From the *Nursing Department, Indiana University-Fort Wayne (IUFW), Fort Wayne, IN, USA; † College of Nursing, Kent State University, Kent, OH, USA; ‡ Section of Palliative Medicine and Supportive Oncology, Department of Solid Tumor Oncology, Cleveland Clinic Taussig Cancer Institute, Cleveland, OH, USA; § The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic, Cleveland, OH, USA; { Faculty of Health Sciences, Trinity College, Dublin 2, Ireland; k Department of Biostatistics, Environmental Health Sciences and Epidemiology, College of Public Health, Kent State University, Kent, OH, USA. Address correspondence to Kawther Ismail Hamash, PhD, RN, Indiana University-Fort Wayne (IUFW), 2101 E. Coliseum Blvd., Liberal Arts Building, LA 345, Fort Wayne, IN 46805. E-mail: Khamash@iu.edu Received January 13, 2017; Revised February 28, 2018; Accepted May 10, 2018. The authors wish to thank Cleveland Clinic Foundation/Taussig Cancer Institute for sharing the deidentified dataset used in this study. The authors acknowledge Barbara Hullihen for helping in data acquisition. 1524-9042/$36.00 Ó 2018 by the American Society for Pain Management Nursing https://doi.org/10.1016/ j.pmn.2018.05.002 The Effect of the Pain Symptom Cluster on Performance in Women Diagnosed with Advanced Breast Cancer: The Mediating Role of the Psychoneurological Symptom Cluster --- Kawther Ismail Hamash, PhD, RN, * Wendy Umberger, PhD, RN, PMHCNS-BC, † Aynur Aktas, MD, ‡,§ Declan Walsh, MSc, FACP, FRCP (Edin), ‡,§ ,{ and Vinay K. Cheruvu, PhD, MS, MSc, PGD-MISCA k - ABSTRACT : Background: Pain, depression, anxiety, sleep disturbances, and con- stipation were reported in different symptom clusters at different stages of breast cancer. Managing symptom clusters rather than indi- vidual symptoms can improve performance status. Aim: The study examined the effect of pain symptom cluster (pain and constipation) on performance when mediated by the psychoneurological symptom cluster (depression, anxiety, and sleep disturbances) using age as a moderator. Design: A secondary analysis. Settings: Palliative care center at a tertiary medical center in northeast Ohio. Participants: Eighty-six women diagnosed with advanced breast cancer. Method: A quantitative cross-sectional approach. Results: Ordinal logistic regression showed that pain symptom cluster did not have a signifi- cant mediation effect on performance. Odds ratio indicated that sub- jects with pain symptom cluster were 63% more likely to be bedridden (odds ratio ¼ 1.63, confidence interval ¼ .69-3.84). Women who re- ported pain symptom cluster were 5% more likely to have psycho- neurological symptom cluster (odds ratio ¼ 1.05, confidence interval ¼ .400-2.774). Stratified analysis of age showed no differences in performance. Post-hoc analysis showed that the components of pain symptom cluster had a significant effect on psychoneurological symptom cluster (odds ratio: 3 [1.18-7.62]). Conclusions: Pain, Pain Management Nursing, Vol -, No - (--), 2018: pp 1-10 Original Article