trans people who identify as bisexual) were not examined due to small sample size. As SGM patients with cancer become an increasing priority within cancer research,⁴⁴ researchers should continue to examine potential pain inequities.

Socioeconomic Cancer Pain Inequities

Two studies demonstrated that inequities by socioeconomic status (SES; e.g., income, education, employment) are prevalent in cancer-related pain.^28,31 One study reflected an analysis attentive to individual and structural-level markers of SES as drivers of cancer pain for women with early-stage breast cancer in Tennessee.²⁸ The authors used census data to examine neighborhood-level poverty (the percent of the neighborhood that was at or below the poverty line) and blight (proportion of abandoned/vacant housing) as correlates of individual-level cancer-related pain measured on the NRS. Women living in high poverty and high blight areas reported higher likelihood of cancer-related pain than those in less distressed neighborhoods. Odds of reporting pain for women with breast cancer increased incrementally: with every 1% increase in neighborhood poverty level, a patients’ cancer-related pain intensity also increased 1%.²⁸ Independent of structural SES, unemployed patients also reported significantly more pain than employed patients, reflecting unique impacts of individual and structural-level factors.

Another study with a convenience sample of patients with cancer from the Internet and cancer support groups across the US found that those who reported sufficient income (vs insufficient) to meet their needs reported lower levels of pain on the MPQ.³¹ Interactions with “race” revealed intersecting inequitable patterns. For White patients, as income levels increased, pain severity decreased. But for racially/ethnically minoritized patients, analyzed in one group as “non-White,” income did not predict lower pain.³¹ This pattern of inequity is consistent with research demonstrating that economic benefits on health are not equitably experienced for racially minoritized people, especially Black people.^46,47 This is especially notable because when “race” was analyzed individually in this study, as we reported above, Black and Asian patients reported lower pain than White and Hispanic patients. This study therefore demonstrates the importance of examining cancer pain at intersections of SES and racial and/or ethnic group.

Four studies included in our review included SES indicators in their analyses.^26,31,33,36 In a nationally representative cohort of patients, higher income related to lower pain severity for patients with colorectal and lung cancer.²⁶ In a convenience sample of Black and White patients with cancer, higher education predicted lower sleep interference on the BPI from cancer-related pain, though income was not a significant predictor.²⁷ Furthermore, among working-age cancer survivors, employed participants were less likely to report cancer-related pain than those who were unemployed.³⁶ Yet education did not relate to worst pain severity on the MPQ in a sample of palliative care patients with cancer in Seattle and Chicago.³³ The current research demonstrates that people with lower SES experience higher levels of cancer-related pain and should be considered a priority group for cancer pain interventions.

Age-Related Pain Inequities

Five^26-28,30,32 studies included age as a factor in cancer pain, but as a covariate and thus were not the focus of any study. One study found age had no relationship with pain interference via the BPI.²⁷ Whereas 4 found that older age is related to lower pain severity^26,28,30 and likelihood of pain occurrence.^26,32 Thus, the reviewed research suggests that younger patients may be at increased risk of uncontrolled cancer-related pain.

Current Research Gaps in Cancer Pain Inequities

Collectively, these studies made important contributions to the cancer pain literature by highlighting key demographic inequities, summarized in Table 2. Yet the research left questions about how people at multiple socially marginalized positions (e.g., within “race” and SES) are at risk for exacerbated cancer-related pain, and the mechanisms that explain cancer pain inequities.

Table 2.

Summary of findings from the review of cancer pain inequities research.

Social Position	Positions Assessed	Summary of Findings
Racial/Ethnic group	• Black • White or “Caucasian” • “Multiracial” • Hispanic and/or Latina/o/x • Chinese • Japanese • Native Hawaiian • Filipino • “Mixed Asian” • Asian • Korean	• White was the common reference group across studies • Racialized inequities may depend on whether pain incidence vs severity is assessed • Social context may be key to consider when assessing racialized inequities • Intersections of “race” with sex and/or SES are important to consider
Sex and/or gender	• Males or men • Females or women	• No reliable gender/sex difference in pain • Findings indicate that intersecting influences of age, “race,” and/or SES are important to consider
Sexual and gender minority people	• Lesbian • Gay • Bisexual • SGM as a group vs non-SGM	• SGM patients were least examined in our review • Pain is potentially inequitably experienced for SGM patients • More research is needed
Socioeconomic status (SES)	• Income • Education • Employment • Neighborhood deprivation	• Consistent results that people with lower SES experience more pain than people with higher SES • Historically racially/ethnically marginalized patients experience exacerbated inequities by SES • Structural and individual-level indicators are important to consider in cancer pain
Age	• Older vs younger (category) • Continuous measure of age	• Results suggest younger participants may be at increased risk of uncontrolled cancer pain

Gap 1: Attend to Interdependent, Intersecting Social Positions

The reviewed studies pinpoint a need to identify patients with cancer and cancer survivors who, based on their demographic social positions (i.e., “identities”), may be most at risk for experiencing uncontrolled and/or exacerbated cancer-related pain. The research demonstrated mixed findings on racial and/or ethnic inequities and gender and/or sex inequities in pain. Yet, research supported that lower SES predicts higher cancer-related pain, and that younger patients may be at increased risk for cancer-related pain. Our review demonstrates that more high-quality research is needed to chart the complexities of cancer-related pain inequities.

A potential contributor to the mixed findings could be that the studies we reviewed statistically or methodologically (e.g., through case-matching) considered each “social determinant” as a predictor of cancer-related pain independent of the other “social determinants.” This approach reflects traditional single-axis approaches to health equity research that assess one social position (e.g., “race”) as independent of others such as class, gender, and/or age. When researchers examined social positions’ interactions,^25,31 or separately by sex/gender,³⁶ intriguing patterns emerged. Higher SES was less protective against cancer-related pain for female (vs male)²⁵ and “non-White” (vs White) patients with cancer.³¹ Black working-age male survivors (vs White) may have increased risk of chronic cancer-related pain; whereas this distinction was not present for Black (vs White) female survivors.³⁶ Another study illustrated that older age predicted higher cancer-related pain for women but not men,²⁵ whereas another study indicated that among working-age men, younger age related to increased chronic cancer-related pain.³⁶

These results indicate that examining social positions in parallel masks inequities for multiply marginalized people and point to the complexities of intersectional marginalization. Such independent analyses may create voids in knowledge about people exposed to intersecting social drivers of pain such as stereotyping, discrimination, and structural-level oppression (e.g., Black women experiencing gendered racism). Thus, a key solution to better understanding cancer-related pain inequities is in conceptualizing these factors as interdependent (vs independent) of one another.

The current research was also not designed to interrogate or challenge traditional gender and/or sex categorizations and focused (presumably exclusively) on patients who are cisgender, leaving open questions about sex (a biological classification) and/or gender (a performed identity which may or may not align with typical Western correspondence with sex)⁴² in cancer pain. Pain researchers may be interested in more carefully distinguishing between biological (e.g., sex-derived), or psychological and social processes (e.g., discrimination) driving gender and/or sex differences in pain.¹³ The current research also did not adequately include sexual minorities. One study with patients in Florida suggests that gay/lesbian participants are potential populations of interest for researchers interested in mitigating cancer-related pain.³⁸ Some community-based research finds that bisexual people report more insurance coverage than gay or lesbian people,⁴⁸ which could illustrate a need for intersectional analyses with SES. We also did not find research on pain inequities based on disability, an understudied social position.⁴⁹ To best identify patients in need for better cancer pain control, future research should also prioritize including understudied marginalized social positions.

Gap 2: Attend to Processes Responsible for Pain Inequities

In the studies we reviewed, there was no connection of the social-structural processes (e.g., discrimination, resource access) that connect social positions (“race,” sex, SGM, age) to pain experience; a key gap in knowledge for designing interventions.⁵⁰ Research supports that discrimination is a key social driver of health inequities.⁸ Prevailing pain stereotyping⁵¹ can also drive discrimination in cancer pain treatment. For example, women are stereotyped as more likely to complain about pain than men,^51,52 and are less likely than men to receive analgesics for pain.⁵³ Women’s pain is also underestimated by health care providers compared to men’s, even when women report higher pain severity.⁵⁴ Racialized stereotypes also remain highly prevalent. The mythology of Black people’s thicker skin and higher pain tolerance (compared to White people)^55,56 was still believed by over half (58.11%) of one 2016 sample of medical students.⁵⁷ This can translate to inequities; a large registry study illustrated that Black patients with cancer are less likely to receive an opioid prescription at diagnosis than White.¹⁰ Structural factors are also key to consider – for example neighborhood residency can influence opioids access for Black patients with cancer.⁵⁸

Beyond pain treatment discrimination, research illustrates that experiencing discrimination (ageism, racism, or general discrimination with no attribution) can drive pain sensitization,^15,59–63 which could impact cancer-related pain for people from marginalized groups. For example, an experimental study illustrated that Chinese women who experienced sexism (vs not) had higher acute pain sensitivity.⁶⁴ For Black people, experiences of racism also predict lower pain tolerance^65,66; and health care discrimination predicted increased pain sensitivity.⁶⁷

Some studies we reviewed did include information on pain assessment,²⁴ or pain prescribing.³² Yet these factors were not analytically connected to the pain inequities (e.g., through mediation). Connecting these mechanisms to patients’ pain experience is critical to minimizing cancer pain inequities. Research on mechanisms should also examine more than one social position (e.g., “race” AND sex). For example, research demonstrates that Black women with cancer are less likely to be referred for psycho-oncology services (2%) relative to Black men (9%), White men (5%), and White women (10%).⁶⁸ Research could elucidate how intersectional discrimination may drive (in)adequate pain control for patients with cancer.

Intersectionality: A Key Framework for Understanding Cancer Pain Inequities

Intersectionality is a critical theoretical framework highlighting how experiences and outcomes (e.g., pain inequities) are shaped by multiple interlocking power structures (e.g., racism, classism, and sexism) depending on a person’s social position (e.g., “race,” class, sex, and gender) within society.^19-21 The origins of intersectionality are traced to Black women activists in the 18th century,⁶⁹ though within health research the application of intersectionality is emergent.^70,71 A key component of intersectionality is that interlocking systems and structures shape health inequities, not sociodemographic identities.⁷² This is a departure from typical biomedical, biobehavioral, and psychosocial approaches to health disparities, which focus on demographics (e.g., “race”) as predictors of health outcomes instead of social-structural processes, and examine them independently instead of examining how multiple marginalization impacts outcomes.⁷³ Research with an intersectional lens therefore shifts the focus from individual-level causes to highlighting how individual experiences often reflect multilevel oppressive systems that are interdependent (e.g., racism and classism).

Intersectionality in Cancer Pain Research

We make several recommendations for how an intersectionality framework can aid in filling gaps in knowledge of cancer pain inequities (Table 3). We recommend first and foremost that researchers interested in an intersectional approach study foundational intersectional texts^20,21,74,75 and works of scholars in the intersectionality and health equity space.^71,72,76,77 Quantitative methods attentive to the core tenets of intersectionality^78,79 can help promote visibility for intersectionally “invisible” people, or people who are “prototypical” members of their pre-defined social position.⁸⁰ For example, a study in our review found that Hispanic (vs White) patients with cancer experience more pain severity.³³ This finding may prompt a vision of a Mexican man as the exemplar of this finding, though the analysis may included men, women, and people with backgrounds across the “Hispanic” diaspora. An intersectional lens encourages researchers to pull apart this finding and make less “prototypical” groups more visible. Indeed, extant survivorship work demonstrates that “Hispanic” cancer survivors have inequities dependent on country of origin.⁸¹

Table 3.

Recommendations for incorporating intersectional perspective in research and practice.

Review action items	Intersectional considerations for cancer pain Researchers	Intersectional considerations for medical practitioners
Attend to marginalized intersecting social positions, acknowledging that these positions are not able to be independently experienced	• Read foundational intersectional theory^20,21,74,75 and scholars applying intersectionality to health research^71,72,76,77
	• Discuss and analyze how social positions (measured via demographics) are interdependent (vs Independent) of one another	• Screen for social determinants of health,⁹⁵ which influence access to equitable pain care, including non-pharmacological pain interventions.¹⁰⁰ understand how social determinants may influence patients’ experience based on racism, sexism, ageism, and/or heterosexism
	• Consider including people who have underrepresented social positions in research as participants, including sexual minorities and people with disabilities, in research	• Understand how intersecting stereotypes influence the perceiving others’ pain; e.g., pain for people with mental health conditions is “all in their head;” women as “complainers”⁵¹
	• Consider whether research questions are focused on gender (identities of the spectrum of masculinity and femininity including men, women, or people who do not rigidly identify to either) or sex (a biological mechanism)
Attend to processes responsible for cancer pain inequities	• Measure (and analyze) potential multilevel contributors²² to cancer-related pain inequities	• Utilize standardized tools for pain assessment/treatment e.g., WHO pain Analgesic ladder⁹⁷ for patients with cancer
	• Examine the intersecting nature of individual and structural processes across social positions (e.g., individual stereotypes at the intersection of race and gender; structural barriers based on insurance, referral, or geographic access to high quality care)	• Consider consulting palliative care¹⁰¹ at diagnosis of advanced disease or when reporting moderate-severe pain in two or more consecutive visits
		• Work toward structural competency,^72,88 gaining awareness of structural barriers to effective pain management such as opioid stocking patterns of pharmacies, polices on opioid stocking, and variable payor controlled substance pre-authorization policies
		• Be aware of financial, logistical, and supportive resources for patients experiencing barriers: e.g., patient assistance programs, community supports, patient navigators, and/or patient support services

Two methodological approaches may be helpful for researchers in applying intersectionality in cancer pain research: intercategorical and intracategorical.⁷⁹ Intersectional intercategorical approaches compare between intersectional positions to analyze complexity of multiple sociodemographic positions.^79,82 Such approaches could build on existing research to compare how people low SES exacerbates vulnerability to pain based on a person’s “race.” Intersectional intracategorical approaches focus on pulling to the surface the complexity of within-group experience for people at intersectional social positions.⁸² Such approaches might explore how cancer pain differs for Black people specifically at low (vs high) SES.

Utilizing an intersectional lens also shifts researchers’ focus from exclusively individual-level factors to critically understudied social-structural processes that drive the cancer pain experience. These occur on the structural-institutional (e.g., access to pain treatment,^10,83 referral to palliative treatment for cancer pain^11,84) and interpersonal (e.g., provider bias^85,86 and experiencing discrimination^64,87) levels to worsen cancer-related pain for those at intersectionally marginalized positions. Interpersonal-level stigmas occur due to structural causes, but have direct impacts on targets.⁸⁸ Stigma/discrimination predicts pain,^{59,61,62,65,85,89} yet this research does not examine intersectional stigma/discrimination, which is crucial to understanding health inequities.⁸ Reflecting inattention to intersectional stigma, women⁵⁴ and Black people⁹⁰ are less likely to have their pain recognized. But research on how Black women’s pain is perceived is rare, even though Black women report exacerbated pain dismissal by providers due to gendered racism.⁹¹ The invisibility of Black women’s experience in both gender and/or sex and “race”-based research is a key issue an intersectional approach would help address. Research on intersectional stigma is burgeoning in other fields such as HIV, forging a path that pain and cancer researchers can follow.⁹² Methodologically, qualitative and mixed-methods research would facilitate a contextually-grounded understanding of the intersectional structural facilitators of cancer pain and experiences for subsequent quantitative study.

Researchers utilizing an intersectionality framework are also attentive to the social and economic forces that are the mechanisms that drive cancer-related pain inequities.^72,88 One study we reviewed illustrated that structural-level poverty measured at the census-tract level was related to cancer-related pain.²⁶ This finding demonstrates structural classism’s role in shaping cancer-related pain. However, future researchers utilizing an intersectional lens might consider how low-SES areas are confounded by racial and or ethnic groups (especially Black and Hispanic people) in the US due to the interlocking nature of structural racism and classism. For example, patients with metastatic cancer at minority-serving hospitals, which tend be in more impoverished areas due to racist redlining and underfunding, are less likely to receive referral to palliative care than patients at non-minority-serving hospitals.⁸⁴ Other research demonstrates that for Black, White, and Hispanic patients, cancer-related pain reporting increases with neighborhood racial segregation.⁹³ Structural approaches might also explore how access to opioids⁹⁴ may be inequitable for intersectionally marginalized groups.

Intersectionality’s Implications for Practice and Policy

Critically minded clinicians should also consider studying foundational intersectionality work and its applications to health equity (Table 3). Additionally, clinicians should consider screening for social determinants of health⁹⁵ and consider how such factors may influence patients through multiple levels of marginalization, including trust and subsequent pain communication during appointments.⁹⁶ Neighborhood residency can influence opioids access for Black patients with cancer⁵⁸; clinicians who are aware of such inequities could identify alternate strategies for opioid access (e.g., hospital pharmacy). Oncology providers, or people within providers’ practices, can gain awareness of pharmacy analgesic stocking practices to know how such geographic inequities in access could influence your cancer patients’ pain management. Additionally, to maximize equity of pain relief, clinicians should develop practice processes that lower barriers to patients obtaining appropriate prescriptions. For example, there are payor restrictions and processes that influence dispensation without pre-authorization based on a patients’ insurance.

Research also demonstrates that pain stereotypes can influence prescribing tendencies of clinicians; utilizing standardized tools, such as the WHO analgesic ladder for patients with cancer-related pain,⁹⁷ are a key way to mitigate the roles of such biases. When available, consulting with interdisciplinary palliative care early in treatment can be a way to promote multimodal symptom management in your patients early in their cancer journey.⁹⁸ Clinicians should also consider partnering with social-behavioral researchers to develop interventions to promote equity in pain management for patients with cancer.

With research connecting intersectional social-structural processes in treatment inequities (e.g., gendered racism) in pain experiences,⁹⁹ researchers and clinicians can work together toward structural interventions to ultimately decrease cancer pain among historically multiply marginalized groups.⁷⁷ Large-scale community-specific, multi-sector, equity-oriented interventions are feasible and effective for improving health outcomes in communities experiencing generations of intersectional structural racism and classism.⁹ This includes initiatives such as housing redevelopment (with only temporary displacement), cradle-to-college curriculum, and programs designed to promote health and interrupt the cycle of intergenerational poverty.⁹ Researchers could consider structural interventions targeting cancer-related pain through environmental changes focused on increasing physical activity accessibility, access to pain clinics, and ensuring equal access to opioids for pain management.

Conclusion

Addressing cancer inequities is a high-priority issue for The National Cancer Institute, and our review demonstrated that there are inequities in cancer-related pain based on SES and age, and continued exploration by racial and/or ethnic group, sex/gender, and SGM and their intersections, are warranted. Our review specifically maps the ways researchers focused on cancer-related pain could benefit from an intersectional approach. Because pain is constructed through social, psychological, and biological pathways, intersectionality offers key benefits to understanding and ultimately mitigating cancer-related pain inequities.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Katarina AuBuchon is supported by NCI Grant #T32CA261787 and Myla Lyons is supported by NIMH Grant #5T32MH130247-02.

Ethical Statement

ORCID iD

Katarina E. AuBuchon

Appendix

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A Narrative Review of the Current Research in Cancer-Related Pain Inequities: The Necessity of Applying Intersectionality to Advance Cancer Pain Research

Abstract

Plain Language Summary

Keywords

Introduction

Reviewing Recent Research on Inequities Among Patients with Cancer-Related Pain

Racial And/Or Ethnic Group Inequities

Sex and/or Gender Inequities in Cancer Pain

Sexual and Gender Minority Pain Inequities

Socioeconomic Cancer Pain Inequities

Age-Related Pain Inequities

Current Research Gaps in Cancer Pain Inequities

Gap 1: Attend to Interdependent, Intersecting Social Positions

Gap 2: Attend to Processes Responsible for Pain Inequities

Intersectionality: A Key Framework for Understanding Cancer Pain Inequities

Intersectionality in Cancer Pain Research

Intersectionality’s Implications for Practice and Policy

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

Ethical Statement

ORCID iD

Appendix

References