Graduation Year


Document Type




Degree Name

Doctor of Public Health (Dr.PH.)

Degree Granting Department

Community and Family Health

Major Professor

Dinorah Martinez Tyson, Ph.D.

Co-Major Professor

Bruce Levin, Dr.PH.

Committee Member

Jason Beckstead, Ph.D.

Committee Member

Khary Rigg, Ph.D.

Committee Member

Victoria Marshall, Ph.D., R.N.


Cancer Survivorship, judgment analysis, Pain management, Quality of life


Introduction: Breast cancer is the most frequently reported malignancy among women in the United States. Cancer-related pain is highly prevalent occurrence and is often the most fearful side effect following curative intent treatment. Opioid pain management is considered a standard of care and can be of great benefit to treat moderate to severe pain. However, undertreatment of pain remains a significant issue affecting the patient’s physical function, psychological well-being, and overall quality of life. Barriers to adequate pain management are multifactorial and often attributed to patients’ beliefs and attitudes revolving around opioid pain management. In addition, the opioid epidemic has also created unique challenges in cancer care. However, little is known about how cancer survivors assess and combine information when making decisions about taking prescribed opioid medication to manage pain.

Objective: The overall objective of this dissertation study was to identify and understand how breast cancer survivors use psychosocial factors (cues) associated with forming judgments regarding opioid medication for cancer-related pain.

Methods: This study utilized an exploratory sequential mixed-method study design. Purposive sampling techniques were used to recruit women aged 18-64 years who had been diagnosed with breast cancer within the last five years and been prescribed opioid medication for cancer-related pain. In Phase 1, qualitative methods were applied by using a Freelisting exercise and an in-depth interview (N=20) among women recruited from the community throughout the United States. Salience analysis was conducted to identify psychosocial factors that breast cancer survivors take or refuse opioids for cancer-related pain. Next, inductive applied thematic analysis techniques were employed to identify emergent themes from the interviews. In phase 2, quantitative methods used judgment analysis tasks (N=191) to understand the decision-making policies of opioid medication among breast cancer survivors recruited from an NCI-designated Comprehensive Cancer Center. Hypothetical scenarios, representing real-life situations were developed using a factorial arrangement design approach. Breast cancer survivors were asked to make prioritization decisions on each case scenario. A model was derived using multiple regression analysis to elicit the weighting given to cues and cue levels by survivors when prioritizing decisions. In addition, the Beliefs of Medicine Questionnaire was also completed to assess general and specific medication beliefs.

Results: Overall, breast cancer survivors favored the use of opioid pain management for cancer-related pain. Psychosocial factors, specifically the severity of pain, concern about side effects, and the possibility of addiction were the primary factors that affected opioid use. In addition, through the BMQ, findings suggest that medication beliefs held by breast cancer survivors play a role in their overall judgment of using opioids for pain management. When the survivor believes the necessity of taking medication outweighs their concerns, they will implement the pain medication.

Conclusion: This study explored the psychosocial factors that affect the use or refusal of opioids among breast cancer survivors. Findings support ongoing efforts to understand decision-making policies to help inform evidence-based interventions to overcome barriers to pain management and improve outcomes and patient’s overall quality of life.

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