Pain, Sleep Disturbance, and Fatigue in Patients With Cancer: Using a Mediation Model to Test a Symptom Cluster

Susan Beck

William N. Dudley

Andrea M. Barsevick

ONF 2005, 32(3), E48-E55. DOI: 10.1188/05.ONF.E48-E55

Purpose/Objectives: To test whether sleep disturbance mediates the effect of pain on fatigue.

Design: Cross-sectional.

Setting: Radiation therapy clinic, oncology ambulatory clinic, and inpatient oncology unit in an urban teaching hospital.

Sample: 84 patients with cancer with multiple primary diagnoses who were experiencing pain. Fifty-three percent were female and 92% were Caucasian, with a mean age of 54 years.

Methods: All participants completed a symptom questionnaire that included the Brief Pain Inventory-Short Form, the Pittsburgh Sleep Quality Index, and the fatigue subscale of the Profile of Mood States questionnaire. Multistage linear regression was used to test a mediation model.

Main Research Variables: Fatigue, pain, and sleep disturbance.

Findings: Mediation analyses indicate that pain influences fatigue directly as well as indirectly by its effect on sleep. About 20% (adjusted R2 = 0.20) of the variation in fatigue is explained by pain. Thirty-five percent of the variance in fatigue explained by pain was accounted for by the mediation pathway.

Conclusions: Some of the effect of pain on fatigue is mediated by sleep disturbance, but pain has a direct effect on fatigue as well.

Implications for Nursing: Although the relationship can be explained only partially by the commonsense point of view that people who are in pain lose sleep and naturally report more fatigue, this finding is important and leads to a potential intervention opportunity. Strategies to improve sleep by better pain management may contribute to decreased fatigue.

Jump to a section


    American Sleep Disorders Association. (1990). International classification of sleep disorders. Diagnostic and coding manual. Rochester, MN: Author.

    Armstrong, T.S. (2003). Symptoms experience: A concept analysis. Oncology Nursing Forum, 30, 601-606.

    Baron, R.M., & Kenny, D.A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182.

    Beck, S.L. (2004). Symptom clusters: Impediments and suggestions for solutions. Journal of the National Cancer Institute Monographs, 32, 137-138.

    Beck, S.L., Schwartz, A.L., Towsley, G., Dudley, W., & Barsevick, A. (2004). Psychometric evaluation of the Pittsburgh Sleep Quality Index in cancer patients. Journal of Pain and Symptom Management, 27, 140-148.

    Berger, A.M., & Farr, L. (1999). The influence of daytime inactivity and nighttime restlessness on cancer-related fatigue. Oncology Nursing Forum, 26, 1663-1671.

    Berger, A.M., & Walker, S.N. (2001). An Explanatory Model of Fatigue in women receiving adjuvant breast cancer chemotherapy. Nursing Research, 50, 42-52.

    Broeckel, J.A., Jacobsen, P.B., Horton, J., Balducci, L., & Lyman, G.H. (1998). Characteristics and correlates of fatigue after adjuvant chemotherapy for breast cancer. Journal of Clinical Oncology, 16, 1689-1696.

    Buysse, D.J., Reynolds, C.F., III, Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28, 193-213.

    Buysse, D.J., Reynolds, C.F., III, Monk, T.H., Hoch, C.C., Yeager, A.L., & Kupfer, D.J. (1991). Quantification of subjective sleep quality in healthy elderly men and women using the Pittsburgh Sleep Quality Index (PSQI). Sleep, 14, 331-338.

    Carpenter, J.S., Elam, J.L., Ridner, S.H., Carney, P.H., Cherry, G.J., & Cucullu, H.L. (2004). Sleep, fatigue, and depressive symptoms in breast cancer survivors and matched healthy women experiencing hot flashes. Oncology Nursing Forum, 31, 591-598.

    Clark, J., Cunningham, M., McMillan, S., Vena, C., & Parker, K. (2004). Sleep-wake disturbances in people with cancer part II: Evaluating the evidence for clinical decision making. Oncology Nursing Forum, 31, 747-771.

    Daut, R.L., Cleeland, C.S., & Flanery, R.C. (1983). Development of the Wisconsin Brief Pain Questionnaire to assess pain in cancer and other diseases. Pain, 17, 197-210.

    Dodd, M.J., Miaskowski, C., & Lee, K.A. (2004). Occurrence of symptom clusters. Journal of the National Cancer Institute Monographs, 32, 76-78.

    Dodd, M.J., Miaskowski, C., & Paul, S.M. (2001). Symptom clusters and their effect on the functional status of patients with cancer. Oncology Nursing Forum, 28, 465-470.

    Dudley, W.N., Benuzillo, J.G., & Carrico, M.S. (2004). SPSS and SAS programming for the testing of mediation models. Nursing Research, 53, 59-62.

    Engstrom, C.A., Strohl, R.A., Rose, L., Lewandowski, L., & Stefanek, M.E. (1999). Sleep alterations in cancer patients. Cancer Nursing, 22, 143-148.

    Gaston-Johansson, F., Fall-Dickson, J.M., Bakos, A.B., & Kennedy, M.J. (1999). Fatigue, pain, and depression in pre-autotransplant breast cancer patients. Cancer Practice, 7, 240-247.

    Geisser, M.E., Perna, R., Kirsch, N.L., & Bachman, J.E. (1998). Classification of chronic pain patients with the Brief Symptom Inventory: Patient characteristics of cluster profiles. Rehabilitation Psychology, 43, 313-326.

    Gentili, A., Weiner, D.K., Kuchibhatla, M., & Edinger, J.D. (1995). Test-retest reliability of the Pittsburgh Sleep Quality Index in nursing home residents. Journal of the American Geriatric Society, 43, 1317-1318.

    Gift, A.G., Jablonski, A., Stommel, M., & Given, C.W. (2004). Symptom clusters in elderly patients with lung cancer. Oncology Nursing Forum, 31, 202-212.

    Given, C.W., Given, B., Azzouz, F., Kozachik, S., & Stommel, M. (2001). Predictors of pain and fatigue in the year following diagnosis among elderly cancer patients. Journal of Pain and Symptom Management, 21, 456-466.

    Glover, J., Dibble, S.L., Dodd, M.J., & Miaskowski, C. (1995). Mood states of oncology outpatients: Does pain make a difference? Journal of Pain and Symptom Management, 10, 120-128.

    Hann, D.M., Jacobsen, P.B., Martin, S.C., Kronish, L.E., Azzarello, L.M., & Fields, K.K. (1997). Fatigue in women treated with bone marrow transplantation for breast cancer: A comparison with women with no history of cancer. Supportive Care in Cancer, 5, 44-52.

    Jacobsen, P.B., Hann, D.M., Azzarello, L.M., Horton, J., Balducci, L., & Lyman, G.H. (1999). Fatigue in women receiving adjuvant chemotherapy for breast cancer: Characteristics, course, and correlates. Journal of Pain and Symptom Management, 18, 233-242.

    Judd, C.M., & Kenny, D.A. (1981). Process analysis: Estimating mediation in treatment evaluations. Evaluation Review, 5, 602-619.

    Lawrence, D.P., Kupelnick, B., Miller, K., Devine, D., & Lau, J. (2004). Evidence report on the occurrence, assessment, and treatment of fatigue in cancer patients. Journal of the National Cancer Institute Monographs, 32, 40-50.

    Lenz, E.R., & Pugh, L.C. (2003). The Theory of Unpleasant Symptoms. In M. Smith & P.R. Liehr (Eds.), Middle range theory for nursing (pp. 69-90). New York: Springer.

    Lin, C.C., & Ward, S.E. (1995). Patient-related barriers to cancer pain management in Taiwan. Cancer Nursing, 18, 16-22.

    Longman, A.J., Braden, C.J., & Mishel, M.H. (1999). Side-effects burden, psychological adjustment, and life quality in women with breast cancer: Pattern of association over time. Oncology Nursing Forum, 26, 909-915.

    MacKinnon, D.P. (1994). Analysis of mediating variables in prevention and intervention research. NIDA Research Monograph, 139, 127-153.

    McGuire, D.B. (2004). Occurrence of cancer pain. Journal of the National Cancer Institute Monographs, 32, 51-56.

    McNair, D.M., Lorr, M., & Droppleman, L.F. (1992). Profile of Mood States manual (2nd ed.). San Diego, CA: Educational and Industrial Testing Service.

    Meek, P.M., Nail, L.M., Barsevick, A., Schwartz, A.L., Stephen, S., Whitmer, K., et al. (2000). Psychometric testing of fatigue instruments for use with cancer patients. Nursing Research, 49, 181-190.

    Miaskowski, C., & Lee, K.A. (1999). Pain, fatigue, and sleep disturbances in oncology outpatients receiving radiation therapy for bone metastasis: A pilot study. Journal of Pain and Symptom Management, 17, 320-332.

    Morin, C.M. (1993). Insomnia: Psychological assessment and management. New York: Guilford.

    Nail, L.M. (2002). Fatigue in patients with cancer. Oncology Nursing Forum, 29, 537-546.

    Patrick, D.L., Ferketich, S.L., Frame, P.S., Harris, J.J., Hendricks, C.B., Levin, B., et al. (2003). National Institutes of Health state-of-the-science conference statement: Symptom management in cancer: Pain, depression, and fatigue, July 15-17, 2002. Journal of the National Cancer Institute, 95, 1110-1117.

    Reynolds, C.F., III, Hoch, C.C., Buysse, D.J., Houck, P.R., Schlernitzauer, M., Pasternak, R.E., et al. (1993). Sleep after spousal bereavement: A study of recovery from stress. Biological Psychiatry, 34, 791-797.

    Sarna, L. (1993). Correlates of symptom distress in women with lung cancer. Cancer Practice, 1, 21-28.

    Serlin, R.C., Mendoza, T.R., Nakamura, Y., Edwards, K.R., & Cleeland, C.S. (1995). When is cancer pain mild, moderate, or severe? Grading pain severity by its interference with function. Pain, 61, 277-284.

    Stasi, R., Abriani, L., Beccaglia, P., Terzoli, E., & Amadori, S. (2003). Cancer-related fatigue: Evolving concepts in evaluation and treatment. Cancer, 98, 1786-1801.

    Stein, M.B., Chartier, M., & Walker, J.R. (1993). Sleep in nondepressed patients with panic disorder: I. Systematic assessment of subjective sleep quality and sleep disturbance. Sleep, 16, 724-726.

    Stein, M.B., Kroft, C.D., & Walker, J.R. (1993). Sleep impairment in patients with social phobia. Psychiatry Research, 49, 251-256.

    Woods, N.F., Mitchell, E.S., & Lentz, M. (1999). Premenstrual symptoms: Delineating symptom clusters. Journal of Women's Health and Gender-Based Medicine, 8, 1053-1062.