Pain, Depressive Symptoms, and Self-ecacy for Pain Management: Examination in Black Women With Breast Cancer

Purpose: Black women with breast cancer face signicant disparities, including high levels of pain. Depressive symptoms and self-ecacy for pain management impact how women with breast cancer manage pain, yet little is known about how these variables relate to pain specically for Black women with breast cancer. Methods: Baseline regression analyses were conducted using a sample of women (n=98) with stage I-III breast cancer identifying as Black or African-American who were part of a larger intervention trial. Model 1 explored depressive symptoms and pain (i.e., severity and interference). Model 2 explored self-ecacy for pain management and pain. Covariates were age (M=57.22,SD=10.76), cancer stage (50%=stage 1), and education level (36%=some college). Results: Participants reported moderate levels of pain severity and interference. Higher depressive symptoms were related to both higher pain severity and interference; (B=.06, p<.01, 95% CI [.02,.09], β=.32) and (B=.13, p<.001, 95% CI [.09, 17], β=.55) respectively. Likewise, lower self-ecacy for pain management was also related to both higher pain severity and interference; (B=-.04, p<.001, 95% CI [-.05,-.02], β=-.44) and (B=-.06, p<.001, 95% CI [-.08,-.04], β=-.53) respectively. Women reporting less than a high school diploma endorsed signicantly higher pain severity and interference than women reporting some college. Age and cancer stage were not signicantly related to pain. Conclusion: Pain for Black women with breast cancer may be inuenced by depressive symptoms and self-ecacy for pain management, in addition to other important variables. Attending to better assessment and treatment of depressive symptoms and self-ecacy for pain management may improve outcomes. 27.6% (p<.001) of the variance in pain severity and pain interference, respectively, above and beyond the covariates. The dummy code comparing “less than high school diploma” to “some college” was a signicant predictor of both pain severity (B=2.27, p<.01, 95% CI [.64, 3.90], β = .27) and pain interference (B=2.34, p<.05, 95% CI [.39, 4.29], β = .20). These results indicate that, on average, women reporting “less than high school diploma” endorsed pain severity and pain interference 2.27 and 2.34 higher than those reporting “some college,” respectively. Age and cancer stage were not signicantly related to pain.


Introduction
Breast cancer is one of the most common cancers for women, affecting approximately 4 million women in the United States [1]. Black women with breast cancer have higher rates of mortality and worse survivorship outcomes than other racial and ethnic groups [2][3][4]. Black women diagnosed with breast cancer are also more likely to experience higher pain levels compared to other groups [5]. Several factors contribute to these persistent and signi cant disparities. Pain related to cancer or its treatment affects more than half of women with breast cancer [6] and is consistently related to poor outcomes for survivors [7]. Black women may carry additional risk for pain above that of non-Hispanic Whites due to both systemic and health risk factors [5,8]. Systemic factors such as inequitable access to cancer screenings and timely cancer care often mean that Black women may be diagnosed at later cancer stages [9] or require more aggressive treatments [10], contributing to greater pain [7]. Black women with breast cancer may also experience suboptimal pain management related to inadequate screening, concern about medication side effects, fear of addiction, and lack of access to behavioral pain treatments [3,11]. Research highlights that Black women are more likely than White women to have health risk factors such as being diagnosed at a younger age [9] and with more aggressive cancers (e.g., triple negative breast cancer [TNBC 12]) and these factors are associated with high pain levels [4]. In addition to these health risk factors, there may be other variables relevant to the pain experience of Black women with breast cancer. It is critical to better understand the experience of pain for this group to optimize treatment and improve outcomes.
Black women with breast cancer often endorse depressive symptoms, and depressive symptoms are related to higher pain levels [13]. Changes in physical appearance and functioning due to surgery and other treatments, and concerns about mortality may contribute to depressive symptoms for women with breast cancer [13]. Black women may be at additional risk for depressive symptoms due to systemic stressors such as mistrust in the medical system [14] as well as younger age and later stage at time of diagnosis [15,16]. Understanding the burden of depressive symptoms for Black women with breast cancer is important for pain management [17,18].
Self-e cacy for pain management, or one's con dence in her ability to enact particular pain coping strategies, has implications for how women with breast cancer manage pain [19]. In heterogenous samples of cancer patients, self-e cacy for pain management has been shown to help reduce pain and other important pain-related variables (e.g., depression, disability) [20][21][22]. Black women with breast cancer may be particularly likely to have lower levels of self-e cacy for managing cancer-related pain given the unique stressors they face. Emerging evidence suggests that self-e cacy is also potentially important for Black women with breast cancer. Sheppard and colleagues [23] reported that low selfe cacy for symptom management was associated with increased anxiety and depression for Black women with breast cancer. Likewise, Watkins and colleagues [24] found lower capacity to cope to be associated with higher psychological distress when Black women were receiving chemotherapy. Yet, despite the potential for Black women to carry a higher burden of pain, no study to date has critically examined the role of self-e cacy for pain management in this group.
This study aimed to examine the relationships between pain (i.e., severity, interference), depressive symptoms, and self-e cacy for pain management in a sample of women with breast cancer who identi ed as Black (n=98). This was an exploratory, secondary analysis of baseline data from a larger trial (N=327) that assessed a cognitive behavioral pain management intervention for women with breast cancer and pain [25]. The rst hypothesis was that Black women who reported higher levels of depressive symptoms would report higher levels of pain (i.e., severity, interference). The second hypothesis was that Black women who reported lower levels of self-e cacy for pain management would report higher levels of pain (i.e., severity, interference). These relationships were expected to be evident even after controlling for demographic and medical variables (i.e., age, cancer stage, education level [26]) known to be related to pain.

Participants
Women at least 18 years of age were recruited from 2017-2020 at Duke University Medical Center and a liated cancer clinics. Eligibility criteria included the following: 1) diagnosis of stage I-IIIC breast cancer (initial or recurrence) within the past two years; 2) life expectancy ≥ 12 months; and 3) pain severity rating ≥ 5 out of 10 at screening, consistent with moderate-to-severe pain [27]. Exclusion criteria included the following: 1) cognitive impairment; 2) brain metastases; 3) presence of a severe psychiatric condition (e.g., psychotic disorder or episode, suicidal intent) that would contraindicate safe participation; or 4) current or past (< 6 months) engagement in cognitive behavioral coping skills treatment for cancer pain. The parent study was a randomized trial with ethical approval by the Duke University Institutional Review Board (IRB #: Pro00070823) and registered on ClinicalTrials.gov (NCT02791646). Procedures Potential study participants were assessed for eligibility by study staff using electronic medical record review and mailed recruitment letters and interested participants engaged in informed consent procedures. Written informed consent for participation in study procedures as well as permission for data publication was obtained from enrolled participants. After enrollment in the parent trial, participants completed an online baseline assessment consisting of self-report questionnaires measuring pain severity, pain interference, depressive symptoms, and self-e cacy for pain management. The current analysis is a secondary analysis of baseline data from the larger clinical trial. Additional trial information and another baseline analysis has been published elsewhere [25,28].

Measures
Demographic and Medical Characteristics. Data were collected through electronic medical record review and self-report. Demographic information included: age, sex, race and ethnicity, education, and household income. Medical characteristics included breast cancer stage and other cancer speci c variables (e.g., initial or recurrent diagnosis, surgeries).
Pain Severity and Interference. Pain was assessed with the Brief Pain Inventory (BPI) [29]. Four pain severity items asked participants to rate their pain at its worst, least, and average over the past week as well as their current pain. Response options ranged from 0 (no pain) to 10 (worst pain imaginable). Severity items were averaged for a composite score (Cronbach's α = .86). Seven pain interference items asked participants to rate the degree to which, over the past week, pain interfered with daily activities (i.e., general activity, mood, walking ability, normal work [including house work], relations with others, sleep, and enjoyment of life). Response options ranged from 0 (does not interfere) to 10 (completely interferes). Pain interference items were averaged for a composite score (Cronbach's α = .91).
Depressive Symptoms. Depressive symptoms were assessed with the 20-item Center for Epidemiological Studies Depression Scale (CES-D) [30]. Participants were asked to rate how frequently they experienced various depressive symptoms (e.g., low mood, anhedonia, lack of appetite, di culty concentrating) over the past week. Response options ranged from 0 (rarely or none of the time, less than one day) to 3 (all of the time, ve to 7 days). Items were summed for a total score (Cronbach's α = .91).
Self-e cacy for Pain Management. Self-e cacy for pain management was assessed with the ve-item Chronic Pain Self-E cacy Scale [31]. Participants were asked to rate their con dence in their ability to decrease their pain, continue their daily activities, keep pain from interfering with their sleep, make a small-to-moderate reduction in pain using methods other than taking extra medication, and make a large reduction in pain using methods other than taking extra medication. Response options ranged from 10 (very uncertain) to 100 (very certain). The ve items were averaged for a composite score (Cronbach's α = .86).

Statistical Methods
Analyses were conducted using SPSS (version 27). Preliminary descriptive analyses included identi cation of outliers and examination of main study variable distributions for kurtosis, skewness, and assumptions of normality for multivariate data. There were no outliers and all main study variables exhibited normal distributions, with kurtosis and skewness values within -2 and +2 [32]. Bivariate correlations were run for all main study variables: pain severity, pain interference, depressive symptoms, and self-e cacy for pain management. Four regression models were run. Two regression analyses were conducted to examine the association between depressive symptoms and pain severity and pain interference. Likewise, two regression analyses were conducted to examine the association between selfe cacy for pain management and pain severity and pain interference. Regressions were run both with and without covariates (i.e., age, cancer stage, education level). Cancer stage was dummy coded with stage 1 disease as the referent group. Education level was also dummy coded with "some college" as the referent group. Referent groups were determined based on largest represented cancer stage and education level group among our sample. The data that support the ndings of this study are available from the corresponding author upon reasonable request.

Participant Characteristics
From the parent sample of 327 women with breast cancer, 98 participants (30.0%) self-identi ed as Black or African-American. The number of women who identi ed as Black or African-American enrolled in the parent study was representative of the population served by the treating cancer clinics based on clinic catchment area statistics. The current study used this sub-sample of women identifying as Black or African-American for the analyses. The average age of women in this sub-sample was 57.22 (SD=10.87) years. Approximately one-third (36%) of participants reported "at least some college"; nearly half (44%) of participants reported household income of up to $39,000/year. For nearly all women (97%), this was their rst breast cancer diagnosis. Forty-nine participants (50%) had stage 1 disease. Additional demographic and medical characteristics are reported in Tables 1 and 2, respectively. Participant reported pain severity (M=4.59; SD=1.90) and interference (M=4.52; SD=2.59) were in the moderate range. Additional variable means and correlations are reported in Table 3. Note. M = mean; SD = standard deviation.  Note. M = mean; SD = standard deviation; Fatigue scores shown as T-score; *p<.05; **p<.01. These results indicate that, on average, women reporting "less than high school diploma" endorsed pain severity and pain interference 2.24 and 2.30 higher than those reporting "some college," respectively. Age and cancer stage were not signi cantly related to pain.

Discussion
The purpose of this study was to examine the relationships between pain, depressive symptoms, and self-e cacy for pain management among women who identify as Black or African American. Higher levels of depressive symptoms were signi cantly associated with both greater pain severity and pain interference. Lower self-e cacy for pain management was signi cantly associated with higher pain severity and pain interference. Lower education signi cantly predicted both greater pain severity and interference in all regression models; age and cancer stage were not independently related to pain. Depressive symptoms and self-e cacy for pain management remained signi cant predictors of both pain severity and interference over and above the contribution of education level.
The current study is the rst to demonstrate that depressive symptoms and self-e cacy for pain management signi cantly predict pain severity and pain interference, over and above relevant covariates of age, cancer stage, and education level, in a sample of Black women with breast cancer. Literature suggests that this population is particularly vulnerable to high levels of pain due to the in uence of numerous health risk and systemic factors. However, this is one of the rst studies to examine how psychosocial variables (e.g., depressive symptoms and self-e cacy for pain management) affect the pain experience in this population.
Greater depressive symptoms predicted both higher pain severity and pain interference. Notably, 27% of the variance in pain interference was explained by depressive symptoms, as opposed to only 9% of the variance in pain severity. Depressive symptoms such as reduced motivation and persistent negative attitudes about the future may exacerbate systemic vulnerabilities of reduced access to and engagement in care for Black women. When patients experience depressive symptoms alongside greater pain severity and even greater pain interference, the combined burden of these symptoms may reduce patients' willingness to seek or persist in accessing adequate cancer care, ultimately worsening outcomes. Indeed, higher overall symptom burden is associated with reduced engagement with breast cancer treatments [33,34]. These data lend support for the importance of adequate screening and treatment of depressive symptoms among Black women with breast cancer as a means of improving pain.
While previous studies have examined self-e cacy in relation to anxiety and depressive symptoms for Black women with breast cancer, this is the rst study to directly assess the impact of self-e cacy for pain management for this population. We found that lower pain self-e cacy predicted both higher pain severity and higher pain interference. This is consistent with previous work [20,22,35] and provides support for self-e cacy for pain management's relevance for Black women coping with breast cancer and pain. Breast cancer diagnosis and treatment can challenge many women's ability to cope. Black women may be particularly vulnerable to lower self-e cacy for pain management due to health risk and systemic factors. Lack of access to adequate nancial and other resources during cancer care, structural racism leading to poor responsiveness from the medical community, and vulnerabilities for more aggressive cancers requiring more intensive treatment may further burden Black women coping with breast cancer. This increased burden may reduce self-e cacy for pain management, leading to greater pain problems because women may not actively seek out and effectively troubleshoot known ways to improve pain (e.g., through pleasant activities, relaxation, exercise).
Pain self-e cacy and depressive symptoms remaining signi cant predictors of pain over and above the contribution of education level is informative. While education level cannot be changed, self-e cacy for pain management and depressive symptoms can be targeted in evidence-based behavioral interventions (e.g., Pain Coping Skills Training [36]) that teach effective pain coping strategies. In circumstances where breast cancer patients have lower levels of education, targeting pain self-e cacy and depressive symptoms may serve as an effective means of reducing pain. Indeed, promising research shows that lowliteracy adaptations of self-e cacy skills training can improve cancer pain outcomes in medically underserved communities [35].

Future Directions
If not adequately addressed, cancer-related pain can become persistent pain, leading to poor overall functioning [37]. These results point to the critical importance of adequate screening and treatment of depressive symptoms and pain self-e cacy as a means of treating cancer-related pain and preventing persistent pain among Black women. Larger, longitudinal studies are needed to best characterize these relationships over time. Future research assessing these variables should move beyond those served in a large academic medical center and incorporate those (i.e., in rural areas) who may not have access to such care. Additional variables that can also contribute to disparities in pain outcomes for Black women with cancer, such as patients' experience of racism and medical mistrust [3,38], could be assessed in later studies. Cognitive behavioral interventions promoting self-e cacy have been shown to reduce depressive symptoms, pain severity, and pain interference for breast cancer patients more broadly [22]; however, future research should speci cally examine and potentially adapt these interventions to best support Black women with breast cancer and pain. Spiritual practices and interpersonal support may also increase self-e cacy [39] and could play an important role in interventions aimed at reducing pain for Black women with breast cancer.

Declarations
Funding: This study was funded through an NIH/NCI 1R01CA202779-01 awarded to senior author, Tamara J. Ethics approval: Procedures complied with ethical guidelines and received Duke University Institutional Review Board approval (Pro00070823).

Consent to participate:
Informed consent was obtained from all individual participants included in this study.

Consent for publication:
The authors a rm that all human research participants provided informed consent for publication of the data included in this publication.

Con ict of interest/Competing interests:
All authors declare that they have no nancial or other competing interests to disclose.
Availability of data and material: N/A Code availability: N/A Authors' contributions: