Perceived discrimination and physical activity mediate the associations between receiving a survivorship care plan and cancer pain

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Introduction

As of January 2019, there were approximately 16.9 million cancer survivors in the U.S. [1] . Due to advances in cancer treatment, the overall five-year survival rate has increased to 68%, with 56% for ten or more years [1] . Given the increased duration of cancer survivorship, later effects of cancer treatment and comorbidities are expected [23] . This trend demands increased attention to during- and after-cancer health issues, including pain. Cancer survivors’ pain can result from cancer, including tumor cells pressing on nerves or internal organs, or from cancer treatment(s). Furthermore, 40% of cancer survivors experience pain [4] and 66% of survivors with advanced conditions report some degree of pain [5] , which negatively affects cancer survivors’ social and physical functioning and psychological well-being [6] . Minimizing pain, which is vital for improving survivors’ quality of life [7] , can be achieved through education, lifestyle modification, medication therapies, and integrative methods [89] .

Physical activity is one of the most salient modifiable factors for improving pain management in cancer survivorship [1011] . The 2018 Physical Activity Guidelines for Americans highlighted that physical activity lowers cancer survivors’ mortality rates and enhances their quality of life [12] . Additionally, the level of physical activity influences symptoms experienced by cancer survivors, including pain [13] . Despite the advantages of regular physical activity, one in three cancer survivors report no leisure-time physical activity [14] . As a component of the survivorship care plan (SCP), the level of engagement in physical activity should be addressed to promote cancer survivors’ quality of life.

Building trusting patient-provider relationships is the foundation of effective pain management [1516] . The Institute of Medicine’s Report on Cancer Survivorship highlighted that the essence of cancer survivorship care is a personalized approach, including effective patient-provider communication. Furthermore, the report recommended providing each cancer survivor with treatment summaries across survivorship trajectory, including information regarding the later effects and referrals [17] . Yet, one in three cancer survivors received SCPs [18] . This underutilization likely results in survivors not having high-quality communication with their providers as characterized by discussions of care plans, wellness recommendations, and social-emotional needs [19] . Additionally, survivors’ characteristics, including race/ethnicity and perceived discrimination, are related to the quality of patient-provider communication [20] .

Perceived discrimination is defined as perceived unfair treatment due to sex, gender, race, and other factors [21] . A conceptual model proposed by Pascoe and Smart Richman [21] delineated the pathways through which discrimination influences stress responses or lifestyle factors, including physical activity, thereby affecting health. In pain management, the suggested pathways have been partially verified in non-cancer patients [2223] . Discrimination led to lower physical activity levels, increased stress [24] , and contributed to chronic pain among U.S. middle-aged adults [22] . Additionally, discrimination was an independent barrier to patient satisfaction with pain treatment among older Black and White cancer survivors (B= −0.29, p < .05) [25] . However, no prior research has investigated the mediation pathways through which discrimination affects cancer pain, including receiving SCPs and physical activity, which is associated with cancer survivors’ mental and physical health [1213] . This study aimed to determine the associations among patients receiving SCPs, perceived discrimination, physical activity, and pain among cancer survivors. Our hypotheses were as