Exploring Acceptance of Pain Management Strategies in Oncology: A Single-Center Cross-Sectional Survey.

Introduction
Pain represents a constant struggle for cancer patients.1 According to Globocan 2022 data, there are over 19 million new cancer cases reported annually.2 Research findings report that more than half of these patients will experience pain during the course of their illness.3 As a result, the number of individuals suffering from cancer-related pain is substantial. The primary approach to pain management remains pharmacological treatment. However, pain killers are not always sufficient and may be limited by dosage constraints and adverse side effects.4 Consequently, alternative methods of pain relief are continually being explored.
Non-invasive brain stimulation has emerged in the last years as a new complementary method for chronic pain.5 Among the techniques used for stimulation, transcranial direct current stimulation (tDCS) is the most simple, affordable and safe, being in the same time evidence proved.5–7 tDCS, which involves placing two electrodes on the scalp of a patient and administering a low-intensity electrical current, has been shown to modify underlying neuronal activity. Its use in oncology remains limited, with some case reports8,9 and a handful of studies of varying design and quality.10–15 Recent systematic reviews and meta-analyses have highlighted the significant need of this specific patient population.16–18 Currently, transcranial electrical stimulation is being investigated in cancer palliative care settings through the STIMPAL randomized controlled trial and the Pan-European Horizon initiative, PAINLESS.19,20
Randomized clinical trials are a cornerstone of medical advancement, although public perception is not uniformly favorable.21–23 Among cancer patients, enrollment has constantly increased over time, mostly influenced by ongoing education initiatives, growing awareness, and targeted efforts to address patient concerns.21–23 A study found that individuals from the general population are more inclined to participate in clinical trials when confronted with serious health conditions, such as a cancer diagnosis.24
For many years, patients have expressed fear and skepticism toward opioid use, and numerous myths surrounding these medications continue to persist.25,26 It is therefore unsurprising that some individuals may be hesitant to embrace novel approaches to pain management.
Patients’ acceptability of a new treatment as tDCS that involves the application of electrical current to the brain is theoretically shaped by perceptions of safety, usability and efficacity. Patients’ acceptance or reluctance will directly impact trial recruitment rates and adherence to intervention and will therefore be a direct measure of trial feasibility. Data are starting to appear regarding neuromodulation reluctancy. Several barriers to the acceptance of transcranial direct current stimulation (tDCS) have been identified in non‑cancer populations.27,28 Limited awareness and limited understanding of the underlying mechanisms often hinder patient confidence in the technique. Concerns regarding safety and potential side effects further contribute to hesitancy. In addition, aspects related to device design and aesthetics, including comfort and usability, may affect willingness to engage with the intervention.27,28 Other potential barriers identifiable, are the need for public insurance coverage of NIBS therapies as well as improved local or home‑based accessibility under professional supervision.28
These barriers are likely to be equally relevant in cancer patients and may be further compounded by the comorbidities associated with their chronic condition. As, no data are currently available regarding the acceptability of this technique among oncologic patients, systematic study is warranted.
The primary objective of the present study was to assess the prevalence of pain in our clinic as well as the openness among patients with cancer, to pain management interventions, with particular emphasis on tDCS as a complementary therapeutic option.

Materials and Methods

Study Design
The study is an observational, cross-sectional survey designed to explore patients’ acceptance of pain therapies and openness to engage in clinical trials. Additionally, it investigates predictive factors as demographic characteristics, clinical aspects and pain presence and intensity.

Participants
Participants included adult cancer patients under active care at the Oncology Department of Dr. Pompei Samarian County Emergency Hospital, Călărași, Romania, a single medical center serving a population of approximately 200,000 people.
Eligibility Criteria
Participants were eligible if they met the following criteria:
● Age ≥18 years
● Histopathological confirmed malignant disease
● Adequate cognitive function, without consciousness impairments (eg, delirium, dementia)
● Literacy sufficient to understand and complete the questionnaires.

Procedure
Both inpatients and outpatients presenting during the study period—from 1st February 2024 to 31st January 2025—were assessed for eligibility. Participants were informed about the study protocol and provided informed written consent. Eligible individuals received for study a brief educational material on pain and pain treatment options. Afterward, they submitted demographic data (age, marital status, gender, education level) and completed a survey on pain treatment preferences (see Annex 1). Additionally, they filled out the Brief Pain Inventory (BPI). All questionnaires were completed independently by patients in a quiet setting, without medical staff intervention. Assistance from a relative was permitted.
For each participant, the investigator extracted from the patients’ medical record clinical data including:
Cancer primary localization and stage of disease

Site of metastases (if present)

Current and past cancer directed treatment: history of surgical interventions as a cancer treatment, radiotherapy, chemotherapy, targeted therapies, immunotherapy or hormonal therapy.

ECOG performance status

Pain treatment history.

Materials

Survey Questionnaire
The survey assessed acceptance of various pain management methods. It included 10 items (Annex 1):
A single-item: numerical rating scale (0–10) to measure patients fear of pain.

Seven single-choice items: evaluating acceptance of interventions such as morphine, medicated alternative therapies for pain, non-medicated pain relief alternatives, and tDCS, along with willingness to enroll in trials for each.

Two multiple-choice items: identifying factors that would encourage or discourage the use of tDCS.

Survey Validation was conducted in two phases:
1. Initial testing with three healthy volunteers to assess clarity, difficulty, and completion time.
2. A pilot study involving 10 cancer patients to further evaluate comprehension and usability.
The survey was considered clear and feasible. A highlight of the multiple-choice possibility in the last two questions was employed to enhance better visualization.

Brief Pain Inventory (BPI)
The BPI is a multidimensional, self-rated pain assessment tool, widely used in cancer pain evaluation.29 Pain is assessed on an 11-point numerical rating scale (NRS) from 0 to 10 across four dimensions: average pain in the past 24 hours, pain at the time of assessment, least pain in the last 24 hours and worst pain in the past 24 hours. Clinically significant pain was defined in this study as NRS ≥4.
The pain inference section was divided as suggested by the guideline into:
WAW Subscore – Activity Interference - reflecting how pain affects physical functioning and mobility.

REM Subscore – Affective Interference - reflecting how pain interferes with emotional and social well-being.29

The official Romanian translation of this questionnaire was requested and provided by The University of Texas MD Anderson Cancer Center.

Data Analysis
Descriptive statistics—proportions, means, and standard deviations (SD)—were used to summarize patient demographics and disease-related variables. Microsoft Excel was utilized for dataset compilation and processing. Pivot Tables were employed to perform descriptive statistical analyses and organize data, facilitating efficient summarization and visualization of key variables. Statistical analyses used Fisher test or Chi-Square test to evaluate associations between groups as well as Spearman correlation and linear regression. There were performed using JASP (version 0.95.1.0; JASP Team, Amsterdam, The Netherlands). Statistical significance was set at p < 0.05. As the survey was exploratory, simplicity and transparency were more important than precision. Some participants have skipped questions without any relation to the observed data, and this missing data was considered as – Missing Completely at Random (MCAR). For statistical reasons a listwise deletion was used for these participants.

Ethics
The study was conducted in accordance with the updated Declaration of Helsinki. Approval was obtained from the Institutional Ethics Committee of the Călărași County Emergency Hospital (no 2450/30.01.2024). Written informed consent and General Data Protection Regulation (GDPR) compliance documentation were mandatory for all participants prior to inclusion.

Results
Between February 2024 and January 2025, a total of 179 oncology patients were considered for participation in this study within the Medical Oncology Department of the Călărași County Emergency Hospital. Of these, 24 patients declined to participate, citing primarily lack of time (n=19) and ophthalmological conditions (n=5) as the main reasons. A total of 155 questionnaires were distributed, of which 149 were returned (participation rate: 96.1%) yielding an overall response rate of 83.2% (from the initial 179). Of the 149 respondents, 25 were excluded due to incomplete responses in one or more key questionnaires, resulting in a final sample of 124 (usable rate: 83.2%).

Demographic Characteristics
The average age of the study lot was 62 years (62.08 ± 11.28) range 24–87years, with 32 patients over 70 years and five over 80 years old. There was a better representation of females (59.67%), patients living in urban areas (56,45%), and patients that were married (69.35%). Among the recorded cancer incidences, the first two were: colorectal cancer (23.4%) and breast cancer (22.6%). Almost half of patients were stage IV cancer, receiving life prolonging and palliative treatment (Table 1).

Pain
Throughout this article, significant pain is defined as a self-reported score of 4 or higher on the NRS. In the observed cohort, clinically significant pain on average in the previous 24 hours was reported by 43 patients (34.68%), (Mean = 2.72, SD = 2.96, 95% CI SD [2.63–3.39]). Pain on completion (pain right now) was reported by 26 patients (20.9%), (Mean = 2, SD = 2.85, 95% CI SD [2.53–3.26]).
Among patients with metastatic disease, 46.5% (n=27) reported an average pain NRS score of ≥4. This proportion was significantly higher compared to the 24.2% of patients with localized disease (Stage I–III) who reported similar levels of pain (X2=6.783, p = 0.009; Fisher`s exact test=0.014). For pain during completion the tests revealed: X2=6.664, p = 0.01; Fisher`s exact test=0.014. No significant association was found for worst or least pain (Tables 2–5).

An association between pain level and functional impairment was found, as the chi-squared test revealed a significant relationship, χ2 (2) = 9.682, p =0.008. Patients with higher pain scores were more likely to have poorer ECOG performance status Table 6.
No significant association was found for other demographic characteristics (age, gender, residential setting) and pain levels (worst, least and average) Table 7.
Corelating average pain with areas of interference, Spearman’s correlation analysis indicated positive and moderate associations overall, with a strong correlation (ρ >0.7) observed only for the WAW variable Table 8.
In the multiple linear regression, the significant predictors were relationships with other people and sleep quality. The beta coefficient for sleep was positive, indicating a direct relationship—sleep interference is associated with higher values on the average pain level. For social relationship, as interference increases, the average pain score decreases Table 9.

Survey Responses
In relation to the survey findings, Table 10 displays participants’ responses to questions related to various pain treatment modalities. Table 11 illustrates their willingness to participate in a clinical trial investigating pain alleviation strategy, including pharmacological, non-pharmacological, and tDCS interventions.

Notably, morphine elicited the most polarized responses: while many participants indicated they would “do anything to avoid pain”, a substantial proportion simultaneously expressed distrust toward its use. In contrast, non-medication methods and alternative approaches—particularly those endorsed by a physician—were met with more consistent acceptance. Transcranial stimulation received moderate support; however, fewer participants stated they would “definitely” try it, compared to morphine.
Chi-square tests were conducted to explore associations between patient characteristics and two survey questions: openness to use tDCS and willingness to participate in a tDCS trial (Table 12). No statistically significant associations were found between either question or the following predictors:

Pain-related variables: average pain, worst pain, least pain, completion pain (all p > 0.18)

Demographic variables: age, gender, residential setting, matrimonial status, educational level (all p > 0.37)

Clinical variables: ECOG performance status, cancer stage, current pain treatment (all p > 0.22)

However, this interpretation must acknowledge that the limited sample size may have constrained the ability to detect small effects.
Table 13 illustrates the distribution of responses to the multiple response question assessing factors that may encourage patients to consider using tDCS for pain management. Conversely, Table 14 highlights the factors contributing to patient hesitation or opposition toward tDCS use.

Discussion
The findings in the observed study group suggest mild to moderate pain levels, with considerable variability and heterogeneity among patients. Considering other papers looking at pain prevalence, these studies show a range of pain prevalence from 22% to 42%, depending on the population and treatment context.30–33 The study cohort’s 34.6% prevalence of clinically significant pain falls within this spectrum, suggesting consistency with broader literature. The lower prevalence of pain during attendance (20.9%) compared to the average pain may reflect fluctuations in pain or the effect of analgesic interventions during hospitalization.
The clinically and statistically significant difference in average pain intensity between patients with metastatic disease and those with localized disease underscores the heightened symptom burden in advanced-stage cancer and aligns with existing literature on disease progression and pain severity.3,33 Moreover, patients reporting higher average pain scores were more likely to exhibit poorer functional status, reinforcing the bidirectional relationship between symptom severity and physical debilitation.3 Findings from Spearman´s correlation highlights the substantial impact of pain on patients’ ability to engage in meaningful daily activities and may inform targeted interventions to preserve functional autonomy. Moreover, in the multiple linear regression model, sleep quality and interpersonal relationships emerged as significant predictors of average pain scores. Sleep interference was positively associated with pain intensity, consistent with the well-documented interplay between sleep disruption and heightened pain sensitivity. Interestingly, increased interference in social relationships was linked to lower average pain scores. This counterintuitive finding may reflect complex psychosocial dynamics, such as emotional withdrawal or altered pain reporting behaviors, and warrants further qualitative exploration.
Using the survey, participants were asked a series of questions regarding their attitudes toward pain management strategies, focusing on current pain treatment options, including opioid treatment, alternative methods, non-pharmacological intervention and tDCS. Morphine administration was refused by twenty-four patients. When combined with patients who chose the “Other” response category, it accounts for nearly one-quarter of the sample refusing morphine administration, indicating a notable level of resistance toward opioid-based pain management. Despite the long-standing use of opioids in cancer care, some patients continue to oppose treatments involving morphine or similar drugs. This form of opposition is well-documented among cancer patients, many of whom perceive morphine as a “last resort” treatment that signals the end of life, thereby intensifying their reluctance.26 A major obstacle in the hesitation to use opioids, is due to persistent myths and misconceptions.25,26,34,35 Stigma, both internal and external, is pervasive. Many patients reported feeling judged or misunderstood when using opioids, even when medically necessary.35–37 Moreover, patients often fear: addiction or just being labeled as addicts, developing tolerance to analgesics, and experiencing adverse side effects.25,26,34,35
Cancer pain management increasingly benefits from integrative and complementary approaches that address both physical discomfort and emotional distress. A systematic review by Ng and Sharma from 2021 examined clinical practice guidelines for cancer-related pain and found that out of 771 records, only 13 guidelines mentioned complementary and alternative medicine (CAM), and just 11 provided specific recommendations, covering therapies such as acupuncture, massage, herbal medicine, and mind-body interventions.38 For example, the American Society of Clinical Oncology has endorsed the use of complementary therapies—including meditation, yoga, and acupuncture—as supportive strategies for alleviating symptoms and side effects associated with breast cancer treatment.39
CAM remains a vital component of cancer care across diverse regions, as suggested by multiple studies and reviews.39–43 A comprehensive review confirms that CAM use among cancer patients is both widespread and increasing.42 This growth over the decades reflects evolving attitudes toward integrative care and a patient-driven interest in holistic approaches. A landmark European survey further highlights the extensive and varied use of CAM among cancer patients, with significant differences observed across countries.44 As motivation for CAM usage, in a systematic review encompassing 42 studies, nearly three-quarters of participants reported that their primary motivation for using CAM was the intention to cure or treat cancer.45 However, a more recent study from 2021 indicates a shift in purpose: CAM is increasingly used as a complementary tool to manage symptoms such as pain and decreased appetite, rather than as a primary treatment for cancer—reflecting a more pragmatic approach.41
These results align with those observed in the current cohort analysis, where approximately nine out of ten patients would consider alternative or non-pharmacological methods to avoid pain, with the vast majority expressing still a need for medical approval before pursuing such treatments. It is worth noting that, in the literature, disclosure rates of CAM usage to physicians have remained low, ranging from 21% to 35%.40,41,43 On the other hand physicians opposition towards CAM usage indicates a growing medical skepticism.40,42 This paradox—high patient interest, as observed also in our study, coupled with low disclosure and high physician opposition—underscores the need for improved dialogue and mutual understanding in clinical settings.
New methods to alleviate cancer pain, whether pharmacological or using neuromodulation techniques, are continually being researched.46–48 Several reviews have examined patient perceptions of neuromodulation therapies, indicating that repetitive transcranial magnetic stimulation (rTMS) is generally well accepted among psychiatric patients, while tDCS has shown similar acceptance in individuals with tinnitus, especially when it promises substantial symptom relief.49,50 Using an online survey, accompanied by a short informative note about tDCS, another study from 2022 explored how receptive individuals with poststroke aphasia are to tDCS and found that patients were generally open to its use.51 However, no studies to date have investigated the acceptance of tDCS among cancer patients.
In this first study on cancer patients’ acceptance of tDCS, the number of participants fully open to using this method was lower compared to patients open to using the other pain-relieving options as morphine or CAM. This small number of patients open to tDCS is even more significant when added to the number of negative responses, in which patients explicitly stated they would not consider trying it. Nevertheless, the proportion of participants (73.4%) who would use tDCS with a doctor’s approval remains significantly high. Moreover, the study found that neither demographic characteristics nor pain levels influenced whether cancer patients were open to using tDCS. Their responses were not statistically dependent on these factors.
Studies show that cancer patients are generally willing to participate in clinical trials when offered the opportunity, with participation rates ranging from 55% to as high as 88% depending on the context and how the trial is presented.51–55 Motivations often include the hope for personal benefit and a desire to help future patients, while common barriers include limited trial availability, strict eligibility criteria, and lack of understanding about the trial process.21,22,52,53 Research also highlights that patients who are well-informed about clinical trials are significantly more likely to participate, underscoring the importance of clear communication and education.22,54
The limited number of studies involving cancer patients and techniques such as tDCS and rTMS have demonstrated promising outcomes, including moderate to significant improvements in quality of life and minimal adverse effects reported by participants.16,55 Trials and projects such as: the PAINLESS project, STIMPAL trial, Neuromod-PCSCI study and the NESA trial demonstrates the interest to non-invasive neuromodulation, especially when conventional treatments have failed.19,20,56,57 As none of these trials have reported results, the patient’s willingness to participate in neuromodulation trials is unknown. The data resulted from the present study showed that a notable proportion of respondents indicated openness to participating in clinical trials, suggesting a general interest in exploring alternative pain management strategies. Our cohort responses suggest a general willingness to participate in studies involving either pharmacological (54%) or non-pharmacological interventions (52%). However, the proportion of patients who indicated they were likely or very likely to participate in a tDCS trial (42%) was comparatively lower, with a higher frequency of responses falling into the “very unlikely”, “unlikely” or “not sure” categories.
There were no statistically significant associations between patient characteristics and either openness to tDCS or willingness to participate in a tDCS trial. Specifically, pain-related variables—including average, worst, least, and completion pain—did not significantly influence attitudes toward tDCS. This suggests that pain severity alone may not be a decisive factor in shaping patient receptivity to neuromodulation interventions. Similarly, demographic factors such as age, gender, residential setting, marital status, and educational level were not significantly associated with either question outcome. Clinical variables—including ECOG performance status, cancer stage, and current pain treatment—also failed to show significant associations. This lack of differentiation suggests that clinical burden or treatment context does not substantially influence patients’ willingness to engage with tDCS. Taken together, these null findings indicate that openness to tDCS and trial participation may be governed by factors not captured in the present analysis, such as psychological readiness, or perceived innovativeness of the intervention. Future studies may benefit from incorporating qualitative assessments or psychometric measures to better elucidate the determinants of patient engagement with novel therapies.
A marked psychological ambivalence emerged when comparing encouraging motives with the factors that generated hesitation toward tDCS. In examining the motivations underlying patients’ consideration of tDCS for pain relief, findings reveal that approximately one-quarter of respondents (n = 34) are strongly inclined to pursue any available method to avoid pain. This represents the most prominent driver for accepting tDCS. The second most cited motivation pertains to the mechanism of action of tDCS—its modulation of brain activity—which appears to influence patients’ openness to the technique. Additionally, a subset of participants (n = 20) expressed a “nothing to lose” attitude, suggesting a willingness to try tDCS in the absence of other effective options. Remarkably, 22% of respondents (n = 31) reported that no factor would persuade them to consider tDCS and explicitly stated their unwillingness to use the method. This proportion exceeds the number of patients who responded negatively to the direct question regarding tDCS usage, indicating a deeper level of resistance when motivations are explored more broadly.
While a proportion of participants expressed strong openness to innovation—stating that they would try the method—some endorsed discouraging factors. With respect to factors contributing to patients’ resistance toward the use of tDCS, the most frequently cited barrier was a lack of a clear understanding regarding the underlying mechanism of action, reported by approximately one-third of respondents (n = 47). This was followed by a general reluctance to embrace novel interventions (n = 23) and a mistrust of non-pharmacological approaches to pain management (n = 21). Concerns specifically related to the use of electrical current were expressed by only 13% of participants (n = 19), while only a small minority (n = 4) perceived the technique as potentially harmful. Despite these reservations, a notable subset of patients (n = 26) indicated a clear willingness to consider tDCS as a viable method for pain relief. Together, these findings illustrate a tension between the desire for pain relief and the apprehension elicited by novel technologies.
A 2018 study demonstrated that expectations can significantly modulate the behavioral outcomes of tDCS. In this study, participants who were primed with high expectations showed greater cognitive improvements than those with low expectations, regardless of whether they received active or sham stimulation.58 Rabipour’s findings underlines the psychological dimension of neuromodulation, reminding us that the brain’s response to stimulation may not be purely physiological—but shaped by belief, anticipation, and context.58 These data suggest that when considering tDCS interventions it is essential to align recruitment and protocol strategies with ethical and patient-centered principles. Drawing on recommendations from the American Society of Pain and Neuroscience,59 a flexible trial design, including the potential for remote education and telemedicine-based follow-ups, to accommodate patients facing health-related barriers are already put in practice in the PAINLESS trial.20
Education is the cornerstone of acceptance. As information gaps are the fuel for hesitation, only by providing up-to-date and evidence-based information to professionals and patients could we hope for more openness.
On the consumer’s part, clear, structured explanations of how tDCS works, what patients can realistically expect, and how safety is ensured can substantially reduce fear and uncertainty. Integrating video demonstrations and patient-forum discussions with testimonials may further strengthen understanding and therefore grow acceptance.
As patients generally place considerable trust in their physicians and therefore follow the advice they receive, educational interventions for professionals should be focused on enhancing clinicians’ confidence and competence in applying tDCS. They could include seminars on neuromodulation techniques with mentorship from experienced practitioners, hands-on courses with practical training, as well as workshops focused on clinical indications, standardized protocols and interdisciplinary case-based discussions.

Strengths and Limitations
While this survey offers valuable insights into patient acceptance of pain strategies and trial participation within an oncology setting, its single-institution design introduces notable limitations. The findings may lack generalizability, as patients may not accurately represent the broader oncology population in terms of demographics, cultural attitudes, or access to healthcare services. Without data from multiple institutions, it is challenging to validate these findings or assess their applicability across diverse healthcare systems. To enhance the robustness and generalizability of future research, multi-center studies involving diverse patient populations and institutional settings are strongly recommended.
Despite its limitations, this study has notable strengths. The controlled setting also enabled close monitoring of participant eligibility and data quality, ensuring a high level of internal validity. Beyond being the first study on this topic, it offers valuable insights into patient attitudes toward tDCS in cancer care. We consider that the present study even a single-site investigation can be considered a foundational step in understanding emerging interventions before scaling to larger, more heterogeneous populations.

Conclusions
This study highlights the complex landscape of cancer pain perception and management among oncology patients in a Romanian clinical setting. Clinically significant pain was reported by slightly more than one-third of patients, with higher prevalence among those with metastatic disease and with altered functionality. Despite the availability of opioid treatments, a substantial proportion of patients expressed reluctance toward morphine use. In contrast, non-pharmacological and alternative methods—particularly those endorsed by physicians—were more widely accepted. While tDCS received moderate support, most patients indicated they would consider it only with medical approval. Notably, demographic and clinical variables, including pain intensity, did not significantly influence attitudes toward tDCS or willingness to participate in related clinical trials. These null findings suggest that receptivity to neuromodulation may be broadly distributed across patient subgroups and not readily predicted by conventional clinical or demographic variables.
Acceptance of tDCS is likely modifiable—many participants reported willingness to try the technique with physician endorsement—highlighting the importance of integrating structured patient‑education modules into future trials to support informed and confident decision‑making.
Moreover, these findings reinforce the need for personalized pain management strategies that emphasize the need for healthcare professionals to proactively discuss pain methods with patients, provide evidence-based guidance, and support integrative care approaches that respect patient preferences. Future research should consider integrating qualitative methods and psychometric assessments to better capture the nuanced determinants of treatment receptivity and pain-related interference.