Exploring the Interplay of Social Determinants of Health, Psychological Distress, Cancer-Related Worry, and Physical Activity in Predicting Pain Among Pediatric Acute Lymphoblastic Leukemia Survivors: Insights from the St. Jude LIFE Cohort Dataset

Abstract

Background: Acute Lymphoblastic Leukemia (ALL) is the leading childhood cancer diagnosis. Survivors of ALL often face long-term effects, such as chronic pain, psychological distress, and Cancer-Related Worry (CRW). While treatment-related effects are well-documented, the impact of Social Determinants of Health (SDoH) on pain outcomes in this population is less understood. Adverse SDoH may contribute to increased pain. Additionally, psychological distress, including CRW, may amplify these effects. Physical activity is widely recognized for its potential to promote health and resilience, often mitigating the adverse effects of social and psychological challenges on physical symptoms like pain. The current study investigated the interplay between SDoH, psychological distress, CRW, and physical activity in predicting pain among pediatric ALL survivors.

Methods: The study utilized cross-sectional data from the St. Jude LIFE study and included 1,433 survivors of pediatric ALL. Structural equation modeling (SEM) was employed to test five hypotheses involving mediation and moderation pathways between the variables of interest.

Results: The moderated mediation model showed good convergence and explained substantial variance in pain (R² = .620). Greater adverse SDoH were associated with a lower likelihood of reporting pain (β = −0.104, 95% CI [−0.135, −0.074]). Physical activity significantly moderated this relationship (β = 0.044, 95% CI [0.026, 0.061]), weakening the inverse association among those with higher activity levels. Similarly, more adverse SDoH predicted a lower likelihood of psychological distress (β = −0.100, 95% CI [−0.163, −0.036]) and CRW; β = −0.093, 95% CI [−0.147, −0.039]). Psychological distress and CRW interacted to increase pain likelihood (β = 1.369, 95% CI [1.179, 1.551]). Physical activity moderated these effects by amplifying the distress–pain link (β = 0.035, 95% CI [0.004, 0.068]) and buffering the CRW–pain link (β = −0.203, 95% CI [−0.242, −0.164]). A three-way interaction showed physical activity reduced the compounded effect of co-occurring CRW and distress on pain (β = −0.248, 95% CI [−0.282, −0.216]). Significant moderated indirect effects through psychological distress (β = −0.011) and CRW (β = 0.010) were also found.

Conclusion: This study elucidates how adverse SDoH, psychological distress, CRW, and physical activity interact to influence pain experiences in survivors of pediatric ALL. Contrary to expectations, survivors facing greater social adversity reported less pain, psychological distress, and CRW, suggesting potential resilience or alternative coping strategies within this group. Importantly, psychological distress and CRW jointly amplified pain, highlighting the substantial burden of co-occurring psychological symptoms. Physical activity played a nuanced role, sometimes intensifying the distress–pain link but buffering the impact of CRW on pain, and reducing the combined effect of distress and CRW on pain. These findings underscore the necessity for pain management interventions that move beyond biological treatment alone. Specifically, integrated care approaches should include screening for psychological distress and CRW, as their co-occurrence markedly increases pain risk. Physical activity programs may be most beneficial when tailored to the survivor’s psychological profile, potentially prioritizing psychological symptom reduction before or alongside activity promotion to maximize pain relief. Longitudinal studies are needed to track these dynamics over time and inform targeted, personalized survivorship care strategies.