Abstract
Background:
Previous studies identified physical function limitations in older cancer survivors, but few have included objective measures and most focused on breast and prostate cancer survivors. The current study compared patient-reported and objective physical function measures between older adults with and without a cancer history.
Methods:
Our cross-sectional study used a nationally representative sample of community-dwelling, Medicare beneficiaries from the 2015 National Health and Aging Trends Study (n = 7,495). Data collected included patient-reported physical function, including a composite physical capacity score and limitations in strength, mobility, and balance, and objectively measured physical performance metrics, including gait speed, five time sit-to-stand, tandem stand, and grip strength. All analyses were weighted to account for the complex sampling design.
Results:
Thirteen percent of participants (n=829) reported a history of cancer, of which more than half (51%) reported a diagnosis other than breast or prostate cancer. In models adjusted for demographics and health history, older cancer survivors had lower Short Physical Performance Battery scores (unstandardized beta (B)=−0.36; 95% CI: −0.64, −0.08), slower gait speed (B=−0.03; 95% CI: −0.05, −.01), reduced grip strength (B=−0.86; 95% CI: −1.44, −0.27), worse patient-reported composite physical capacity (B=−0.43; 95% CI: −0.67, −0.18) and patient-reported upper extremity strength (B=1.27; 95% CI: 1.07,1.50) compared to older adults without cancer. Additionally, the burden of physical function limitations was greater in women than in men, which may be explained by cancer type.
Conclusions:
Our results extend studies in breast and prostate cancer to show worse objective and patient-reported physical function outcomes in older adults with a range of cancer types compared to those without a cancer history. Moreover, these burdens seem to disproportionately affect older adult women, underscoring the need for interventions to address functional limitations and prevent further health consequences of cancer and its treatment.
Keywords: physical performance, physical capacity, mobility, oncology, older adults
INTRODUCTION
Improved cancer survival rates have resulted in 18 million estimated cancer survivors in the US in 2022, with 67% age 65 and older.1 Despite improved survival from cancer, older cancer survivors are at risk of other health consequences, likely attributable, in part, to cancer and/or its treatments.2,3 Consequently, the majority of cancer survivors live with impaired function and increased risk for high symptom burden.4–6
Physical function is a key indicator of overall health status, with reduced physical function associated with lower quality of life and increased risk of falling, depression, and all-cause mortality in older cancer survivors.7–12 Cancer survivors are at higher risk for physical function limitations compared to individuals without a history of cancer based on patient-reported measures.6,13,14 While patient-reported physical function measures are important for understanding the lived experience of survivorship, objective physical function assessments are valid and reliable measures that can identify impairments amenable to rehabilitation interventions.15 Prior studies that included objective measures of physical function focused on breast and prostate cancer survivors to the exclusion of other cancer types, with mixed findings regarding the presence of physical functional limitations.16–18 Although breast and prostate are the most common cancer types, less is known about physical function in older adults with other cancer types and how physical function impairments might differ between men and women with a cancer history. Overall, there is a lack of studies incorporating both patient-reported and objective measures examining physical function across cancer types and by sex. Therefore, the purpose of this study was to compare patient-reported and objective measures of physical function between older adults with and without a cancer history in a nationally representative sample of U.S. Medicare beneficiaries, without exclusion by cancer type.
METHODS
We analyzed Data from Round 5 of the National Health and Aging Trends Study (NHATS) collected in 2015.19 The overarching aim of the NHATS is to examine trends in functional changes and to advance understanding of disability in U.S adults aged 65 and older. Data collection consisted of in-home standardized interviews and objective measures of physical performance. All participants, or their proxy respondents, provided written informed consent.
Study Population
Starting in 2011, the NHATS used an age-stratified, three-stage sample design, with the Medicare enrollment database as the sampling frame, to recruit 8,245 participants Medicare beneficiaries age 65 and older (72% survey response rate). The multi-stage sampling design oversampled Black, non-Hispanic adults and the oldest-old (≥90 years). In Round 5, conducted in 2015, the study sample was replenished with 4,182 (70.6%) new participants in addition to 3,856 remaining from the original sample. For the current study, participants with proxy-respondents were retained in the analyses. Participants living in nursing homes or other residential care facilities who were not expected to return to their previous residence (n=539, 6.7%) and those who did not complete the in-person interview (n=39, <1%) were excluded from the analyses, resulting in a final sample of 7,495 community-dwelling older adults.
Measures
Cancer History
Participants were asked if they had ever been diagnosed with cancer by a doctor. Those who responded yes were asked to name the type of cancer. Responses were grouped under the categories of breast, prostate, colon, gynecological (cervical, ovarian, uterine), bladder, kidney, or skin. All other types were documented as ‘other’ in the NHATS dataset. Participants who reported more than one type of cancer were categorized as such, allowing for all groups to be mutually exclusive.
Demographics and Health History
During the interview, participants were asked about age, sex, self-identified race and ethnicity, and highest education level achieved. Age was categorized into 5-year increments (beginning at age 65 up to ≥90) and race/ethnicity was categorized into five groups (White-non-Hispanic, Black-non-Hispanic, Hispanic, American Indian/Asian/Native Hawaiian, and Unknown). Participants were asked about the highest level of education completed, which was categorized as less than high school, high school graduate, some college, or college graduate. Household income was categorized based on relationship to the poverty threshold for 2015 (below the poverty line, 100%−199% above the poverty line, and ≥200% above the poverty line). Participants were asked if a doctor has ever told them that they have certain medical conditions, including heart disease, hypertension, osteoarthritis, osteoporosis, diabetes, pulmonary disease, or stroke. Participants were classified as having probable dementia using the previously validated algorithm based on self-report of medical provider diagnosed dementia, the AD8 Dementia Screening questionnaire20 completed by proxy respondents, and tests of memory, orientation, and executive function.21 A previously validated index of multi-morbidity was employed by summing the number of diagnoses reported including classification of probable dementia.22 Body mass index (BMI) was calculated from measured height and weight. Weight status was classified as underweight (BMI < 18kg/m2), normal, overweight (25 kg/m2 to 29.9 kg/m2 BMI), and obese (BMI ≥ 30.0 kg/m2). Self-rated health was reported on the scale of excellent, very good, good, fair, or poor.
Objective Measures of Physical Function
Participants completed four measures of physical performance including grip strength testing, the five times sit-to-stand test, usual gait speed test, and the four-stage balance test. For grip strength, we used the higher value of kilograms from two trials of testing with a handheld dynamometer. For usual gait speed, we used the faster value, in meters per second, from two trials of walking three meters from a standing start. After a trial ensuring that participants were safe and able to complete a single chair rise, participants completed the five times sit-to-stand test with the time to complete the test recorded. Procedures included starting in a seated position with arms folded across the chest and then standing up and sitting back down again five times as quickly as possible while keeping the arms folded. The static balance testing consisted of progression through a series of increasingly difficult postures, including standing with feet side by side, semi-tandem stand, and tandem stand. If a participant could not hold a position for 10 seconds in one attempt, they did not proceed to the more challenging postures. For this study, we used the outcome of ability to hold the tandem stand for at least 10 seconds (yes/no).
A composite score of physical performance was calculated based on the Short Physical Performance Battery (SPPB).23 The SPPB score on the range of 0–12 is based on gait speed, the most challenging balance position held for 10 seconds up to the tandem stand, and time to complete the five times sit-to-stand test. Higher scores indicate better physical function. Physical function status was categorized as no limitations (score=12), minimal limitations (10–11), mild limitations (7–9), moderate limitations (5–6), and severe limitations (0–4).
Patient-reported Measures of Physical Function
The patient-reported measure of physical capacity has been previously validated in older adults.24,25 For this measure, participants were asked a series of paired questions assessing functional abilities. They were first asked about their ability to perform the more challenging task of each pair. If they confirmed their ability to complete the more difficult version of the task, they were not asked about the easier version and were assumed to be able to do it. Participants were asked about ability to walk 3 and 6 blocks, ability to walk up 10 and 20 stairs, ability to lift and carry 10 and 20 pounds, ability to bend over and kneel down without upper body support, ability to reach overhead and place a heavy object overhead; and ability to grasp small objects and open a sealed jar with hands only. A score for physical capacity was calculated by summing the total number of activities the respondent reported they were able to do on the range of 0–12 with higher values indicating greater physical capacity.24 The physical capacity score was also categorized as no limitations (score=12), minimal limitations (9–11), moderate limitations (5–8), and severe limitations (0–4).
For patient-reported balance problems, participants were asked if balance or coordination problems had limited their activities in the last month (yes/no). Similarly, for patient-reported upper extremity strength, participants were asked if limited strength in their shoulders, arms, or hands limited activities in the past month (yes/no). The same question was posed about limited lower extremity strength in the hips, legs, knees, or feet limiting activities in the last month.
Patient-reported mobility dysfunction was assessed based on difficulty and/or assistance needed to complete mobility inside and outside the home. In the interview, participants were asked if they had difficulty with indoor mobility (yes/no) and if they required help with indoor mobility (yes/no). The responses from these two questions were then combined into a single outcome indicating difficulty &/or help required for indoor mobility (yes/no). The same questions were asked related to outdoor mobility with the answers combined to create a dichotomous indicator for difficulty &/or help needed with outdoor mobility.
Data Analysis
For all analyses, the 2015 analytic sample weights were applied to account for non-response, incomplete interviews, oversampling of Black participants and oldest old subgroups, and sample replenishment. Per the NHATS recommended procedures, Taylor series linearization was used to calculate prevalence estimates and 95% confidence intervals (CI) including prevalence of each cancer type (Supplemental Table 1). A history of skin cancer was not included in the analyses examining outcomes by cancer history. Prevalence of any cancer history was estimated for the population as a whole and by age, sex, race/ethnicity, education level, income, weight status, number of non-cancer co-morbid conditions, and self-rated health (Table 1). Differences in demographic characteristics, medical conditions and objective and patient-reported measures of physical function (Table 2) by cancer history were evaluated using the adjusted Wald statistic. We used linear and Poisson regression, for continuous and dichotomous outcomes, respectively, to model the association of cancer history and physical performance measures (SPPB, gait speed, five times sit-to-stand test, grip strength, tandem balance for 10 seconds; Table 3) and of cancer history and patient-reported measures of physical capacity, indoor and outdoor mobility, lower and upper body strength, and balance (Table 4). All models were adjusted for age, sex, race/ethnicity, education, income, BMI, and multimorbidity. We compared physical limitation severity, based on the SPPB and physical capacity categories, by sex (Figure 1). For context, we also compared mean SPPB and physical capacity scores among men and women, by cancer history. We calculated prevalence in each of the SPPB and patient-reported physical capacity categories by the seven cancer categories available (Supplemental Figure 1). All analyses were performed with Stata (Version 17.0 Stata Corp., College Station, TX).
Table 1.
Demographic and Health Characteristics by Cancer History
| Total (n=7495) |
Cancer history (n=829) |
No cancer history (n=6666) |
P | |
|---|---|---|---|---|
|
| ||||
| Variables | Weighted % (95% CI) |
Weighted % (95% CI) |
Weighted % (95% CI) |
|
| Age | 0.002 | |||
| 65–69 | 28.9 (27.9–30.0) | 29.1(25.2–33.4) | 28.9 (27.7–30.1) | |
| 70–74 | 27.1 (26.1–28.2) | 21.7 (19.2–24.4) | 27.9 (26.7–29.2) | |
| 75–79 | 18.7(17.9–19.5) | 20.2 (17.4–23.4) | 18.5 (17.7–19.3) | |
| 80–84 | 12.6 (11.9–13.3) | 15.4 (13.3–17.8) | 12.2 (11.5–12.9) | |
| 85–89 | 8.1 (7.7–8.6) | 8.8 (7.1–10.9) | 8.0 (7.5–8.5) | |
| ≥90 | 4.6 (4.2–5.0) | 4.8 (3.8–6.1) | 4.5 (4.2–4.9) | |
| Sex | 0.17 | |||
| Female | 55.4 (54.2–56.6) | 53 (49.5–56.5) | 55.7 (54.4–57) | |
| Male | 44.6 (43.4–45.9) | 47.0 (43.5–50.6) | 44.3 (43.0,45.6) | |
| Race and Ethnicity | 0.10 | |||
| White | 77.9 (75.7–80) | 80.2 (76.3–83.6) | 77.5 (75.3–79.6) | |
| Black | 8.2 (7.3–9.1) | 6.8 (5.6–8.3) | 8.3 (7.5–9.3) | |
| Hispanic | 6.9 (5.7–8.5) | 5.4 (3.7–7.9) | 7.2 (5.8–8.8) | |
| American Indian/Asian/ Native Hawaiian | 3.9 (3.1–4.9) | 3.4 (2–5.6) | 4 (3.2–4.9) | |
| Unknown | 3.1 (2.5–3.9) | 4.1 (2.6–6.4) | 3 (2.3–3.7) | |
| Education | 0.44 | |||
| < High school | 17.2 (15.8–18.7) | 16.5 (13.9–19.4) | 17.3 (15.8–18.9) | |
| High school | 26.2 (24.6–27.8) | 27.8 (23.5–32.4) | 26.0 (24.4–27.6) | |
| Some college | 28.4 (26.9–29.9) | 25.7 (22.0–29.8) | 28.8 (27.3–30.3) | |
| ≥College graduate | 28.3 (26.0–30.7) | 30.1 (25.3–35.3) | 28.0 (25.8–30.2) | |
| Income | 0.007 | |||
| Below poverty line | 14.8 (13.6–16) | 11.3 (9.4–13.5) | 15.3 (14.0–16.6) | |
| 100–199% above poverty line | 21.3 (19.9–22.8) | 21.4 (18.7–24.3) | 21.3 (19.8–22.8) | |
| ≥200% above poverty line | 63.9 (62.1–65.8) | 67.4 (63.9–70.6) | 63.4 (61.4–65.4) | |
| BMI | 0.14 | |||
| Under weight (<18 kg/m2) | 2.0 (1.6–2.5) | 2.3 (1.3–4) | 2.0 (1.6–2.5) | |
| Normal (18–25 kg/m2) | 30.1 (29–31.2) | 33.6 (30.2–37.2) | 29.6 (28.4–30.8) | |
| Overweight (25–30 kg/m2) | 36.7 (35.4–37.9) | 35.1 (32.1–38.2) | 36.9 (35.6–38.2) | |
| Obese (≥30 kg/m2) | 31.2 (30.1–32.4) | 29 (25.9–32.3) | 31.6 (30.4–32.7) | |
| No. of non-cancer medical conditions | 0.36 | |||
| 0 | 10.8 (9.9–11.7) | 8.8 (6.6–11.6) | 11.1 (10.1–12.2) | |
| 1 | 21.4 (20.3–22.5) | 21.5 (17.3–26.5) | 21.4 (20.3–22.4) | |
| 2 | 26.8 (25.7–28.4) | 25.7 (22.5–29.1) | 27.0 (25.7–28.4) | |
| 3 | 21.6 (20.4–22.9) | 23.9 (20.2–27.9) | 21.3 (20.1–22.5) | |
| ≥4 | 19.4 (18.5–20.4) | 20.1 (16.8–24.0) | 19.3 (18.3–20.3) | |
| Self-rated health | <0.001 | |||
| Poor | 5.3 (4.7–5.9) | 8.9 (6.7–11.9) | 4.7 (4.1–5.4) | |
| Fair | 17.5 (16.4–18.7) | 20.9 (17.4–24.8) | 17 (15.8–18.3) | |
| Very good | 30.8 (29.5–32.1) | 21.9 (19–25) | 32.1 (30.7–33.5) | |
| Excellent | 14.3 (13.1–15.6) | 12.3 (9.5–15.7) | 14.6 (13.3–16.1) | |
Table 2.
Objective and Self-reported Physical function by Cancer History
| Cancer history | No cancer history | P | |
|---|---|---|---|
|
| |||
| Mean (95% CI) or Weighted % (95% CI) | Mean (95% CI) or Weighted % (95% CI) | ||
| Objective Measures | |||
| SPPB score (0–12) | 6.5 (6.2–6.9) | 7.0 (6.9–7.1) | 0.02 |
| SPPB category | 0.09 | ||
| No limitations | 5.4 (3.8–7.6) | 7.1 (6.1–8.4) | |
| Minimal limitations | 17.2 (13.7–21.5) | 21.2 (19.8–22.6) | |
| Mild limitations | 33.7 (29.9–37.7) | 31.3 (30.2–32.6) | |
| Moderate limitations | 20.8 (18.1–23.8) | 21.5 (20.2–22.8) | |
| Severe limitations | 22.9 (19–27.5) | 18.9 (17.6–20.3) | |
| Gait speed (m/s) | 0.81 (0.78–0.83) | 0.84 (0.8–0.9) | 0.009 |
| Unable to hold tandem balance for 10 seconds | 43.7 (39.5–48.0) | 39.3 (37.6–40.9) | 0.03 |
| Five-time-sit-to-stand (sec) | 11.9 (11.5–12.3) | 11.6 (11.5–11.8) | 0.19 |
| Grip strength (kg) | 26.8 (25.8–27.8) | 27.4 (27–27.8) | 0.27 |
|
| |||
| Self-report Measures | |||
|
| |||
| Physical capacity (0–12) | 8.9 (8.6–9.2) | 9.4 (9.2–9.5) | 0.004 |
| Physical capacity category | 0.01 | ||
| No limitations | 29.5 (25.5–33.9) | 36.7 (35.3–38.2) | |
| Minimal limitations | 35.3 (34.1–36.5) | 37.1 (33.5–40.9) | |
| Moderate limitations | 17.1 (14.7–19.8) | 14.6 (13.7–15.5) | |
| Severe limitations | 16.3 (13.2–19.9) | 13.4 (12.5–14.5) | |
| Difficulty &/or help required for inside mobility | 21.1 (18.1–24.4) | 16.4 (15.3–17.6) | 0.003 |
| Difficulty &/or help required for outside mobility | 22.6 (19.5–26) | 17.9 (17.1–18.7) | 0.002 |
| Balance or coordination problem limits activities | 18 (15.2–21.2) | 14.8 (13.8–15.9) | 0.05 |
| Limited lower body strength impacts activities | 27.2 (23.2–31.6) | 23.6 (22.5–24.9) | 0.12 |
| Limited upper body strength impacts activities | 22.0 (18.7–25.7) | 16.8 (15.7–18.0) | 0.01 |
CI=Confidence Interval
Table 3.
Association of cancer history with the Short Physical Performance Battery, gait speed, five time sit-to-stand test, grip strength, and ability to hold tandem stand for 10 seconds.
| SPPB score | Gait Speed m/sec | Five time sit to stand in seconds | Grip Strength | Unable to hold tandem balance for 10 seconds | |
|---|---|---|---|---|---|
| (n=6798) B (95% CI) |
(n=6355) B (95% CI) |
(n=5360) B (95% CI) |
(n=6320) B (95% CI) |
(n=7277) IRR (%) |
|
| Cancer history | |||||
| No | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| Yes | −0.36 (−0.64,−0.08) | −0.03 (−0.05,−0.01) | 0.25 (−0.08,0.58) | −0.86 (−1.44,−0.27) | 1.07 (0.98,1.17) |
All models adjusted for age, sex, race/ethnicity, education, income, body mass index, and multi-morbidity. Bold values indicate p<0.05. SPPB=Short Performance Physical Battery, m/sec=meters/seconds, B=unstandardized coefficient, IRR= Incidence Rate Ratio, CI= Confidence Interval
Table 4.
Association of cancer history with the self-report measures of physical capacity, indoor and outdoor mobility, lower and upper body strength, and balance.
| Physical Capacity | Difficulty &/or assistance for indoor mobility | Difficulty &/or assistance for outdoor mobility | Limited lower body strength impacts activities | Limited upper body strength impacts activities | Balance or coordination problem limits activities | |
|---|---|---|---|---|---|---|
| (n=7242) B (95% CI) |
(n=7371) IRR (95% CI) |
(n=7371) IRR (95% CI) |
(n=7379) B (95% CI) |
(n=7377) B (95% CI) |
(n=7372) IRR (95% CI) |
|
| Cancer history | ||||||
| No | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 | 1.0 |
| Yes | −0.43 (−0.67,−0.18) | 1.26 (1.09,1.46) | 1.25 (1.09,1.40) | 0.03 (−0.01,0.07) | 1.27 (1.07,1.50) | 1.18 (0.98,1.42) |
All models adjusted for age, sex, race/ethnicity, education, income, body mass index, and multi-morbidity. Bold values indicate p<0.05. B=unstandardized coefficient, IRR= Incidence Rate Ratio, CI= Confidence Interval
Figure 1.
Physical Performance on the Short Performance Physical Battery (a) and Patient-Reported Physical Capacity (b) Among Men and Women with a Cancer History.
RESULTS
In the 2015 round of the NHATS, 829 (12.8 weighted percent; 95% CI: 12.0–13.7) participants, representing about 5,227,000 older adults based on the weighted sample, reported a history of cancer, excluding skin cancer diagnoses. Most of those with a cancer history reported a breast (24.9%; 95% CI: 21.5–28.7) or prostate cancer (23.7%; 95% CI: 20.6–27.1) diagnosis (See Supplemental Table 1). Sixty-one participants (7.6%; 95% CI: 5.5–10.4) reported more than one cancer type. Those with a cancer history were significantly older, had a higher percentage living ≥200% above the poverty level, and worse self-reported health compared to older adults without a cancer history (See Table 1). The participants with a cancer history were comparable to those without a reported cancer history with respect to sex, race/ethnicity, education, BMI, and number of co-morbid conditions, not including cancer.
The unadjusted mean score on the SPPB for older adults with a cancer history (6.5; 95% CI: 6.2–6.9) was lower among those without a cancer history (7.0; 95% CI: 6.9–7.1; p=0.02) (Table 2) due to slower gait speed (0.80 vs. 0.84) and worse balance (43.7% vs. 39.3% unable to hold the tandem stand for 10 seconds), while there was no difference for time to complete five times sit-to-stand test or grip strength. Older adults with a cancer history reported lower physical capacity compared to those without a cancer history (8.9 vs 9.4, p=0.004), with a significantly higher number of cancer survivors classified as having moderate and severe limitations. Compared to older adults without a cancer history, a significantly higher percentage of cancer survivors reported limitations in indoor and outdoor mobility, balance, and upper extremity strength.
In regression models adjusted for demographic characteristics, BMI, and multi-morbidity, participants with a cancer history had significantly worse SPPB scores, slower gait speed, and lower grip strength (p<0.05), but no significant difference in time to complete the five time sit-to-stand test or ability to hold a tandem stand for at least 10 seconds by cancer history (Table 3). Adjusted models for patient-reported measures mirrored the objective measurement outcomes, with significantly worse physical capacity, indoor and outdoor mobility, and upper extremity strength limitations in those with a history of cancer compared to those without, while patient-reported lower extremity strength and balance limitations were not different.
To better understand sex differences in physical function, we compared severity of objective physical performance and patient-reported physical capacity limitations in men and women with a cancer history. As shown in Figure 1, there was a significant difference in categorical physical performance limitations by sex (p=0.002). Men with a cancer history were more likely to have mild limitations based on the SPPB, compared to women with a cancer history (39.5% vs 28.5%). Conversely, women with a cancer history were more likely to have severe limitations, based on the SPPB, compared to men with a cancer history (28.8% vs 16.3%). Also shown in Figure 1, compared to women, men with a cancer history were more likely to report no limitations (44.2% vs 16.2%) whereas women with a cancer history were more likely to report moderate or severe limitations compared to men with a cancer history (46.1% vs. 19.4%, p<0.001).
Notably, there was no significant difference in mean SPPB scores for men with and without a cancer history (7.0; 95% CI: 6.5–7.5 vs. 7.3; 95% CI: 7.2–7.5, respectively; p=0.19) or patient-reported physical capacity (9.9; 95% CI: 9.6–10.4 vs. 10.2; 95% CI: 10.1–10.3, respectively; p=0.24; data not shown). However, women with a cancer history had significantly more impairment compared to women without a cancer history based on SPPB scores (6.1; 95% CI: 5.7–6.6 vs. 6.7; 95% CI: 6.5–6.8; respectively; p=0.02) and patient-reported physical capacity (7.9; 95% CI: 7.5–8.3 vs. 8.7; 95% CI: 8.5–8.8, respectively; p=0.001; data not shown).
Differences in physical performance and physical capacity categorization by cancer type are displayed in Supplemental Figure 1. Older adults with a history of gynecological cancer or more than one cancer site had higher proportions of participants categorized as having moderate to severe limitations based on the SPPB (54%; 95% CI: 38%−70% and 57%; 95% CI: 41%−71%, respectively) compared to those with prostate (36%; 95% CI: 28%−46%) and kidney cancer (35%; 95% CI: 21%−53%). Similarly, a higher percentage of participants with gynecological and more than one cancer site were categorized as having moderate-to-severe limitations based on patient-reported physical capacity (64%; 95% CI: 48%−77% and 53%; 95% CI: 39%−68%, respectively) versus those with prostate (20%; 95% CI: 14%−28%) or colon (25%; 95% CI: 16%−38%) cancer history. Notably, 40% (95% CI: 32%−48%) of women with a history of breast cancer perceived themselves as having moderate-severely limited physical capacity, with a higher percentage, 48%, (95% CI: 41%−55%) categorized as having moderate-severe limitations based on the SPPB objective tests.
DISCUSSION
We compared objective and patient-reported measures of physical function in older adults with and without a cancer history in a nationally representative sample of U.S. older adults. An estimated 12.8 percent, representing over 5 million older adults, reported a history of cancer, of which over half reported a diagnosis other than breast or prostate cancer. Overall, after adjusting for demographic and health factors, we found lower objectively measured SPPB scores, gait speed, and grip strength in older adult cancer survivors compared to older adults without a cancer history, consistent with lower patient-reported physical capacity scores. While the differences in physical function outcomes were statistically significant, the findings should also be considered in light of clinically meaningful differences. Overall, the differences in mean SPPB scores and gait speed between older adults with a cancer history and those without align with small but meaningful differences.26 Additionally, the results of the patient-reported measures suggest these modest reductions are robustly perceived by older cancer survivors. Our findings add new information to the literature by showing older women with a cancer history experience more severe functional limitations compared to older men with a cancer history by objective and patient-reported measures. On average, older woman with a cancer history have significantly lower scores on objective and patient-reported measures of physical function compared to older women without a cancer history. These outcomes demonstrate that perceptions of worse physical function in older cancer survivors reflect impairments in physical performance by objective tests across a broad range of cancer diagnoses and identify aspects of physical function that need rehabilitative interventions in women.
Previous studies that examined objectively measured outcomes in cancer survivors showed mixed results. Winters-Stone et al. found lower SPPB scores and worse handgrip strength in older breast cancer survivors compared to age-matched controls but, in contrast to our results, longer time to complete the sit to stand test and no difference in gait speed.18 Similar to our findings, in a longitudinal study of older breast cancer survivors using objective measures, Luo et al. reported significant declines in grip strength and gait speed over time compared to cancer-free controls.16 Our study advances the field by showing that these limitations are not unique to breast cancer patients, but extend to a wider range of cancer types with women survivors experiencing greater functional limitations. Interventions to mitigate these declines are needed, particularly in women, given the impact of physical function limitations on risk for frailty, falls, and mortality.7,27–29 The consistent findings across studies of decreased physical function in older women with a cancer history reinforces the need for interventions that target strength and functional mobility.
A novel finding is the differential burden of physical function limitation by sex. Older women with a history of cancer experienced greater severity of limitations in physical function compared to men with a cancer history. The higher prevalence of moderate and severe patient-reported physical capacity limitations provides insight on how physical function impairment impacts functional abilities needed in daily life. We are not able to discern if the increased severity of limitations in women with a cancer history is attributable to the cancer, cancer treatment, or the impact of a serious health-related event. However, these findings contribute to our knowledge of the additional challenges women face in survivorship with implications for quality of life and functional mobility. Considerations for long term support and interventions to address functional loss in aging women survivors are needed. While exercise and rehabilitation are needed to address individual factors, universal housing design and age friendly communities are two examples of environmental approaches to reducing the burden of physical function impairment. Given that close to 40% of women will be diagnosed with cancer in their lifetime30 and the longer average life span for women, environmental approaches, with policies that support them, are more likely to achieve significant impact on quality of life and ability to remain community-dwelling.
As a cross-sectional study, we are limited to identifying associations, not causation, between cancer history and physical function limitations among community-dwelling older adults. Additionally, with the focus on Medicare beneficiaries age 65 and older in the NHATS, there is a risk of survivor bias in the population studied. The NHATS study allowed us to examine multiple physical function outcomes in a large, nationally representative sample of U.S. older adults, although we were limited by the lack of information on time since diagnosis and cancer treatment received. Given this limitation, we are not able to consider the effect of time and interventions on the physical function outcomes. However, the differences that were found, particularly among older women with a cancer history, suggest a persistence of impairment, consistent with other studies using subjective measures of physical function,31,32 that warrant further investigation with longitudinal studies. Cancer history was self-reported and may be subject to recall bias. Future studies linking Medicare claims to NHATS to confirm cancer diagnoses and co-morbidities, including the interaction of new diagnoses with a cancer history, on physical function trajectories is needed.
This study demonstrates worse physical function outcomes, across multiple objective and patient-reported measures, in older adults with a cancer history compared to those without cancer. Further study is needed to identify if the differences in physical function are relatively stable or continue to decline over time in comparison to those without a cancer history. Additionally, longitudinal follow-up can provide insight on the stability of balance and lower extremity functional strength in older adults with a cancer history apart from age-related decline. Overall, the findings reinforce the need for interventions addressing physical function to prevent further sequalae from cancer and cancer treatment in older adults, and especially in older women with a history of cancer.
Supplementary Material
Supplemental Table 1. Distribution of participants by cancer type (n=829).
Supplemental Figure 1. Physical Performance by Cancer Type based on the Short Performance Physical Battery (a) and Patient-Reported Physical Capacity (b).
Key Points.
Both performance-based and patient-reported measures of physical capacity were worse among older cancer survivors than in those without a cancer history
Older women with a cancer history exhibit greater severity of limitations in multiple dimensions of physical function compared to older men with a cancer history.
Older adults with gynecological and breast cancer or more than one cancer had worse objective and patient-reported physical function.
Why does this matter?
Reduced physical function is associated with poor quality of life and increased fall risk and all-cause mortality in older adults. Based on a nationally representative sample, our findings demonstrate limitations in both patient-reported and objective measures of physical function in older adults with a cancer history compared to those without. Older women experience greater severity of physical function impairment compared to men, which has implications for quality of life and aging support services. Identifying aspects of physical function that are impacted by cancer and its treatment can help target interventions to prevent functional loss and associated risks.
Funding:
The research reported in this manuscript was supported by the National Institutes on Aging and Arthritis and Musculoskeletal and Skin Disease of the National Institutes of Health under award numbers U01AG032947 and R01 AR065826.
Funding Information:
This study was funded by the National Institutes on Aging and Arthritis and Musculoskeletal and Skin Disease.of the National Institutes of Health under award number U01AG032947 and R01 AR065826.
Footnotes
Conflict of Interest: The authors declare no conflicts of interest.
Sponsor’s Role: The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders or the authors’ affiliated academic institutions. The funders had no role in the design, collection, analysis, and interpretation of data or writing/submission of this report.
SUPPORTING INFORMATION
Additional supporting information can be found online in the Supporting Information section at the end of this article.
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Associated Data
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Supplementary Materials
Supplemental Table 1. Distribution of participants by cancer type (n=829).
Supplemental Figure 1. Physical Performance by Cancer Type based on the Short Performance Physical Battery (a) and Patient-Reported Physical Capacity (b).