Do older adult cancer survivors experience worse health-related quality of life in comparison to middle-aged cancer survivors? A secondary data analysis of the 2014 behavioral risk factor surveillance study

INTRODUCTION

Cancer is primarily a disease of aging, with a majority of cancer diagnoses and deaths occurring in adults over the age of 65.^[1] Today, 62% of cancer survivors in the U.S. are age 65 years or older. In just 20 years, this proportion will climb to 73%, and older adult cancer survivors will number over 19 million.^[2] This growth in the older adult cancer survivor population warrants further inquiry into the impact of cancer on older adults’ health outcomes.

Cancer frequently brings about chronic pain, fatigue, and decreases in performing occupational activities.^[3-6] For instance, individuals diagnosed with prostate cancer have cited complications with sexual functioning; and those with colorectal cancer have reported struggling with bowel and urinary incontinence.^[3,6,7] Cancer survivors also report increased anxiety, depression, and intense fears about cancer recurrence.^[5,8-10] These health challenges may be further exacerbated in older adults, who must also contend with many age-related health problems, such as declines in sensory function, restrictions in physical mobility, and increases in chronic disease development.^[11-15] Despite these reports, little is known about older adult cancer survivors’ health-related quality of life (HRQOL) and how this might compare with the HRQOL of cancer survivors who are in middle age (45–64 years old).

HRQOL is a subjective assessment of the impact of a disease on an individual’s quality of life, particularly the extent to which the disease interferes with one’s physical and mental functioning.^[16] It is an important endpoint in clinical cancer care and provides the medical team with a meaningful comparison of a patient’s well-being in relation to the non-cancer population.^[17,18] Existing research on the effect of age on HRQOL outcomes in older cancer survivors has reported mixed findings. For instance, while some studies reported that older adult cancer survivors had a higher risk of psychological distress than middle-aged survivors,^[19,20] other studies have reported the opposite or no relationship between age group and psychological distress.^[21-25] One difficulty with understanding how age impacts HRQOL in cancer survivors is that a vast majority of HRQOL studies focus on breast or prostate cancer survivors, which are highly treatable.^[26] In addition, many HRQOL studies are drawn from convenience samples, such as a particular hospital or survivor support group, and are not representative of the population.

The current study will add to the literature by examining the physical and mental HRQOL of adult cancer survivors of multiple cancer sites using a population-based sample from the Behavioral Risk Factor Surveillance Study (BRFSS).^[27] We hypothesize that the age group (middle age vs. older age) will be associated with physical and mental HRQOL, such that older adults will report worse HRQOL outcomes than their middle-aged counterparts.

Conceptual framework

To examine predictors of HRQOL, this study utilized the contextual model of HRQOL as shown in Figure 1,^[28,29] which posits that HRQOL is influenced by the macro-systemic domain, which comprises: (a) Demographics, such as age and gender; (b) cultural context, such as ethnicity; (c) socioecological factors, such as income, education, and employment; and (d) health-care system factors, such as health insurance status. HRQOL is also posited to be influenced by the micro-individual domain, which consists of: (1) General health, such as disease status and comorbidities; (2) cancer-related factors, such as cancer stage and treatment type; (3) psychological well-being, such as depression; and (4) health efficacy, such as health practices and medical adherence.

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Figure 1:: Contextual model of health-related quality of life.

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MATERIAL AND METHODS

Data for this study were drawn from the 2014 wave of BRFSS, a cross-sectional survey conducted annually in the United States about health behaviors and conditions. The data analytic sample for this study included participants age 45 years and older who reported ever having had a cancer diagnosis and who completed the cancer survivorship questionnaire (n = 5656). This study was approved by the Institutional Review Board of Columbia University.

RESULTS

DISCUSSION

Findings from this study revealed that older adult cancer survivors reported better HRQOL than middle-aged survivors. This finding comes as a surprise, given that declines in physical functioning tend to occur with increasing age.^[12,36]

However, it is in line with the previous findings.^[8,21,22] One explanation could be that a cancer diagnosis presents a greater threat or life interruption for middle-aged survivors, who are typically still working and raising a family; unlike older survivors, who might perceive cancer as yet another “bump in the road.”^[37]

The current study also suggests that being married improves mental HRQOL. This could be due to social support and caregiving benefits received from spouses following a cancer diagnosis. The extant literature supports this notion with studies finding that married cancer patients were up to 20% less likely to die from cancer than unmarried cancer patients.^[38-41] These findings highlight the importance of marital support in improving survivorship outcomes and the need to focus greater attention on survivors who do not have a spouse.

The present study also found that experiencing financial cost as a barrier to care was a predictor of poor mental HRQOL, echoing that of the literature.^[42-44] This could indicate that concerns over ability to afford health care take a great toll on cancer survivors’ mental HRQOL. Indeed, studies have found that survivors who faced financial barriers to care were more likely to experience depression and increased worry about cancer recurrence.^[42-44] Thus, efforts to improve HRQOL in cancer survivors should focus on removing financial barriers to care.

In addition, having a stroke history was found to detrimentally affect physical and mental HRQOL. This finding was not surprising, as research with non-cancer populations has shown stroke lowers functioning and quality of life.^[45,46] Even 15 years after experiencing a stroke, 39% of respondents were depressed and 63% had some form of physical disability.^[45] This underscores the importance of including comorbid conditions, especially stroke, when considering efforts to improve HRQOL.

Having completed treatment was found to be a significant predictor of better physical and mental HRQOL. This finding is expected, as research consistently has documented the positive relationship between treatment completion and survival.^[47,48] Patients still in treatment have frequently reported pain, fatigue, and loss of memory and motor functions, all of which can contribute to a poorer HRQOL.^[3-6] Thus, interventions should be developed to help patients complete timely treatment.

In the present study, having a history of depression was associated with poor mental HRQOL. This is not surprising, given that the literature largely documents strong links between depression and worse mental HRQOL in cancer survivors.^[5,8-10] Rieke et al.^[49] showed that among older head-and-neck cancer patients, those with pre-cancer depression were 49% more likely to die from their cancer, while those diagnosed with depression after their cancer were 38% more likely to die from their cancer compared to patients without depression. These reports warrant greater efforts for combating the debilitating effect of cancer on mental HRQOL.

Finally, the current study also found that preventive health behaviors, such as exercising and not smoking, were predictors of better HRQOL – findings that are also in line with the literature.^[50,51] These reports underscore the importance of promoting healthy behaviors in cancer survivors to enhance HRQOL.

CONCLUSION

Despite these limitations, this study has several important implications. Middle-aged cancer survivors should be targeted in efforts to improve HRQOL. In addition, cancer survivors who are unmarried, experienced cost as a barrier to care, have physical comorbidities, or a history of depression should be included in interventions to improve HRQOL. Special attention should be paid to cancer survivors who have had a stroke, as they could be at greater risk of poor HRQOL. Greater effort needs to be made to reach individuals who have difficulty adhering to treatment. Overall, the findings from this study indicate that contextual factors influence middle-aged and older adult cancer survivors’ HRQOL.