ArticleSupportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer2026
Cancer pain and its impact on quality of life, distress, and spiritual well-being in the war-torn Gaza Strip.
Article in Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 2026. The graph could read no effect estimate from its abstract, so it casts no vote on the map. Not yet cited in PubMed.
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Abstract
backgroundOncology services in the Gaza Strip have been severely disrupted by the ongoing war since 2023. Therefore, the region provides a crucial example for understanding how pain affects health-related quality of life (HRQoL), psychological distress, and spiritual well-being under extreme conditions.
methodsWe conducted a cross-sectional study of 349 adult cancer patients attending the three operational outpatient cancer clinics in Gaza (July-August 2025). Data were collected using convenience sampling and employed the validated Arabic versions of the Brief Pain Inventory-Short Form (BPI-SF), the EORTC QLQ-C30, the PHQ-4, and the FACIT-Sp-12. Patients with a BPI-SF worst pain score ≥ 4 were classified as "having pain." Analgesic adequacy was assessed using the Pain Management Index (PMI). Group comparisons between patients with and without pain were performed using Mann-Whitney U and Chi-square tests, and associations were assessed using Spearman's rank correlation. Mediation analyses were conducted to test whether psychological distress mediated the relationship between pain and both spiritual well-being and global health status (QLQ-C30 GHS), using ordinary least squares regression with 2,000 bootstrap resamples, adjusting for age, sex, and income.
resultsAmong participants, 53.6% reported having cancer pain. Pain undertreatment was common: 41% of all participants were inadequately managed, and only about 10% received strong opioids. Those experiencing pain had markedly poorer HRQoL, with lower scores in global health status and functional domains and worse financial difficulties (all p < 0.001), along with substantially higher symptom burdens, including fatigue, nausea, insomnia, and appetite loss. Psychological distress was greater among patients with pain (PHQ-4 median 4.0, IQR 3.0-7.0, vs. 2.5, IQR 0.0-5.0; p < 0.001), with over one-third experiencing moderate-to-severe distress compared to about one-fifth without pain (35.8% vs. 21.0%). Spiritual well-being was also worse (FACIT-Sp: 32.0 vs. 38.0, p < 0.001), with lower scores on meaning, peace, and faith. Pain intensity correlated positively with psychological distress (ρ = 0.36, p < 0.001) and negatively with spiritual well-being (ρ = -0.37, p < 0.001), while psychological distress and spiritual well-being were strongly inversely related (ρ = -0.69, p < 0.001). Mediation analyses suggested that psychological distress may partially account for the association between pain and spiritual well-being (indirect effect = - 0.51, 95% CI - 0.68 to - 0.35; 56% of the total effect), and, to a lesser extent, the association between pain and global health status (indirect effect = - 1.01, 95% CI - 1.40 to - 0.66; 26% of the total effect).
conclusionsCancer patients in Gaza face significant multidimensional suffering, including undertreatment, poor HRQoL, and inadequate pain management. These findings underscore the pressing need for integrated pain, psychosocial, and palliative care services, as well as international efforts to safeguard healthcare services and ensure access to essential medicines in conflict zones.
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