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Systematic Review

Update on Prevalence of Pain in Patients with Cancer 2022: A Systematic Literature Review and Meta-Analysis

Rolf A. H. Snijders
Linda Brom
Maurice Theunissen
3,4 and
Marieke H. J. van den Beuken-van Everdingen
Department of Research & Development, Netherlands Comprehensive Cancer Organisation (IKNL), 3511 DT Utrecht, The Netherlands
Netherlands Association for Palliative Care (PZNL), 3511 DT Utrecht, The Netherlands
Centre of Expertise for Palliative Care, Maastricht University Medical Centre+ (MUMC+), 6229 HX Maastricht, The Netherlands
Department of Anaesthesiology and Pain Management, Maastricht University Medical Centre+ (MUMC+), 6229 HX Maastricht, The Netherlands
Author to whom correspondence should be addressed.
Cancers 2023, 15(3), 591;
Submission received: 23 December 2022 / Revised: 13 January 2023 / Accepted: 14 January 2023 / Published: 18 January 2023
(This article belongs to the Special Issue Cancer-Related Pain)



Simple Summary

Pain associated with cancer diagnoses is a serious concern and one of the most common symptoms reported by cancer patients. The insufficient relief of cancer pain can have a major impact on patients’ quality of life. Recent developments in oncology such as new pain management guidelines, drugs and treatment strategies may have had a positive effect on the prevalence and severity of pain. Therefore, the aim of this systematic literature review was to assess the prevalence of pain and pain severity in cancer patients throughout all phases of treatment in the 2014–2021 literature period. Our results show a decline in both the prevalence and severity of cancer pain, compared to previous research. Nevertheless, with 44.5% of cancer patients still experiencing pain, the prevalence remains high, emphasizing the need for ongoing attention regarding the management of cancer pain.


Experiencing pain and insufficient relief can be devastating and negatively affect a patient’s quality of life. Developments in oncology such as new treatments and adjusted pain management guidelines may have influenced the prevalence of cancer pain and severity in patients. This review aims to provide an overview of the prevalence and severity of pain in cancer patients in the 2014–2021 literature period. A systematic literature search was performed using the databases PubMed, Embase, CINAHL, and Cochrane. Titles and abstracts were screened, and full texts were evaluated and assessed on methodological quality. A meta-analysis was performed on the pooled prevalence and severity rates. A meta-regression analysis was used to explore differences between treatment groups. We identified 10,637 studies, of which 444 studies were included. The overall prevalence of pain was 44.5%. Moderate to severe pain was experienced by 30.6% of the patients, a lower proportion compared to previous research. Pain experienced by cancer survivors was significantly lower compared to most treatment groups. Our results imply that both the prevalence of pain and pain severity declined in the past decade. Increased attention to the assessment and management of pain might have fostered the decline in the prevalence and severity of pain.

1. Introduction

Each year, more than ten million people worldwide are diagnosed with cancer [1]. Pain associated with cancer diagnoses is a serious concern and one of the most common symptoms reported by cancer patients. Experiencing pain and insufficient relief can be devastating and negatively affect a patient’s performance status and emotional well-being, leading to increased anxiety, anger, feelings of depression and even cognitive dysfunction, reducing a patient’s quality of life [1,2,3,4,5,6].
Despite increased attention to the assessment and management of pain in cancer patients, previous research concluded that no major advances have been made in the management of cancer pain in 50 years [7,8]. A recent systematic literature review on the prevalence of pain during cancer treatment by Evenepoel et al. (2022) showed that pain during cancer treatment remains high during and up to three months after curative cancer treatment [9].
Literature indicates several reasons for the lack of improvement in the prevalence of cancer pain. Common professional barriers include a lack of knowledge and skills, clinicians’ reluctance to prescribe opioids, and poor pain assessment [10]. Patient-related barriers include patients’ reluctance to discuss pain with clinicians, patients’ reluctance to receive treatment for their pain, adherence to analgesic prescriptions, limited knowledge on the assessment of undertreatment, and cognitive and psychological factors of patients such as depression [11,12]. A systematic literature review by Makhlouf and colleagues (2020) found similar attitudinal barriers to effective cancer pain management among professionals and patients, including fear of medication addiction, tolerance of medication, and side effects of opioids [13].
Global trends may have influenced the prevalence of cancer pain. People worldwide are living longer, and ageing populations are associated with increased multimorbidity [14,15,16]. Developments in oncology, including new drugs and treatment strategies, may also have influenced the prevalence of cancer pain and pain severity [17,18,19,20]. Global opioid analgesics use increased between 2015 and 2019, but regional variations exist [21]. This was probably influenced by the response to the opioid epidemic [22,23]. Chen et al. (2022) performed a study on opioid use among cancer patients in the United States and showed a declining trend between 2013 and 2018 [24]. This could potentially lead to further undertreatment of cancer pain. On the other hand, the publication of new pain therapy guidelines may have improved the management of cancer pain [25,26,27].
Many new studies have been published on the prevalence of cancer pain since the 2016 systematic literature review of van den Beuken-van Everdingen et al. The review of Evenepoel et al. (2022) was limited to cancer patients receiving curative treatment, excluding other phases of the disease. Therefore, the aim of this systematic literature review was to assess the prevalence of cancer pain and pain severity in cancer patients throughout all phases of the disease.

2. Material and Methods

A systematic literature review was performed in accordance with the recommendations of the “Preferred Reporting Items for Systematic Reviews and Meta-analyses” (PRISMA) guidelines [28].

2.1. Search Strategy

A systematic electronic search of the literature published from January 2014 until December 2021 was performed on the 19th of January 2022 using the databases PubMed, Embase, CINAHL, and Cochrane. The search string was inspired by the search strings of van den Beuken-van Everdingen et al. (2016), Evenepoel et al. (2022) and Rietjens et al. (2019) [7,9,29]. Important search terms were “pain”, “symptom”, “prevalence”, and “cancer”. The search string was initially developed for PubMed and later adapted for the other databases: Embase, CINAHL, and Cochrane. More details of the search strategy can be found in Supplemental S1.

2.2. Study Selection

After identification and exclusion of duplicates, one author (R.A.H.S.) screened the titles and abstracts. Full texts of selected studies were examined by all four authors (R.A.H.S., L.B., M.T., and M.H.J.v.d.B.-v.E.) regarding the eligibility criteria. Studies that reported on the prevalence of cancer pain were eligible for inclusion. Inclusion of studies was based on the design, including original studies and secondary analyses of studies in which the patient group had not been included yet, population (studies that included patients ≥18 years, studies reporting on pain, and differentiating between cancer and noncancer patients), setting (including inpatient, outpatient, and palliative care facility (e.g., hospice, palliative care unit, and referred to a palliative care service)), while studies performed in pain clinics/including only patients with pain were excluded (Figure 1). In case of doubt about whether or not to include a study, the study in question was discussed among the authors until consensus was reached.
Corresponding authors of studies that met the inclusion criteria were contacted by e-mail to obtain missing information on the prevalence of pain. If this information remained unclear after a term of two weeks, the respective percentages of pain were estimated based on study figures.

2.3. Data Extraction

A standard extraction form was developed for consistent data extraction across the authors. General characteristics were listed for each study and included the author(s), year of publication, continent of origin, study design, method of data collection, aim of the study, and the sample size. Study population characteristics included: ethnicity, gender, age, setting (inpatient, outpatient, patient in palliative care facility), Eastern Cooperative Oncology Group performance status (ECOG), and the type of cancer (head and neck, oesophagus, bronchus/lung, breast, pancreatic, other gastro-intestinal, prostate, other urological, ovary, uterus, other gynaecological, haematological, and other). Studies that included >3 types of cancer were registered as such.
Phases of the disease trajectory were registered and used to categorise studies. Nine groups were defined. Group 1—treatment-naïve cancer patients; Group 2—including cancer patients receiving curative treatment; Group 3—including cancer patients receiving palliative treatment; Group 4—including patients with either curative or palliative treatment, or treatment intent not specified; Group 5—including patients after curative cancer treatment; Group 6—including patients for whom anti-cancer treatment is no longer feasible or wanted; Group 7—including patients in different phases of treatment; Group 8—including patients on anti-cancer treatment (Group 2, Group 3 and Group 4); Group 9—including patients with advanced, metastatic or terminal disease (Group 3 and Group 6).
With regard to the experience of pain, the main percentage of pain (%) in a study was extracted. In cases where a study reported on different types of pain (e.g., headache, abdominal pain, and joint pain) and did not report an overall percentage of pain, the highest percentage was registered. In addition, pain severity was extracted and registered as prevalence (%) of mild, moderate, moderate–severe, and severe pain. In case the severity of pain was not specified in the study and presented with Visual Analogue Scale (VAS) or Numeric Rating Scale (NRS), the rating of Serlin et al. (1995) was applied: none (0), mild (1–4), moderate (5–6), and severe (≥7) [30]. Finally, the pain recall period was extracted (point prevalent, week(s), month(s), year(s)).

2.4. Methodological Quality

The quality of the included studies was assessed by all four authors (R.A.H.S., L.B., M.T., M.H.J.v.d.B.-v.E.) using the scoring criteria presented in Table 1. These criteria were also used in the systematic literature review of van den Beuken-van Everdingen et al. (2016) and based on LeBoeuf-Yde and Lauritsen (1995), including criteria developed to assess the methodological quality for prevalence studies [31]. The criteria relate to the representativeness of the study sample (three items); quality of the data (three items); description of the methods and results (three items); and a definition of the prevalence of pain (one item), resulting in a methodological quality score ranging from 0–20 points. Studies were included in this systematic literature review regardless of the methodological quality score.

2.5. Data Analyses

Descriptive statistics are presented for both studies with <15 points, and studies with ≥15 points on the methodological quality assessment. Details of the studies scoring <15 points on the methodological quality assessment can be found in Supplemental S2.
A meta-analysis was performed on the included studies using STATA (version 17.0, StataCorp Texas). The meta-analysis included studies with ≥15 points, a defined sample size, and pain prevalence or proportion of moderate to severe pain reported. Prevalence rates were pooled for each defined patient group with reference to pain, and pain severity (moderate–severe pain). The reciprocal of variance was chosen as a weighting factor to reflect the amount of information that each study contained as it is closely related to the study’s sample size [32]. The 95% Confidence Interval (CI) of each prevalence rate was calculated with the formula: p ± z. √((p(1-p)/n) with p being the pain prevalence rate (p = x/n), with a z-value of 1.96 for a 95% CI. To analyse if the variation in prevalence rates between studies was due to more than chance alone, the grade of heterogeneity was assessed by performing a chi-square test (I2). If the heterogeneity test was significant (p < 0.05), extra variation was incorporated into the analysis by use of the random-effects model. If the prevalence of pain was 100%, the percentage was set as 99.9% in the analysis to avert statistical issues.
A meta-regression analysis was performed to explore if the pooled pain prevalence rates differed significantly between the patient groups. In addition, meta-regression analyses were also used to explore the association between the prevalence of pain and the type of cancer, ECOG score, age of the population, ethnicity, continent of origin, recall period, setting and method of data collection. The coefficient in the meta-regression analysis indicates how each subgroup differs from the nominated reference group; a negative coefficient in each subgroup suggests a lower prevalence of pain compared to the reference. A number of cancer types were regrouped for the analyses; pancreatic and other gastro-intestinal were regrouped as gastro-intestinal; ovary, uterus and other gynaecological were regrouped as gynaecological cancers.

3. Results

3.1. Study Selection

The electronic literature search identified 13,483 studies; PubMed yielded 3227 studies, Embase 8340 studies, CINAHL 1200 studies, and Cochrane 716 studies. After the exclusion of duplicates, titles and abstracts of 10,637 studies were screened, of which 1147 were selected for a full text evaluation. The full text assessment resulted in the inclusion of 444 studies. An overview of the reasons for exclusion is presented in Figure 1. Authors (n = 6) were e-mailed to obtain missing prevalence data, of which pain prevalence was estimated in five studies because they did not respond.

3.2. Study Characteristics

This systematic literature review includes 444 studies, of which 160 studies had <15 points on the methodological quality assessment. Of the 160 studies that scored <15 points on the methodological quality assessment, most were performed in North America (n = 46), and the least in Australia/New Zealand (n = 6). In 24 studies, the primary objective was to evaluate the prevalence of pain in cancer patients. Most studies included solely gastro-intestinal cancer patients (n = 20) and 54 studies included patients of more than three types of cancer (Supplemental S2).
This systematic literature review included 284 studies with a quality score of ≥15 points (Table 2, Table 3, Table 4, Table 5, Table 6, Table 7 and Table 8). Of the studies with a quality score of ≥15 points, most were performed in Europe (n = 97), and the least in Africa (n = 7). In 99 studies, the primary objective was to evaluate the prevalence of pain in cancer patients; 185 studies focused on another primary study objective (e.g., quality of life, predictors of depression, fatigue or sleeping problems). Most studies included solely breast cancer patients (n = 72), and 91 studies included patients of more than three types of cancer. Two hundred seventy-seven studies of the 284 with a quality score of ≥15 points were included in the meta-analysis.

3.3. Prevalence of Pain

The meta-analysis of the pooled pain prevalence rates including all groups (Group 1–Group 7) resulted in an overall pain prevalence of 44.5% (95% CI 41.1–47.9). The pooled pain prevalence rates from the group analyses are presented in Table 9. Forest plots of the meta-analysis on the pooled pain prevalence rates (effect size (ES)) can be found in Supplemental S3.
Patients in both the group after curative treatment (Group 5) and the treatment-naïve group (Group 1) experienced less pain compared with patients in the palliative treatment group and the group without feasible anti-cancer treatment, respectively Group 3, p = 0.000, and p = 0.031; and Group 6, p = 0.001, and p = 0.038. Furthermore, the prevalence of pain was significantly lower in the group after curative treatment (Group 5) compared with the group receiving curative treatment (Group 2, p = 0.005), the group receiving all kinds of treatment (Group 4, p = 0.001), and the group including patients in different phases of treatment (Group 7, p = 0.006).

3.4. Pain Severity

The meta-analysis of the pooled pain severity including all treatment groups (Group 1–Group 7) resulted in a prevalence of moderate to severe pain of 30.6% (95% CI 26.9–34.4). The results of the group analyses on the pooled moderate to severe pain prevalence rates are presented in Table 9.
Patients in both the palliative treatment group (Group 3) and the group without feasible anti-cancer treatment (Group 6) experienced more moderate to severe pain compared with patients included in the all-treatments group and the group after curative treatment, respectively; Group 4, p = 0.035 and, p = 0.023; and Group 5, p = 0.006, and p = 0.005. In addition, the prevalence of moderate to severe pain was significantly higher in the group including patients in different phases of treatment (Group 7) compared with the group including patients after curative treatment (Group 5, p = 0.030).

3.5. Determinants of Pain Prevalence

The results of the meta-regression analyses that included all treatment groups (Group 1–Group 7) are presented in Table 10. The prevalence of pain in patients with prostate cancer was significantly lower than in patients with haematological, lung, and breast cancer (p = 0.034, p = 0.039, and p = 0.036 respectively). Age, ethnicity, and performance status (ECOG) were not associated with the overall prevalence of pain (p > 0.05). Recall periods of a week(s) (p = 0.013) or a month(s) (p = 0.001) did result in lower pain rates compared with using point prevalence. Studies that used medical records for data collection showed significantly higher pain rates than studies that used a patient questionnaire (p = 0.007). The prevalence of pain in patients who stayed in a palliative care setting was significantly higher compared to the prevalence of pain in outpatients (p = 0.040). Studies from South America, Asia and Africa showed significantly higher pain rates compared to studies from Europe (p = 0.033, p = 0.016 and p = 0.000 respectively). Moreover, studies from Africa showed a significantly higher prevalence of pain compared to studies from all other continents, North America (p = 0.000), Asia (p = 0.000), South America (p = 0.014) and Australia/New Zealand (p = 0.000).

4. Discussion

The current literature on the prevalence of pain and pain severity in patients with cancer shows that both the prevalence of pain and pain severity have declined over the past decade. Pooled pain prevalence rates resulted in an overall prevalence of 44.5%. The treatment group with the lowest prevalence of pain was the group after curative treatment (35.8%). Despite the decline found, the results of this systematic literature review show that the prevalence of pain remains high, especially in advanced, metastatic and terminal cancer patients (54.6%).
The meta-analysis of moderate to severe pain resulted in an overall prevalence of 30.6%. The treatment group with the lowest proportion of moderate to severe pain was the group after curative treatment (22.8%). Moderate to severe pain was most frequently reported in the group including patients without feasible anti-cancer treatment (43.3%).
Some findings deserve attention. First, a slight decrease in the prevalence of pain was found compared with the 2016 systematic literature review by van den Beuken-van Everdingen et al. for the group after curative treatment (35.8% < 39.3%), and for the group during anti-cancer treatment (50.3% < 55.0%) [7]. A more substantial decrease was found for the advanced, metastatic or terminal disease group (54.6% < 66.4%). Our systematic review resulted in a pooled prevalence of 47.8% during curative treatment, which is higher than the 40% found by Evenepoel et al. (2022) [9]. A possible explanation can be found in different inclusion criteria. In contrast to Evenepoel et al. (2022), we did include unsolid tumours and studies conducted in nursing homes. The proportion of cancer types may also have been influential, as Evenepoel et al. (2022) included 12 studies of which ten included breast cancer patients (83%). The proportion of studies that included breast cancer patients in our review was high, but lower compared to the review of Evenepoel et al. (2022).
Second, the prevalence of moderate to severe pain decreased (30.6% < 38.0%) compared with the rate presented in the study by van den Beuken-van Everdingen and colleagues (2016) [7]. In contrast to the 2016 systematic literature review, our meta-analysis did include treatment-naïve patients, and patients after finishing curative treatment. This affects the overall prevalence of moderate to severe pain as this is lower in patients after curative treatment [7].
Several factors may have played a role in the decrease in the prevalence of pain and pain severity in cancer patients. In the literature review of Kwon (2014), the suggestion is made that a multidirectional interdisciplinary approach might be the best way to improve cancer pain management [10]. Therefore, more, and better collaboration between healthcare professionals from different disciplines involved in the patients’ treatment may have led to better management of cancer pain. Shrestha et al. (2022) conducted a systematic literature review and meta-analysis on the effect of pharmacists’ involvement in cancer pain management. Their results showed that pharmacists significantly improved cancer patients’ clinical outcomes related to pain. The direct involvement of pharmacists, or in collaboration with a multidisciplinary oncology team, is highly beneficial for patients [316].
The observed decrease in cancer pain prevalence and pain severity may also be positively impacted by raised awareness and knowledge of healthcare professionals about cancer pain treatment and the publication of new pain therapy guidelines [26,27]. However, there is still room for improvement as the literature indicates that there is a difference in knowledge between healthcare professionals and among professionals from different countries [317,318]. Our results showed that the prevalence of cancer pain was significantly higher in South America, Asia and Africa than in Europe. Silbermann and colleagues have shown that the majority of patients with cancer in low-income countries are undertreated for their pain, partly due to a lack of appropriate education [318]. Furthermore, compared with nurses, physicians have more knowledge about pain management, while both lack knowledge regarding the side effects and pharmacology of opioids [317]. Moreover, a systematic literature review on cancer pain management showed that most oncology nurses have poor knowledge about cancer pain management [319].
Furthermore, in line with our results, previous research on the prevalence of undertreatment of pain in cancer patients indicate that undertreatment of pain decreased over time [320,321,322]. In 2008 and 2014, two systematic literature reviews were published in which the prevalence of undertreatment of pain in cancer patients was 43% and 32%, respectively [320,321]. In 2022, an updated review was published including studies published from 2014 to 2020 that showed a mean weighted prevalence score for undertreatment of 40.2% [322].
Developments in oncology, including new drugs and treatment strategies, may also have had a positive impact on the prevalence of cancer pain and pain severity. Targeted therapy and immunotherapy changed the paradigm of cancer treatment. Compared to conventional chemotherapy, these treatment strategies more subtly reduce and control tumour growth, achieving better survival outcomes and improving patients’ quality of life [323,324]. The literature indicates that patients treated with immunotherapy have less cancer pain and reduced pain severity. For example, the study of Zhou and colleagues showed reduced opioid use and cancer pain scores after adoptive immunotherapy with autologous T-cell infusions [325]. They recommend controlled clinical studies to clarify the relationship between immune cell-mediated immunotherapy and pain relief.

Strengths and Limitations

A strength of this systematic literature review is its scope, including cancer patients at all stages of the disease. This allowed us to examine differences in the prevalence of pain and pain severity between treatment groups.
However, this systematic literature review has some limitations that should be taken into account when interpreting the results. First, not every study used the criteria of Serlin et al. (1995) for defining mild, moderate or severe pain [30]. This has led to differences in pain severity as the cut-off score for mild and moderate pain differed between these studies. Furthermore, some studies did not describe the severity of pain, or gave an overall prevalence of pain but described multiple types of pain (e.g., headache, abdominal pain, and joint pain). In these cases, the highest percentage of pain was used. Almost no studies mentioned the type of pain (nociceptive, neuropathic, mixed). Another methodological consideration relates to the meta-regression analyses of the determinants of pain. To obtain a more robust statistical analysis with more data, we chose to perform the meta-regression analyses on all studies regardless of treatment group. If a cancer type is over-represented in a treatment group with respectively low or high pain prevalence, this affects the overall prevalence of pain in that cancer type.
Although our analyses did not allow us to draw conclusions about detailed subgroups, this review provides a valuable overview of cancer pain prevalence and pain severity over the past decade.

5. Conclusions

In conclusion, this systematic literature review shows that both the prevalence of pain and pain severity have declined in the past decade. The development of new treatment strategies and increased attention on assessment and management of pain may have facilitated the decreases in the prevalence and severity of pain. However, with more than half of the patients experiencing pain, the prevalence in advanced, metastatic and terminal patients remains high. To further decrease the prevalence of pain and pain severity, ongoing attention and improved educational programs on cancer pain management are needed.

Supplementary Materials

The following supporting information can be downloaded at:, Supplemental S1: Search strategy.; Supplemental S2: Studies that scored <15 point on the methodological quality assessment [326,327,328,329,330,331,332,333,334,335,336,337,338,339,340,341,342,343,344,345,346,347,348,349,350,351,352,353,354,355,356,357,358,359,360,361,362,363,364,365,366,367,368,369,370,371,372,373,374,375,376,377,378,379,380,381,382,383,384,385,386,387,388,389,390,391,392,393,394,395,396,397,398,399,400,401,402,403,404,405,406,407,408,409,410,411,412,413,414,415,416,417,418,419,420,421,422,423,424,425,426,427,428,429,430,431,432,433,434,435,436,437,438,439,440,441,442,443,444,445,446,447,448,449,450,451,452,453,454,455,456,457,458,459,460,461,462,463,464,465,466,467,468,469,470,471,472,473,474,475,476,477,478,479,480,481,482,483,484,485].; Supplemental S3: Forest plots [33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,52].

Author Contributions

Conceptualization, R.A.H.S., L.B., M.T. and M.H.J.v.d.B.-v.E.; methodology, R.A.H.S., L.B., M.T. and M.H.J.v.d.B.-v.E.; software, R.A.H.S.; validation, R.A.H.S., L.B., M.T. and M.H.J.v.d.B.-v.E.; formal analysis, R.A.H.S.; investigation, R.A.H.S., L.B., M.T. and M.H.J.v.d.B.-v.E.; data curation, R.A.H.S.; writing—original draft preparation, R.A.H.S.; writing—review and editing, R.A.H.S., L.B., M.T. and M.H.J.v.d.B.-v.E.; visualization, R.A.H.S.; supervision, L.B. and M.H.J.v.d.B.-v.E.; project administration, R.A.H.S. All authors have read and agreed to the published version of the manuscript.”


This research received no external funding.

Conflicts of Interest

The authors declare no conflict of interest.


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Figure 1. PRISMA flow diagram of study selection.
Figure 1. PRISMA flow diagram of study selection.
Cancers 15 00591 g001
Table 1. Methodological quality criteria for prevalence studies.
Table 1. Methodological quality criteria for prevalence studies.
A. Representatives of population1. At least one of the following should apply for the study: an entire target population, randomly selected sample, or sample stated to represent the target population (two points)
2. At least one of the following: reasons for nonresponse described, non-responders described, comparison of responders and non-responders, or comparison of sample and target population (two points)
3. Response rate ≥90% (two points)
Response rate 70–90% (one point)
Response rate ˂70% (zero points)
B. Quality of data4. Were the primary data from a prevalence study (two points) or were they taken from a survey not specifically designed for the purpose (one point)?
5. The same mode of data collection should be used for all subjects (two points), if not (zero points).
6. The data have been collected directly from the patient by means of a validated questionnaire/interview (three points), no validated questionnaire/interview (two points), data have been collected from proxies or retrospectively from medical record (zero points)
C. General description of method and results7. Description of the target population and setting where patients were found (two points)
8. Description of stage of disease (one point)
9. Description of type of cancer, gender, and age: all (two points), 2 of 3 (one point), 1 of 3 (zero points)
10. Final sample size (one point)
D. Definition of pain prevalence11. Prevalence recall periods should be stated (one point)
Table 2. Pain prevalence in treatment-naïve cancer patients (Group 1) (n = 20).
Table 2. Pain prevalence in treatment-naïve cancer patients (Group 1) (n = 20).
% Pain
StudyQualityContinent aSetting bCancer cMean AgeSampleNoneMildModerateModSev dSevereOverall
Alt-Epping, 2016 [33]162 260.62222.718.245.559.113.677.3
Andersen, 2014 [34]16225 13360 7 37
Bibby, 2019 [35]15221164229 43.7
Efficace, 2015 [36]161,2,321070.022804543.2 11.8 55
Esser, 2017 [37]15221050.4239 15
Gjeilo, 2020 [38]1821,2465.826460 40
Godby–a, 2021 [39]
Godby–b, 2021 [39]
Hong, 2015 [40]1531662.18165 62.4
Kirchheiner, 2015 [41]17229 50 6.0
Kuon, 2019 [42]1722463.6208 34.6
Lunde, 2019 [43]1822967.2207 16.9
Ravn Munkvold, 2018 [44] 18212 507483012221052
Roy, 2016 [45]1632456.436 47.2
Russo, 2018 [46]1722252.7527 12.5
Salwey, 2020 [47]192 2 6026.720 53.3 73.3
Tang, 2015 [48]18611155.19146.8 21.1 63.2
Thomas, 2017 [49]1512166105 63
Wang, 2021 [50]1632550.9988 4.5
Williams, 2021 [51]1512670.1364 45.1
Yao, 2020 [52]15127 8369.
a 1 = North America; 2 = Europe; 3 = Asia; 4 = South America; 5 = Africa; 6 = Australia/New Zealand; b 1 = inpatient; 2 = outpatient; 3 = patient in a palliative care setting; 4 = all; 5 = other; c 1 = >3 types of cancer; 2 = head and neck; 3 = oesophagus, 4 = bronchus/lung; 5 = breast; 6 = gastro-intestinal; 7 = prostate; 8 = other, urological; 9 = gynaecological; 10 = haematological; 11 = other; d moderate–severe pain.
Table 3. Pain prevalence in patients with curative treatment (Group 2) (n = 34).
Table 3. Pain prevalence in patients with curative treatment (Group 2) (n = 34).
% Pain
StudyQualityContinent aSetting bCancer cMean AgeSampleNoneMildModerateModSev dSevereOverall
Andersen, 2014 [34]16225 13320 26 78
Berliere–a, 2021 [53]
Berliere–b, 2021 [53]
Bretschneider, 2016 [54]1612958.115253.429.78.816.98.146.6
Browall, 2017 [55]1722559124 67
Calderon, 2019 [56]1522553.2240 4.2
Choo, 2019 [57]1732560.35192 59.9
de Menezes Couceiro, 2014 [58]1642554250 44.4
Dylke, 2015 [59]1562555157 83
El-Aqoul, 2018 [60]1731147.680043.6 e 56.4
Fenlon, 2014 [61]1622557455 53
Fjell, 2020 [62]1622549150 42.5
Hagiwara–a, 2018 [63]
Hagiwara–b, 2018 [63]
Haryani, 2018 [64]1632150.51207 38.217.922.74.860.87
Ho, 2015 [65]1532549133 24
Hong, 2014 [66]1631151.24121788 12
Jarden, 2021 [67]16211053.170 55.2
Jensen, 2018 [68]1722949117660.626.
Khan–a, 2017 [69]
Khan–b, 2017 [69]
Kim, 2016 [70]1631550.314998.8 e 91.2
Kirchheiner, 2015 [41]17229 50 42.0
Kirkham, 2018 [71]151155024 54
Lewis, 2015 [72]1662161276 55.0
Lewis, 2021 [73]18322 600 45.2
McFarland, 2018 [74]1512555.4125 19.5
Moloney, 2016 [75]1661554.2121 24 46.2
Nogueira de Oliveira Martins–a, 2017 [76]
Nogueira de Oliveira Martins–b, 2017 [76]
Okamoto, 2018 [77]173255912348.842.38.9145.151.2
Ribas, 2020 [78]1522965109 20.1
Røhrl, 2016 [79]1722660.768 44.1
Shaulov, 2019 [80]1611,21049.131851.38.322.940.417.549.2
Tran, 2020 [81]1631657.7197 87
Wang, 2021 [50]16325 80 12.5
Xu–a, 2020 [82]
Xu–b, 2020 [82]
Xu–c, 2020 [82]
Yi, 2018 [83]1632553.5611013.661.82024.54.586.4
a 1 = North America; 2 = Europe; 3 = Asia; 4 = South America; 5 = Africa; 6 = Australia/New Zealand; b 1 = inpatient; 2 = outpatient; 3 = patient in a palliative care setting; 4 = all; 5 = other; c 1 = >3 types of cancer; 2 = head and neck; 3 = oesophagus, 4 = bronchus/lung; 5 = breast; 6 = gastro-intestinal; 7 = prostate; 8 = other, urological; 9 = gynaecological; 10 = haematological; 11 = other; d moderate–severe pain; e none–mild pain.
Table 4. Pain prevalence in patients with palliative treatment (Group 3) (n = 22).
Table 4. Pain prevalence in patients with palliative treatment (Group 3) (n = 22).
% Pain
StudyQuality Continent aSetting bCancer cMean AgeSampleNoneMildModerateModSev dSevereOverall
Agarwal, 2020 [84]1533146.81104.524.538.270.932.795.5
Al-Zahrani, 2014 [85]183315612414.5 43.585.5
Blank, 2018 [86]15121 1307.746.292.446.2100 *
Bouché, 2018 [87]17226 151 22.5
Bullock, 2017 [88]16126 40 80
Green, 2015 [89]17127 396 682
Iwase, 2015 [90]1632163.518310.525.427.664.136.589.5
Jespersen, 2021 [91]162210 9213.023.956.563.06.586.9
King, 2018 [92]151,2,3,62962.590320.538.523.14117.979.5
Koldenhof–a, 2014 [93]
Koldenhof–b, 2014 [93]
Lavdaniti, 2018 [94]1721163.812341.5017.158.541.458.5
LeBlanc, 2015 [95]161246397 22.7329.3
Lechner, 2016 [96]1611,21 62 25.8
Madsen, 2017 [97]17221163112 45
McFarland, 2017 [98]15121057.7117 21.5
Mercadante–a, 2016 [99]
Mercadante–b, 2016 [99]
Mercadante–c, 2016 [99]
Mercadante–d, 2016 [99]
Røhrl, 2016 [79]1722665.552 59.6
Sampogna–a, 2019 [100]
Sampogna–b, 2019 [100]
Selvy, 2021 [101]17221066.767 59.7
Steel, 2016 [102]151 161261 31.7
Walling, 2015 [103]151 4,6 5422 15 48.2
Zhou–a, 2017 [104]1712151.4119 19.3
Zhou–b, 2017 [104]1712149.642 19.0
Zhou–c, 2017 [104]1712150.293 43.0
Zhou–d, 2017 [104]1712148.752 50.0
a 1 = North America; 2 = Europe; 3 = Asia; 4 = South America; 5 = Africa; 6 = Australia/New Zealand; b 1 = inpatient; 2 = outpatient; 3 = patient in a palliative care setting; 4 = all; 5 = other; c 1 = >3 types of cancer; 2 = head and neck; 3 = oesophagus, 4 = bronchus/lung; 5 = breast; 6 = gastro-intestinal; 7 = prostate; 8 = other, urological; 9 = gynaecological; 10 = haematological; 11 = other; d moderate–severe pain; * 99.9% in meta-analysis.
Table 5. Pain prevalence in patients with either curative or palliative treatment, or treatment intent not specified (Group 4) (n = 36).
Table 5. Pain prevalence in patients with either curative or palliative treatment, or treatment intent not specified (Group 4) (n = 36).
% Pain
StudyQuality Continent aSetting bCancer cMean AgeSampleNoneMildModerateModSev dSevereOverall
Abu-Saad Huijer, 2015 [105] 1632154.32190 45.3
Bernardes, 2019 [106]1561,21 1258110 10 20
Chan, 2015 [107]163 1157.379 25.3
Chen, 2021 [108]15321041.7132 57.6
Cheng, 2021 [109]15325 127 21.3
Damm, 2020 [110]1621,26 139 43.917.918.60.763
Fujii, 2017 [111]1932160.852446.239.97.613.96.353.8
Gosselin, 2016 [112]15126 27548242828052
Han, 2019 [113]1512157.9399 59.4
Joseph, 2021 [114]15521 34714.121.948.76415.385.9
Kim, 2015 [115]1532160.02167 25.7 92.8
Kuperus, 2021 [116]15128 1137414.78.811.32.526
Lee–a, 2016 [117]
Lee–b, 2016 [117]
16 f
31 f
Li, 2017 [118]153 155.3631760.2529.025.3610.415.0539.43
Llamas Ramos, 2016 [119]1522159.98246 13.424.43712.650.4
Matsumoto, 2020 [120]19326 45 55.6
Molassiotis, 2019 [121]162,31,2155.15343 14.2
Moye, 2014 [122]161 2,3,664.66170 21.632.410.8
Pearce–a, 2017 [123]
Pearce–b, 2017 [123]
Pearce–c, 2017 [123]
Pérez, 2015 [124]1722160.735845.8 26.3 54.2
Pettersson, 2014 [125]1622665104 41
Raj, 2014 [126]1922160305 48.2
Ritchie–a, 2014 [127]
Ritchie–b, 2014 [127]
Ritchie–c, 2014 [127]
Ritchie–d, 2014 [127]
Salvetti, 2020 [128]154 155107 42.1
Schumacher–a, 2021 [129]
Schumacher–b, 2021 [129]
Seven, 2016 [130]152195913457.315.720.226.96.742.6
Spoelstra, 2015 [131]1612165.130 63.3
Stamm, 2021 [132]1522106147 69
Steffen McLouth, 2020 [133]161 462.560 41.7
Thiagarajan, 2016 [134]1631,2152.730315.613.819.423.84.437.6
Turner, 2014 [135]1562176.7385 26
Unseld, 2021 [136]1522157.484636.543.513.6206.463.5
van der Baan, 2020 [137]1521,2158.21919 24
Wang, 2014 [138]163 458.25183 71
Yahaya, 2015 [139]163 153.4268 51.1
Zhong, 2017 [140]1731159.751770.2 e 29.8
a 1 = North America; 2 = Europe; 3 = Asia; 4 = South America; 5 = Africa; 6 = Australia/New Zealand; b 1 = inpatient; 2 = outpatient; 3 = patient in a palliative care setting; 4 = all; 5 = other; c 1 = >3 types of cancer; 2 = head and neck; 3 = oesophagus, 4 = bronchus/lung; 5 = breast; 6 = gastro-intestinal; 7 = prostate; 8 = other, urological; 9 = gynaecological; 10 = haematological; 11 = other; d moderate–severe pain; e none–mild pain; f mild–moderate pain.
Table 6. Pain prevalence in patients after curative treatment (Group 5) (n = 88).
Table 6. Pain prevalence in patients after curative treatment (Group 5) (n = 88).
% Pain
StudyQualityContinent aSetting bCancer cMean AgeSampleNoneMildModerateModSev dSevereOverall
Adams, 2014 [141]1722170.6418 15.5
Ahmed, 2014 [142]1732549.3373 5.4
Al Maqbali, 2021 [143]15325 133 45.1
Andersen, 2015 [144]19225 47586 14
Asplund, 2015 [145]18226 54579 721
Baden, 2020 [146]18227 3348 24
Bao, 2018 [147]18125 1280 33.3
Bennedsgaard–a, 2020 [148]
Bennedsgaard–b, 2020 [148]
Boehmer–a, 2021 [149]
Boehmer–b, 2021 [149]
Bøhn, 2019 [150]1622149.11088 10
Bonhof, 2020 [151]17226 477 9
Bovbjerg, 2019 [152]1512559.4417 50.6
Bulley, 2014 [153]1522562.3595 28.8
Cameron, 2018 [154]1612126.9124 54.5
Capelan, 2017 [155]15225 214 29
Chiang, 2019 [156]1862560.2201 23455
Cramer, 2018 [2]18122 17554.92211.623.111.545.1
Cui, 2018 [157]1532552.4420 36.2
de Groef, 2017 [158]1622554.1147 50
Dieterich–a, 2021 [159]
Dieterich–b, 2021 [159]
Drury, 2017 [160]1722666.42526426810236
Dualé, 2014 [161]18225 442 37.1
Efficace, 2019 [162]15221052.52445127 22 49
Engvall, 2021 [163]1622560.7646 46.3
Esser, 2017 [37]15221047.7102 8
Ezendam, 2014 [164]1722965180 31.7
Farrukh, 2020 [165]171210 736 39.4
Feddern, 2015 [166]19226 1369 131318531
Ferreira, 2019 [167]18225 4262 51
Gallaway, 2020 [168]17121 12,019 9.5
Gjeilo, 2020 [38]18224 194 55
Gong, 2020 [169]1632549.31983 28.2
Götze–a, 2018 [170]
Götze–b, 2018 [170]
Hammer, 2014 [171]1512963.5213 22.5
Hamood–a, 2016 [172]
Hamood–b, 2016 [172]
Hamood, 2018 [173]17325 410 64 74.4
Haviland, 2017 [174]1722555.1864 32.3
Henderson–a, 2014 [175]
Henderson–b, 2014 [175]
Henry, 2020 [176]161 263.3145 16.615.921.45.537.9
Hope-Stone, 2015 [177]15221166.717977 23
Huang, 2020 [178]1512133.61208 18.7
Janah, 2020 [179]16221 409336.5 63.5
Jansen, 2018 [180]1522270283 8.8
Jardim, 2020 [181]1642555151 18.5
Jariwala, 2021 [182]1932550212 12
Johannsdottir, 2017 [183]152211 12456.133.310.610.6043.9
Johannsen, 2015 [184]17225 1905 72.7
Juhl, 2016 [185]1922563.6261 1319.
Karlson, 2020 [186]15121 10,01271.4 e 20.528.68.1
Kaur, 2018 [187]1532549.76230 63.5
Kelada, 2019 [188]166210,1126.27404 28.7
Kibar, 2017 [189]1622552.520168.2 31.8
Kjaer, 2016 [190]1522264369 16.0
Knowlton, 2020 [191]15121 294 24.2
Koehler, 2018 [192]191255636 44.0
Kramer, 2019 [193]1552560.05349264614281474
Lou, 2021 [194]1612259.377 40 f
Lunde, 2019 [43]1822967.2207 14.9
Lunde, 2020 [195]1922966.1140 13.6
Madsen, 2017 [97]1722116395 37
Mao, 2018 [196]15125 1103 26.2
Mertz, 2017 [197]19225 4736721 12 33
Miaskowski, 2014 [198]1812554.9839441.6 58.4
Min, 2021 [199]1532764111 12.6
Mulrooney, 2019 [200]191210 980702357230
Paek, 2019 [201]1832162.2103771.9 28.1 28.1
Park, 2018 [202]17321136.4314475 25
Poço Conçalves, 2021 [203]1722165.338577.602022.42.422.4
Ravn Munkvold, 2018 [44]18222 3577019711430
Reilly, 2016 [204]17121047.631 68
Ren, 2021 [205]1712261.55055517.719.526.97.445
Rogers, 2021 [206]15121147248 49
Rosenberg, 2015 [207]1512555.82086 48
Sanchez-Birkhead, 2017 [208]1512552.635 38.3 79
Sanford, 2019 [209]15121 756567.5 32.5
Schou Bredal, 2014 [210]1622556834 211720341
Selvy, 2020 [211]1622666.3406 11.5
Steyaert, 2016 [212]1522556.5128 43.8
Tang, 2015 [48]18611155.17653.9 19.7 46.1
Terkawi, 2017 [213]1632249.6102 30
Tonning Olsson, 2021 [214]1612132.2283661.1 38.9 38.9
Tung, 2019 [215]18126 615 44.87
van de Luijtgaarden, 2014 [216]17221145.724 93
van Eck, 2020 [217]15221160752 14
Variawa, 2016 [218]1852558.5492 38.04
Vuksanovic, 2021 [219]16625 130 34.4
Wang, 2021 [50]16325 75 4.5
Wilson, 2020 [220]171111 136 16.3
a 1 = North America; 2 = Europe; 3 = Asia; 4 = South America; 5 = Africa; 6 = Australia/New Zealand; b 1 = inpatient; 2 = outpatient; 3 = patient in a palliative care setting; 4 = all; 5 = other; c 1 = >3 types of cancer; 2 = head and neck; 3 = oesophagus, 4 = bronchus/lung; 5 = breast; 6 = gastro-intestinal; 7 = prostate; 8 = other, urological; 9 = gynaecological; 10 = haematological; 11 = other; d moderate–severe pain; e none–mild pain; f mild–moderate pain.
Table 7. Pain prevalence in patients without feasible anti-cancer treatment (Group 6) (n = 17).
Table 7. Pain prevalence in patients without feasible anti-cancer treatment (Group 6) (n = 17).
% Pain
StudyQualityContinent aSetting bCancer cMean AgeSampleNoneMildModerateModSev dSevereOverall
Aktas, 2014 [221]17141 1000 84
Corli, 2020 [222]1921,2,4174.2865 60.5
de la Cruz, 2015 [223]15141 78 51
Drat-Gzubicka, 2021 [224]1823 76 29
Gupta, 2016 [225]1631152.4911032.7311.8222.7355.4632.7367.27
Guthrie, 2019 [226]15121 21,119 48.3
Hui, 2020 [227]1814160200 67
Mejin, 2019 [228]1533157,115118.514.619.266.947.781.5
Mercadante, 2018 [229]1523172.1263 6.9
Morita–a, 2014 [230]
Morita–b, 2014 [230]
Rojas-Concha, 2020 [231]17231 544995.
Seow–a, 2021 [232]
Seow–b, 2021 [232]
Silvia, 2021 [233]17431 49049.626.512.923.91150.4
Tofthagen, 2019 [234]1614172.7717 68.9
van der Baan, 2020 [137]1521,2163.4224 45
Yamagishi, 2014 [235]163116785984 16
Yanaizumi, 2021 [236]17321 1086.512.9 80.6 93.5
a 1 = North America; 2 = Europe; 3 = Asia; 4 = South America; 5 = Africa; 6 = Australia/New Zealand; b 1 = inpatient; 2 = outpatient; 3 = patient in a palliative care setting; 4 = all; 5 = other; c 1 = >3 types of cancer; 2 = head and neck; 3 = oesophagus, 4 = bronchus/lung; 5 = breast; 6 = gastro-intestinal; 7 = prostate; 8 = other, urological; 9 = gynaecological; 10 = haematological; 11 = other; d moderate–severe pain.
Table 8. Pain prevalence including patients in different phases of treatment (Group 7) (n = 79).
Table 8. Pain prevalence including patients in different phases of treatment (Group 7) (n = 79).
% Pain
StudyQualityContinent aSetting bCancer cMean AgeSampleNoneMildModerateModSev dSevereOverall
Aguilar, 2017 [237]1612261.723 20.3
Alemayehu, 2018 [238]1851,2143.539031 e 69
Armstrong, 2016 [239]151211 621 15.6
Bacorro, 2017 [240]1531,2251.810053269211247
Batalini, 2017 [241]1642159277 40
Bauml, 2015 [242]1612560.520378.7 e 21.3
Beesley, 2016 [243]1562667116 32
Bhattacharya, 2019 [244]16225 957 10.5
Bonhof, 2018 [245]1622964.898 37.5
Bouhassira, 2017 [246]1822161.4509 28.2
Boyes, 2015 [247]176210 311 12
Braamse–a, 2014 [248]
Braamse–b, 2014 [248]
Braga-Neto, 2018 [249]16426 207 83
Bubis, 2020 [250]1512,41 22,650 33
Buckley, 2018 [251]1611,210 82 60
Cho–a, 2019 [252]
Cho–b, 2019 [252]
Clover, 2017 [253]15621629133 17
Daly, 2020 [254]15251 1027 25.3
Davies, 2021 [255]17231 250 6.011.624.512.930.5
Davis, 2018 [256]1512559.723,840 35.513.2
de Groef, 2016 [257]1822560.5100 50
de Mello, 2020 [258] 16416 348 55.61
de Oliveira, 2014 [259]18125 300 36.7
Deshields, 2014 [260]1612160.6513 44
Deshields, 2017 [261]1612160.63558 45
Dhingra, 2015 [262]1712162.31436 44.9
Donovan, 2014 [263]1812956104 31.7
Doubova–a, 2021 [264]
Doubova–b, 2021 [264]
75.3 e
67.3 e
Feiten, 2014 [265]16225 730 34
Fokdal, 2018 [266]181,2,329 914 13.4
Giuliani, 2016 [267]15124 89 21
Götze, 2019 [268]16221075.6200 34
Gough, 2017 [269]162 1159113 24 77
Guedes, 2018 [270]1642555.9710344.7 55.3
Honkanen, 2021 [271]1622556.9121 35.5 14 49.5
Horick, 2018 [272]18121 309 45
Huang, 2018 [273]173165930039.72525.335.51060.3
Hunnicutt–a, 2017 [274]
Hunnicutt–b, 2017 [274]
Jesdale–a, 2020 [275]
Jesdale–b, 2020 [275]
Jesdale–c, 2020 [275]
Jewett, 2020 [276]1712959.9355 25.1
Karawekpanyawong–a, 2021 [277]
Karawekpanyawong–b, 2021 [277]
Khan, 2021 [278]15325 9775.3 24.7
Kim, 2015 [279]1532552.182756.5 1.143.5
Kim–a, 2017 [280]
Kim–b, 2017 [280]
Lefkowits, 2014 [281]15129 305 32 60.1
Liu, 2015 [282]1615551.797 53.6
Loh, 2018 [283]15121 389 49.6
Lu, 2017 [284]1532152.9919 49.4
Mavros, 2020 [285]16156 2168 39
Mejdahl, 2015 [286]15225 286 28
Nakanotani, 2014 [287]1532157.6807 17.6
Nappi, 2021 [288]1522558.4175 65.9
Oosterling, 2016 [289]17221 89277 e 23
Pandya, 2019 [290]1611181359 56
Pinto, 2021 [291]1551,3146.1294 33.362.629.383.7
Ramsenthaler, 2016 [292]1521,21068.4557 243447.813.871.5
Rau, 2015 [293]1932157.472075 50.7
Reuter, 2019 [294]1612161.62817 35.4
Rosario, 2019 [295]171117533 60
Saarelainen, 2014 [296]1562176.7385 26
Sager, 2020 [297]1812165.31123 26.8
Sakurai, 2019 [298]1732,3164.4142 66.2
Sampogna, 2020 [299]162211 44.3
Sánchez Sánchez, 2020 [300]1522770.7118460.939.1 39.1
Schreiber, 2021 [301]1512555.5201 32
Shen, 2017 [302]1632157265237.429.823.232.89.662.6
Sloan–a, 2016 [303]
Sloan–b, 2016 [303]
Smith, 2019 [304]15125,659.72257 61.2
Tadele, 2015 [305]18521 388 77.6
Tegegn, 2017 [306]15511 838.425.357.866.28.491.6
Tjong, 2021 [307]17124 13,289 62
Tung, 2019 [308]18126 2623 61.8
Valery, 2017 [309]156 1 82 10
van Arsdale, 2016 [310]1612959165 18.8
van den Brekel, 2020 [311]15211602144 28
Vistad, 2018 [312]162 961.982 56
von Gruenigen, 2018 [313]1712963.665 69
Williams, 2020 [314]1711670.1336 20.9
Xu, 2017 [315]15321143.5142 30
a 1 = North America; 2 = Europe; 3 = Asia; 4 = South America; 5 = Africa; 6 = Australia/New Zealand; b 1 = inpatient; 2 = outpatient; 3 = patient in a palliative care setting; 4 = all; 5 = other; c 1 = >3 types of cancer; 2 = head and neck; 3 = oesophagus, 4 = bronchus/lung; 5 = breast; 6 = gastro-intestinal; 7 = prostate; 8 = other, urological; 9 = gynaecological; 10 = haematological; 11 = other; d moderate–severe pain; e none–mild pain.
Table 9. Pooled pain prevalence, and severity rates by treatment group.
Table 9. Pooled pain prevalence, and severity rates by treatment group.
N StudiesN cancer PatientsOverall Pain
Group 118329440.3% (95% CI 30.2–50.4)
Group 231799547.8% (9