Impact of age, comorbidity and symptoms on physical function in long-term breast cancer survivors (CALGB 70803)

The impact of age on physical functioning after treatment for breast cancer, as measured by patient-reported outcome measures: A systematic review

PURPOSE

This systematic review aims to explore the impact of age on physical functioning post-treatment for early-stage, locally advanced, or locally recurrent breast cancer, as measured by patient-reported outcome measures (PROMs), identify PROMs used and variations in physical functioning terms/labels.

METHODS

MEDLINE, EmBase, PsycINFO, CINAHL and AMED were searched, along with relevant key journals and reference lists. Risk of bias (quality) assessment was conducted using a Critical Appraisal Skills Programme checklist. Data was synthesised through tables and narrative.

RESULTS

28,207 titles were extracted from electronic databases, resulting in 44 studies with age sub-groups, and 120 without age sub-groups. Of those with findings on the impact of age, there was variability in the way findings were reported and 21 % found that age did not have a significant impact. However, 66 % of the studies found that with older age, physical functioning declined post-treatment. Comorbidities were associated with physical functioning declines. However, findings from sub-groups (breast cancer stage, treatment type and time post-treatment) lacked concordance. Twenty-eight types of PROM were used: the EORTC QLQ-C30 was most common (50.6 %), followed by the SF-36 (32.3 %). There were 145 terms/labels for physical functioning: 'physical functioning/function' was used most often (82.3 %).

CONCLUSIONS

Findings point towards an older age and comorbidities being associated with more physical functioning declines. However, it was not possible to determine if stage, treatment type and time since treatment had any influence. More consistent use of the terminology 'physical functioning/function' would aid future comparisons of study results.

Applying the Multicultural Orientation in Cancer Care for Sexual and Gender Minority Cancer Survivors: A Cross-Sectional Correlational Study

Purpose: Sexual and gender minority (SGM) cancer survivors report unique needs that are not met by some providers. The multicultural orientation (MCO) holds promise for creating a paradigm shift in providing affirmative cancer care, yet has not been tested empirically. This study examines the predictive strength of MCO's tenets of cultural humility and cultural opportunities for SGM cancer patient-provider relationships. Methods: In this cross-sectional study, 108 SGM cancer survivors completed surveys on perceptions of their oncology providers' cultural humility and actualization of cultural opportunities as predictors of survivors' treatment adherence and the patient-provider alliance. Hierarchical regression analyses were conducted. Results: Average participant age was 50 years (standard deviation = 15 years). Over 10 cancer types were represented and 69% of participants were in active treatment, with the remaining 31% receiving follow-up care. Age at diagnosis and not being in active treatment positively correlated with perceptions of providers' cultural humility, patient-provider alliance, and treatment adherence. Regression models explained 38% and 61%, respectively, of the variance in treatment adherence and patient-provider alliance, with cultural humility remaining a significant predictor in both models after accounting for all other variables. Conclusion: Providers' cultural humility and navigation of cultural opportunities in incorporating their patients' salient cultural identities into cancer care are strongly associated with how supported SGM cancer survivors feel by their oncology providers. The MCO is a useful framework for identifying important dimensions in SGM affirmative cancer care.

Prevalence, patterns, and determinants of multimorbidity among childhood and adult cancer survivors: A systematic review

Development of multimorbidity is common among cancer survivors due to their previous cancer, treatments, or changes in lifestyle. We summarized evidence on the prevalence, patterns, and determinants of multimorbidity among childhood and adult cancer survivors. We searched PubMed and EMBASE databases for articles reporting prevalence, patterns, and determinants of multimorbidity in cancer survivors. Finally, 23/500 articles were included. There was a large variation in the prevalence of multimorbidity (13-89%) among cancer survivors. Bone marrow transplantation, radiation, female sex, lower level of physical activity, increasing age, minority ethnicity, low-income, and low-education were associated with a higher prevalence of multimorbidity. Patterns of multimorbidity were both concordant and discordant. In conclusion, multimorbidity is highly prevalent and a major concern among cancer survivors. A personalized care plan that takes into account the identified risk may be beneficial to reduce the burden of multimorbidity and improve the quality of life among cancer survivors.

Disability risk prediction model based on machine learning among Chinese healthy older adults: results from the China Health and Retirement Longitudinal Study

Background

Predicting disability risk in healthy older adults in China is essential for timely preventive interventions, improving their quality of life, and providing scientific evidence for disability prevention. Therefore, developing a machine learning model capable of evaluating disability risk based on longitudinal research data is crucial.

Methods

We conducted a prospective cohort study of 2,175 older adults enrolled in the China Health and Retirement Longitudinal Study (CHARLS) between 2015 and 2018 to develop and validate this prediction model. Several machine learning algorithms (logistic regression, k-nearest neighbors, naive Bayes, multilayer perceptron, random forest, and XGBoost) were used to assess the 3-year risk of developing disability. The optimal cutoff points and adjustment parameters are explored in the training set, the prediction accuracy of the models is compared in the testing set, and the best-performing models are further interpreted.

Results

During a 3-year follow-up period, a total of 505 (23.22%) healthy older adult individuals developed disabilities. Among the 43 features examined, the LASSO regression identified 11 features as significant for model establishment. When comparing six different machine learning models on the testing set, the XGBoost model demonstrated the best performance across various evaluation metrics, including the highest area under the ROC curve (0.803), accuracy (0.757), sensitivity (0.790), and F1 score (0.789), while its specificity was 0.712. The decision curve analysis (DCA) indicated showed that XGBoost had the highest net benefit in most of the threshold ranges. Based on the importance of features determined by SHAP (model interpretation method), the top five important features were identified as right-hand grip strength, depressive symptoms, marital status, respiratory function, and age. Moreover, the SHAP summary plot was used to illustrate the positive or negative effects attributed to the features influenced by XGBoost. The SHAP dependence plot explained how individual features affected the output of the predictive model.

Conclusion

Machine learning-based prediction models can accurately evaluate the likelihood of disability in healthy older adults over a period of 3 years. A combination of XGBoost and SHAP can provide clear explanations for personalized risk prediction and offer a more intuitive understanding of the effect of key features in the model.

Trajectories of objectively measured physical function among older breast cancer survivors in comparison with cancer-free controls

PURPOSE

Aging associated with progressive declines in physical function is well-known; however, it is unclear how breast cancer diagnosis affects the trajectories of physical function over a long period of time. The current study examined the trajectories in objective measures of physical function over 20 years for women with breast cancer and matched controls.

METHODS

2712 community-dwelling women (452 breast cancer cases and 1:5 matched cancer-free controls) aged 65 years or older at baseline (1986-1988) within the Study of Osteoporotic Fractures were followed for 20 years. Objective physical function was assessed up to 9 times, including hand grip strength, timed chair stand, gait speed and quadriceps strength. Linear mixed models were used to model physical function changes in terms of secular time trend, group (cases or controls), period (pre-and post-diagnosis status), and their interaction terms.

RESULTS

We observed all measures of physical function declined over time. While no differences in trends between cases and controls during the pre-diagnosis period were observed, after cancer diagnosis, grip strength and gait speed declined significantly faster in cases than controls. Quadriceps strength significantly decreased ~ 7 pounds shortly after breast cancer diagnosis, and then improved over time.

CONCLUSION

Our study revealed that older breast cancer survivors relative to older women without cancer had significantly worse declines in grip strength and gait speed. Breast cancer survivors also had a sharp, short-term drop followed by gradual improvement over time in quadriceps strength. These findings suggest exercise training targeting muscle strength and mobility would be beneficial among older breast cancer survivors.

Longitudinal change of quality of life in the first five years of survival among disease-free Chinese breast cancer survivors

PURPOSE

This study aimed to investigate changes of QoL during the first 5 years of survival among disease-free Chinese breast cancer survivors.

METHODS

A prospective cohort study enrolled 1462 Chinese women with early-stage breast cancer, and longitudinally visited those patients at four time-points, namely baseline (T0), 18- (T1), 36- (T2), and 60-month (T3) after diagnosis. This study included 992 patients who were disease-free during the first 5 years of survival and who had completed QoL assessments at all four time-points.

RESULTS

The score of global health status/QoL improved gradually (T1, T2, T3 > T0; P < 0.001 for overall comparisons). Social functioning score significantly improved when compared to that of T0 (T1, T2, T3 > T0; P < 0.001 for overall comparisons). In contrast, cognitive functioning score decreased (T0 > T1, T2, T3; P < 0.001 for overall comparisons). Scores of physical functioning, role functioning and emotional functioning showed a fluctuated picture, with the highest score achieved at T1. In symptoms profile, most of them scored lowest at T1 (best QoL). Multivariate analysis showed that several characteristics significantly correlated to changes in QoL from T0 to T3. For instance, patients with higher education had better recovery of physical functioning, role functioning, and social functioning.

CONCLUSION

During the first 5 years of survival, patients' global health status/QoL improved over time, social functioning consistently improved, but cognitive functioning steadily deteriorated. Most of functioning domains and symptoms improved at 18-month follow-up, but such improvements were not maintained and even deteriorated at 36- and 60-month post-diagnosis. This study suggested that some interventions should be investigated during such period.

Multimorbidity, Function, and Cognition in Aging

Multimorbidity is a global health challenge. Here, we define multimorbidity, describe ways multimorbidity is measured, discuss the prevalence of multimorbidity and how it differs across different populations, examine mechanisms of disease and disability, and discuss the effects of multimorbidity on outcomes such as survival and function.

Postmenopausal Breast Cancer and Physical Function Change: A Difference-in-Differences Analysis

BACKGROUND/OBJECTIVES

While breast cancer and associated therapies can influence physical function (PF), findings for breast cancer's effects on PF among postmenopausal women are not consistent. This research evaluates the effect of breast cancer on change in PF.

DESIGN

Longitudinal cohort study analyzed using difference-in-differences (DID) method to compare the changes in PF over time between women with and without breast cancer, by invasive status, stage, and age.

SETTING AND PARTICIPANTS

Women's Health Initiative participants, aged 50 to 79 years at baseline, with four completed functional status assessments were eligible for inclusion (mean age = 62.1 ± 6.9 years). Women with breast cancer diagnosed between the 3rd and 11th enrollment year (n = 1636) were compared to women without breast cancer (n = 35 660).

MEASUREMENTS

PF was measured using the Medical Outcomes Study Short Form 36 at baseline and years 3, 11, and 12.

RESULTS

Compared with women without breast cancer, women with breast cancer experienced greater PF decline (P < .0001), after adjustment for age, race, education, income, study/trial arm, and body mass index. Overall, functional declines were greatest among women with invasive breast cancer (DID = -4.87; 95% confidence interval = -7.12 to -2.62). In stratified analyses, the breast cancer effect on PF was greater among women in older age groups.

CONCLUSION

Women diagnosed with breast cancer experienced a significant decline in PF beyond what is observed in typical aging in this cohort. To optimally address survivorship issues, disease sequelae need to be distinguished from normal aging in studies incorporating a cancer-free comparison group. J Am Geriatr Soc 68:1029-1036, 2020.

Effects of cancer history on functional age and mortality

BACKGROUND

Cancer, its treatment, and associated adverse effects may accelerate the functional aging of cancer survivors. In the current study, the authors used geriatric assessment (GA) to compare the functional age of long-term cancer survivors with that of similarly aged women without a cancer history, and to examine whether functional age influences all-cause mortality differently between these 2 groups.

METHODS

Participants included 1723 cancer survivors and 11,145 age-matched, cancer-free women enrolled in the Iowa Women's Health Study in 1986 who completed the 2004 questionnaire (at ages 73-88 years). GA domain deficits included ≥2 physical function limitations, ≥2 comorbidities, poor general health, poor mental health, and underweight. The risk of all-cause mortality was estimated for deficits in each GA domain between 4 groups based on the cross-classification of the presence and/or absence of cancer history and GA domain deficit (the referent group was cancer-free women without a GA deficit).

RESULTS

Both cancer history and GA domain deficits significantly predicted 10-year mortality for all GA domains. Cancer survivors without deficits had a 1.3-fold to 1.4-fold risk of mortality, similar to the 1.1-fold to 1.7-fold risk noted among cancer-free women with deficits (all P < .05). Cancer survivors with deficits were found to have the highest mortality risk for 4 of 5 domains (hazard ratio range, 1.6-2.0). Mortality risk increased with the increasing number of GA deficits, which was greater in cancer survivors compared with cancer-free women.

CONCLUSIONS

Even without GA deficits, cancer survivors appear to have an excess risk of death compared with women without cancer, and these deficits add to mortality risk. Interventions are needed to maintain or improve functional/physiological capacity as women age, especially in cancer survivors.

A Longitudinal Pilot Study for Examining Symptom Reduction in Patients With Cancer in a Palliative Care Program: A Primarily Rural Northeast Texas Population

Many patients with cancer live in rural areas and research is lacking on the efficacy of palliative care programs in rural community settings. This pilot study was conducted in a primarily rural setting where healthcare professionals delivered palliative care to 52 mostly lower income patients with a variety of cancers. They were assessed for physical, financial, psychosocial and overall symptom intensity at baseline and at three consequent assessments. This pilot study demonstrated the potential efficacy of an outpatient palliative care program in a mostly rural setting in the reduction of physical, psychosocial, and overall symptom intensity in patients with cancer.

Breast cancer treatment and its effects on aging

Breast cancer is the most common cancer of women in the United States. It is also proving to be one of the most treatable. Early detection, surgical intervention, therapeutic radiation, cytotoxic chemotherapies and molecularly targeted agents are transforming the lives of patients with breast cancer, markedly improving their survival. Although current breast cancer treatments are largely successful in producing cancer remission and extending lifespan, there is concern that these treatments may have long lasting detrimental effects on cancer survivors, in part, through their impact on non-tumor cells. Presently, the impact of breast cancer treatment on normal cells, its impact on cellular function and its effect on the overall function of the individual are incompletely understood. In particular, it is unclear whether breast cancer and/or its treatments are associated with an accelerated aging phenotype. In this review, we consider breast cancer survivorship from the perspective of accelerated aging, and discuss the evidence suggesting that women treated for breast cancer may suffer from an increased rate of physical and cognitive decline that likely corresponds with underlying vulnerabilities of genome instability, epigenetic changes, and cellular senescence.

Differential Impact of Symptom Prevalence and Chronic Conditions on Quality of Life in Cancer Survivors and Non-Cancer Individuals: A Population Study

Background: To compare associations of symptom prevalence, chronic conditions, and health-related quality of life (HRQOL) between cancer survivors and non-cancer individuals using the U.S. National Health Interview Survey.Methods: Study samples comprised 604 survivors and 6,166 non-cancer individuals. Symptoms included sensation abnormality, pain, fatigue, cognitive disturbance, depression, and anxiety. Physical and mental HRQOL was measured by the Patient-Reported Outcomes Measurement Information System.Results: Compared with non-cancer individuals, survivors had higher prevalence in sensation abnormality (OR = 2.4; 95% CI = 1.9 to 3.0), pain (OR = 2.1; 95% CI = 1.7 to 2.6), fatigue (OR = 1.4; 95% CI = 1.1 to 1.8), and decremented physical HRQOL (difference = -3.7; 95% CI = -4.7 to -2.6). The prevalence of individual symptoms was significantly associated with decremented physical HRQOL [range = -5.9 (anxiety) to -8.9 (pain)] and mental HRQOL [range = -4.7 (sensation) to -8.4 (depression)]. The association between cancer experience and physical and mental HRQOL was chiefly explained by the prevalence of six symptoms and presence of chronic conditions. Pain (β = -4.0; 95% CI = -4.5 to -3.6) and ≥2 chronic conditions (β = -9.2; 95% CI = -10.2 to -8.2) significantly decremented physical HRQOL. Depression (β = -5.2; 95% CI = -5.8 to -4.6) and ≥2 chronic conditions (β = -3.3; 95% CI = -4.4 to -2.3) significantly decremented mental HRQOL.Conclusions: Cancer survivors experience more symptom burden than non-cancer individuals, which is associated with more chronic conditions and impaired HRQOL.Impacts: Interventions to manage symptom prevalence especially for older cancer survivors and survivors with more chronic conditions may improve their HRQOL outcomes. Cancer Epidemiol Biomarkers Prev; 26(7); 1124-32. ©2017 AACR.

Physical Functioning among Women 80 Years of Age and Older With and Without a Cancer History

BACKGROUND

Females 80 years and older comprise 22% of the total U.S. survivor population, yet the impact of cancer on the physical well-being of women is this age group has not been well characterized.

METHODS

We compared women, 80 years of age and older in the Women's Health Initiative extension 2, who did (n = 2,270) and did not (n = 20,272) have an adjudicated history of cancer during Women's Health Initiative enrollment; analyses focused on women >2-years postcancer diagnosis. The physical functioning subscale of the RAND-36 was the primary outcome. Demographic, health-status, and psychosocial covariates were drawn from Women's Health Initiative assessments. Analysis of covariance was used to examine the effect of cancer history on physical function, with and without adjustment for covariates.

RESULTS

In adjusted models, women with a history of cancer reported significantly lower mean physical functioning (56.6, standard error [SE] 0.4) than those without a cancer history (58.0, SE 0.1), p = .002. In these models, younger current age, lower body mass index, increased physical activity, higher self-rated health, increased reported happiness, and the absence of noncancer comorbid conditions were all associated with higher physical functioning in both women with and without a history of cancer.

CONCLUSIONS

Women older than 80 years of age with a cancer history have only a moderately lower level of physical function than comparably aged women without a cancer history. Factors associated with higher levels of physical functioning were similar in both groups.

Treatment Summaries and Follow-Up Care Instructions for Cancer Survivors: Improving Survivor Self-Efficacy and Health Care Utilization

To assess the effect of treatment summaries and follow-up care plans on self-efficacy and health care utilization, cancer survivors (≥65 years old) were surveyed. Receiving a verbal explanation of follow-up care instructions was significantly associated with higher self-efficacy scores, which in turn were significantly associated with lower prevalence ratios of emergency room visits and hospitalizations.

Background.

Treatment summaries and follow-up care plan information should be provided to cancer survivors. This study examines the association of receiving summaries and care plans with cancer survivor self-efficacy for chronic illness management, and whether self-efficacy was associated with health care utilization.

Methods.

Four hundred forty-one cancer survivors (≥2 years from diagnosis and had completed treatment) ≥65 years old from 12 cancer centers across 5 states completed telephone surveys. Survivors responded to three questions about receiving a written treatment summary, written follow-up plan, and an explanation of follow-up care plans. Respondents completed the Stanford Chronic Illness Management Self-Efficacy Scale and reported emergency room visits and hospitalizations in the past year. Three multiple linear regression models estimated the association of written treatment summary, written follow-up care plan, and verbal explanation of follow-up plan with total self-efficacy score. Log-binomial models estimated the association of self-efficacy scores with emergency room visits and hospitalizations (yes/no).

Results.

Among survivors, 40% and 35% received a written treatment summary and follow-up care plan, respectively. Seventy-nine percent received an explanation of follow-up care plans. Receiving a verbal explanation of follow-up care instructions was significantly associated with higher self-efficacy scores (β = 0.72, p = .009). Higher self-efficacy scores were significantly associated with lower prevalence ratios of emergency room visits (prevalence ratio, 0.92; 95% confidence interval, 0.88–0.97) and hospitalizations (prevalence ratio, 0.94; 95% confidence interval, 0.89–0.99).

Conclusion.

Explanation of the follow-up care plan, beyond the written component, enhances survivor self-efficacy for managing cancer as a chronic condition—an important mediator for improving health care utilization outcomes.

Implications for Practice:

Older cancer survivors (>65 years) are especially vulnerable to poor outcomes in survivorship because of the complexity of follow-up care and other chronic conditions. Delivering written treatment summaries, written follow-up care plans, and verbal explanations of follow-up care plans all independently increased the self-efficacy for chronic illness management among older survivors. In particular, delivering this information in the verbal format was significantly associated with higher self-efficacy and, subsequently, a lower likelihood of emergency room visits. Understanding the mechanism through which summaries and follow-up care plans may positively influence survivor health is critical to increasing the delivery of the information.

Do long term cancer survivors have better health-promoting behavior than non-cancer populations?: case-control study in Korea

BACKGROUND

We compared the health-promoting behavior of long-term cancer survivors with those of the general population to identify necessary behavioral interventions to reduce the health risk among cancer patients.

MATERIALS AND METHODS

We used data from the 2007 and 2012 Korea National Health and Nutrition Examination Surveys (KNHANES IV [2007~2009] and KNHANES V [2010~2012]) on smoking status, alcohol use, physical exercise, and disease screening. We compared long-term cancer survivors with members of the general population; the controls were matched by propensity score matching. A multiple logistic regression model was used to investigate the association between cancer status and health-promoting behavior.

RESULTS

Long-term cancer survivors had a lower risk of smoking than the general population controls (OR: 0.42, 95%CI: 0.25-0.71). In addition, the long-term cancer survivors had a lower risk of alcohol use than the general population controls (OR: 0.70, 95%CI: 0.50-0.98). However, in terms of physical exercise and disease screening, no statistically significant differences were detected (physical exercise OR: 1.01, 95%CI: 0.75-1.35; disease screening OR: 1.27, 95%CI: 0.93-1.74). All covariates were adjusted.

CONCLUSIONS

The long-term cancer survivors had a much lower risk of smoking and alcohol use than the general population controls. However, almost no differences in physical exercise and screening for cancer recurrence or secondary disease were detected between the long-term cancer survivors and general population controls. To reduce the health risks and challenges facing long-term cancer survivors, interventions to encourage physical exercise and screening for cancer recurrence and secondary disease should be implemented.

Symptoms, weight loss, and physical function in a lifestyle intervention study of older cancer survivors

OBJECTIVES

Many older cancer survivors are overweight or obese, with additional illness burden increasing functional decline, which may affect their ability to engage in lifestyle interventions. This study examined how overweight long-term survivors' symptom severity associated with comorbidity prior to a diet and exercise intervention was associated with post-intervention function and examined symptoms' effects on function through change in physical activity, diet quality, and weight status.

MATERIALS AND METHODS

This is a secondary data analysis of 514 breast, prostate, and colorectal cancer survivors who participated in the one-year home-based diet and exercise intervention Reach-Out to Enhance Wellness trial. Measures included symptoms, weight, physical activity, diet quality, overall physical function (PF), and basic and advanced lower extremity function (BLEF and ALEF). Simple and serial mediation analyses were conducted to examine direct effects of symptom severity on PF, BLEF, and ALEF and indirect effects of symptom severity through changes in diet quality, physical activity, and weight.

RESULTS

Symptom severity was directly associated with lower functioning scores for PF (b=-0.63 p<0.001), BLEF (b=-0.33, p<0.001), and ALEF (b=-0.22, p<0.001). Indirect effects of symptom severity through weight loss, physical activity, and diet were not significant. Weight loss and physical activity were associated with higher PF and ALEF and diet quality was associated with higher BLEF.

CONCLUSION

Symptom severity of older, overweight cancer survivors negatively affects physical function. However, greater weight loss and more physical activity were associated with higher functioning scores, regardless of symptom severity.

The impact of co-morbidity on health-related quality of life in breast cancer survivors and controls

BACKGROUND

The objective of this study was: 1) to compare health-related quality of life (HRQoL) scores of breast cancer survivors to matched controls; and 2) to examine the relative impact (explained variance) of the type and number of co-morbidities on HRQoL.

MATERIAL AND METHODS

Data from the KARMA project was used in this cross-sectional study. For each woman diagnosed with breast cancer (n = 2552) there were two healthy age- and geographically matched females (n = 5104). Breast cancer survivors were categorized according to time since diagnosis: recently diagnosed (0-1 year), short- (2-5 years), mid- (6-10 years), and long-term survivors (> 10 years). Women completed a questionnaire addressing demographics (age, educational level, and geographical location), lifestyle factors (body mass index (BMI) and smoking), co-morbidities, and HRQoL. The difference in explained variance in six HRQoL-domains between demographics, lifestyle factors, and co-morbidity in women with breast cancer and matched controls was examined by hierarchical regression analyses.

RESULTS AND CONCLUSION

Women recently diagnosed (n = 63), reported the worst HRQoL followed by short-term survivors (2-5 years, n = 863). Thereafter, HRQoL scores further improved (6-10 years, n = 726), and were comparable to healthy females after 10 years (n = 893). Co-morbidity has a negative impact on HRQoL, which increased with time after diagnosis. Cardiovascular disease and depression were the strongest associates. Breast cancer survivors report clinically significant improvement in HRQoL scores six years after diagnosis. Co-morbidity has a negative impact on HRQoL, which increases with time after diagnosis, even though the number of co-morbidities remains stable. In long-term survivors there should be increasing awareness of co-morbidity and its impact on HRQoL.

Contextual factors influencing health-related quality of life in African American and Latina breast cancer survivors

PURPOSE

This study explored the relationships between systemic- and individual-level contextual factors and health-related quality of life (HRQOL) in a cohort of African American and Latina breast cancer survivors (BCS).

METHODS

Baseline questionnaire data of 320 BCS who participated in a HRQOL psycho-educational intervention were abstracted from the parent study. Hierarchical regression analysis tested the independent effects of contextual factors on HRQOL.

RESULTS

HRQOL was higher in BCS who: were diagnosed at < stage 2 (b = -1.38, p < 0.05), expressed satisfaction with their health care (b = 0.20, p < 0.001), had fewer comorbidities (b = - 0.60, p < 0.001) and depressive symptoms (b = -0.30, p < 0.001), and practiced healthy diet and exercise habits (b = 0.02, p < 0.05). Demographic and cancer-related factors accounted for 14 % of the variance in HRQOL (F[6, 274] = 7.25, p < 0.001). The socio-cultural context (i.e., ethnicity, life stress, perceived social support) explained 20 % of the variance in HRQOL (FΔ[3, 271] = 27.32, p < 0.001). The health care system context contributed an additional 8 % to explaining HRQOL (FΔ[1, 270] = 34.88, p < 0.001). Health status and behavioral factors accounted for 18 % of the variance (FΔ[4, 266] = 29.55, p < 0.001). The full model explained 59 % of the variance in HRQOL (F[14, 266] = 27.76, p < 0.001).

CONCLUSIONS

HRQOL in ethnic minority BCS is multifaceted and is significantly influenced by cancer-related, socio-cultural, health care system, health status, and behavioral contextual factors. Therefore, survivorship research and practice must address broad multi-level domains to achieve equitable and optimal breast cancer outcomes.

IMPLICATIONS FOR CANCER SURVIVORS

To enhance HRQOL, survivors must be provided the know-how and support to maintain healthy lifestyle and self-management practices. Advocates must engage the care team to consider systemic factors, including life stress and community resources, to be more patient-centered.

Decision-making and cancer screening: a qualitative study of older adults with multiple chronic conditions

OBJECTIVE

To understand how older persons with multiple chronic conditions (MCC) approach decisions about cancer screening.

MATERIALS AND METHODS

We conducted interviews with adults >65 years old with at least two chronic conditions who were taking ≥five medications daily. Patients were first asked how age and multimorbidity influence their cancer screening decisions. After showing them an educational prompt that explained the relationship between life expectancy and the benefits of cancer screening, respondents were then asked about screening in the context of specific health scenarios. Using grounded theory, three independent readers coded responses for salient themes. Sample size was determined by thematic saturation.

RESULTS

Most respondents (26 of 28) initially indicated that their overall health or medical conditions do not influence their cancer screening decisions. After viewing the educational prompt, respondents described two broad approaches to cancer screening in the setting of increasing age or multi-morbidity. The first was a "benefits versus harms" approach in which participants weighed direct health benefits (e.g. reducing cancer incidence or mortality) and harms (e.g. complications or inconvenience). The second was a heuristic approach. Some heuristics favored screening, such as a persistent belief in unspecified benefits from screening, value of knowledge about cancer status, and not wanting to "give up", whereas other heuristics discouraged screening, such as fatalism or a reluctance to learn about their cancer status.

CONCLUSIONS

When considering cancer screening, some older persons with MCC employ heuristics which circumvent the traditional quantitative comparison of risks and benefits, providing an important challenge to informed decision making.

Associations among survivorship care plans, experiences of survivorship care, and functioning in older breast cancer survivors: CALGB/Alliance 369901

PURPOSE

Survivorship care plans (SCP) are recommended for all cancer patients and could be especially useful to survivors 65 years and over ("older"). This study examined receipt of SCPs among older breast cancer survivors and whether SCPs were associated with improved patient-reported outcomes.

METHODS

Three hundred and twenty-eight older women diagnosed with invasive, nonmetastatic breast cancer between 2007-2011 were recruited from 78 cooperative-group sites. Participants completed telephone interviews at baseline and 1-year posttreatment. Regression analyses examined SCP receipt (yes/no) and functioning (EORTC-QLQ-C30), cancer worry, and experiences of survivorship care (care coordination, knowledge).

RESULTS

Only 35% of women received SCPs. For each 1-year increase in age, there was a 5% lower odds of receiving an SCP (odds ratio (OR) = 0.94, 95% confidence interval (CI) 0.91-0.98, p = 0.007). Besides age, no other factor predicted SCPs. SCP receipt was associated with greater knowledge and understanding of requisite follow-up care (p < 0.05); however, functioning was not significantly different among those with vs. without SCPs.

CONCLUSIONS

Receipt of care plans was limited. SCPs improved understanding of breast cancer follow-up care among older survivors, but did not impact functioning one year post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

To impact functioning and salient needs of the growing cohort of older survivors, survivorship care plans likely should be tailored to geriatric-specific issues. To improve functioning, SCP content should expand to include exercise, nutrition, polypharmacy, social support and management of symptom burden from cancer, and other comorbid conditions. To improve follow-up care for cancer survivors, SCPs should delineate shared care roles between oncology and primary care in managing recurrence surveillance, screening, and cancer sequelae.

Examining the cost-effectiveness of radiation therapy among older women with favorable-risk breast cancer

BACKGROUND

Little is known about the cost-effectiveness of external beam radiation therapy (EBRT) or newer radiation therapy (RT) modalities such as intensity modulated radiation (IMRT) or brachytherapy among older women with favorable-risk breast cancer.

METHODS

Using a Markov model, we estimated the cost-effectiveness of no RT, EBRT, and IMRT over 10 years. We estimated the incremental cost-effectiveness ratio (ICER) of IMRT compared with EBRT under different scenarios to determine the necessary improvement in effectiveness for newer modalities to be cost-effective. We estimated model inputs using women in the Surveillance, Epidemiology, and End Results-Medicare database fulfilling the Cancer and Leukemia Group B C9343 trial criteria.

RESULTS

The incremental cost of EBRT compared with no RT was $9500 with an ICER of $44600 per quality-adjusted life year (QALY) gained. The ICERs increased with age, ranging from $38300 (age 70-74 years) to $55800 (age 80 to 94 years) per QALY. The ICERs increased to more than $63800 per QALY for women aged 70 to 74 years with an expected 10-year survival of 25%. Reduction in local recurrence by IMRT compared with EBRT did not have a substantial impact on the ICER of IMRT. IMRT would have to increase the utility of baseline state by 20% to be cost-effective (<$100000 per QALY).

CONCLUSIONS

EBRT is cost-effective for older women with favorable risk breast cancer, but substantially less cost-effective for women with shorter expected survival. Newer RT modalities would have to be substantially more effective than existing therapies in improving quality of life to be cost-effective.

Accelerated aging among cancer survivors: from pediatrics to geriatrics

There are almost 14-million cancer survivors in the United States and the population is growing. Almost two-thirds of these survivors are age 65 or older. Given this, it is imperative to understand the impact of cancer and its therapies on the aging process. Childhood cancer survivors, diagnosed with cancer at age 21 or younger, particularly females, have rates of frailty similar to rates in older adults. This phenomenon appears to start early, suggesting an aging phenotype. Frailty among childhood cancer survivors increases risk for chronic disease and mortality. Adults diagnosed with cancer are faced with the effects of cancer and its therapies compounded by the issues of multiple morbidities that occur with the typical aging process. Intervention studies to date have focused on smoking cessation, diet, and exercise, as well as improving rates of late effects surveillance in childhood cancer survivors. No intervention studies have specifically addressed the issue of frailty or multiple morbidities in cancer survivors. Concerted efforts must continue to create and disseminate survivorship care plans to all cancer survivors.

The impact of comorbidity on Health-Related Quality of Life among cancer survivors: analyses of data from the PROFILES registry

PURPOSE

The aim of this study was to assess the difference in explained variance of Health-Related Quality of Life (HRQoL) between comorbidity, sociodemographic characteristics and cancer characteristics. This association was assessed among thyroid cancer, colorectal cancer, and (non-)Hodgkin's lymphoma patients.

METHODS

Data from three large population-based surveys on survivors of thyroid cancer, colorectal cancer, and (non-)Hodgkin's lymphoma were used. Cancer-specific HRQoL was assessed with the European Organization for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire Core 30 (QLQ-C30) of which physical function, emotional function, fatigue, and pain were included in the analyses. Comorbidity was assessed using the Self-reported Comorbidity Questionnaire. The association between comorbidity and HRQoL was assessed with multivariate linear regression models. Semi-partial R (2) was reported to assess the amount of variance in HRQoL explained by comorbidity in comparison with sociodemographic and cancer characteristics.

RESULTS

In total, 3,792 cancer survivors were included in this analysis. The variance in HRQoL subscales explained by comorbidity was higher compared with sociodemographic and cancer characteristics for physical function (11-17 vs. 2-4 and 1-2 %, respectively) and emotional function (7-17 vs. 1-3 and 1-3 %, respectively), regardless of cancer type. In addition, comorbidity explained 7-20 and 11-13 % of the variance in pain and fatigue, respectively, compared to 0-4 % for both sociodemographic and cancer characteristics. Osteoarthritis and back pain were strongly associated with physical function and pain, while depression was strongly associated with emotional function. Depression and back pain were strongly associated with fatigue.

CONCLUSIONS

This study showed that comorbidity explained more variance in physical and emotional function, pain, and fatigue in comparison with sociodemographic and cancer characteristics in cancer survivors, regardless of cancer type. Our findings emphasize the importance of adjusting for the presence of comorbid diseases when assessing HRQoL in cancer survivors.

IMPLICATION FOR CANCER SURVIVORS

Cancer survivors suffering from comorbid diseases experience lower levels of health-related quality of life. Clinicians should become more aware of the impact of comorbidity on HRQoL and provide necessary psychological support to assist self-management of comorbid diseases.

Assessment of the status of a National Action Plan for Cancer Survivorship in the USA

PURPOSE

There are currently more than 12 million cancer survivors in the USA. Survivors face many issues related to cancer and treatment that are outside the purview of the clinical care system. Therefore, understanding and providing for the evolving needs of cancer survivors offers challenges and opportunities for the public health system. In 2004, the Centers for Disease Control and Prevention and the Lance Armstrong Foundation, now the Livestrong Foundation, partnered with national cancer survivorship organizations to develop the National Action Plan for Cancer Survivorship (NAPCS). This plan outlines public health strategies to address the needs of cancer survivors. To date, no assessment of NAPCS strategies and their alignment with domestic cancer survivorship activities has been conducted.

METHODS

The activities of five national organizations with organized public health agendas about cancer survivorship were assessed qualitatively during 2003-2007. Using the NAPCS as an organizing framework, interviews were conducted with key informants from all participating organizations. Interview responses were supplemented with relevant materials from informants and reviews of the organizations' websites.

RESULTS

Strategies associated with surveillance and applied research; communication, education, and training; and programs, policy, and infrastructure represent a large amount of the organizational efforts. However, there are gaps in research on preventive interventions, evaluation of implemented activities, and translation.

CONCLUSIONS

Numerous NAPCS strategies have been implemented. Future efforts of national cancer survivorship organizations should include rigorous evaluation of implemented activities, increased translation of research to practice, and assessment of dissemination efforts.

IMPLICATIONS FOR CANCER SURVIVORS

The results of this descriptive assessment provide cancer survivors, cancer survivorship organizations, researchers, providers, and policy makers with initial information about cancer survivorship public health efforts in the USA. Additionally, results suggest areas in need of further attention and next steps in advancing the national cancer survivorship public health agenda.

Quality of life in patients with metastatic renal cell carcinoma: assessment of long-term survivors

BACKGROUND

An emerging literature describes the potential for long-term survival with targeted agents, but the health-related quality of life (HR-QOL) in patients who receive chronic therapy with these agents is poorly defined.

METHODS

From an institutional database including 562 patients with renal cell carcinoma (RCC), patients were identified who (1) were alive 3 years beyond initiation of systemic therapy for metastatic renal cell carcinoma (mRCC) and (2) received a targeted therapy as a component of their treatment. European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire-Core 36 (QLQ-C30) and Functional Assessment of Cancer Therapy-Kidney Symptom Index (FKSI-15) questionnaires were administered by telephone survey. Data from questionnaires were compared with historical estimates derived from pivotal studies evaluating targeted agents.

RESULTS

A total of 38 patients met eligibility criteria for the study, and 28 patients participated in the telephone survey. Most were male patients and had clear cell histologic type (75% for both). All patients had either good- or intermediate-risk disease by Heng criteria. The mean QLQ-C30 Global QOL score in the present cohort was higher than the mean score among patients evaluated at baseline in the phase III evaluations of pazopanib (73.5 vs. 65.8; P = .07) and everolimus (73.5 vs. 61.0; P = .007). The FKSI-15 score in the present cohort was similar to the mean score among patients evaluated at baseline in the phase III evaluation of sunitinib (45.1 and 46.5, respectively; P = .41).

CONCLUSION

In this small pilot study, long-term survivors with mRCC who received targeted therapies appear to have an HR-QOL comparable to that of patients who participated in relevant phase III studies. Given the many emerging treatment options for mRCC, the HR-QOL of long-term survivors warrants greater attention.