Evaluation of the relationship between pain and other symptoms with cortisol, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) in patients with advanced-stage cancer experiencing pain, and assessment of changes in these parameters during the pain follow-up period

Purpose: The primary aim of our study is to measure cortisol and inflammatory parameter levels in patients with advanced-stage cancer experiencing pain, both before and after analgesic treatment; to evaluate pain and other symptoms using the Edmonton Symptom Assessment Scale (ESAS); to determine the relationships between these blood parameters and symptoms; and to compare the changes observed after treatment. Based on the data obtained, the study aims to elucidate the biological and symptomatic reflections of pain management strategies used in these patients and to contribute to the development of personalized and more effective pain control protocols. Methods: Following approval from the ethics committee, our study was designed as a cross-sectional and prospective investigation conducted between May 21, 2025, and December 1, 2025. The study included 42 patients with advanced-stage cancer experiencing pain who were hospitalized in the Palliative Care Unit of Tokat Gaziosmanpaşa University and met the predefined inclusion criteria, as well as 43 control group patients who applied to the Family Medicine Outpatient Clinic and also met the specified inclusion criteria. In the patient group, CRP, ESR, and cortisol levels were measured at the time of admission and after analgesic treatment. Changes in symptoms before and after treatment were also assessed using the Edmonton Symptom Assessment Scale (ESAS). Finding: Pre-treatment cortisol, ESR, and CRP levels differed significantly between the patient and control groups (p=0.000). When pre- and post-treatment CRP values were compared, no statistically significant change was observed in the patient group (p=0.157). Similarly, no statistically significant difference was found between pre- and post-treatment ESR values (p=0.175). In contrast, a statistically significant change was detected between pre- and post-treatment measurements in terms of cortisol levels (p=0.009). With regard to the ESAS pain score, a significant reduction was observed in the comparison between pre- and post-treatment assessments (p=0.001). In the patient subgroup that could be evaluated during follow-up, cortisol levels were found to decrease significantly at the second week after treatment. Correspondingly, significant improvements were observed in pain—most notably—as well as in fatigue, nausea, sadness, anxiety, insomnia, appetite loss, poor well-being, and the total ESAS score. In contrast, no statistically significant changes were detected in CRP, ESR, or dyspnea scores. When evaluated in terms of the total ESAS score, the ex group exhibited a significantly higher pre-treatment total symptom burden compared with the surviving group (p=0.014). Results: This study demonstrated the relationship between symptom burden and biomarkers in patients with advanced-stage cancer, as well as the effects of analgesic treatment on these parameters. The significantly higher pre-treatment levels of cortisol, CRP, and ESR in the patient group support the presence of a pronounced stress response and systemic inflammation in these patients. While no significant changes were observed in CRP and ESR levels in the post-treatment period, significant improvements were detected in cortisol levels and in ESAS components—particularly pain. Moreover, the finding that the pre-treatment total ESAS score was the only variable associated with survival independently of biomarkers indicates that baseline overall symptom burden has critical prognostic significance. These results suggest that comprehensive and systematic assessment of symptoms in patients with advanced-stage cancer should be a fundamental approach in palliative care practice, both for clinical monitoring and for prognostic estimation. Keywords: palliative care, cancer, pain, CRP, ESR, cortisol, ESAS