Abstract
Purpose
Using data from the National Health Interview Survey (NHIS), this study examined the odds of functional limitations across nine domains by cancer status (with vs. without cancer history) and age group (18–44, 45–64, 65 + years).
Methods
Participants were 151,509 adults in the 2014–2018 NHIS. Functional limitations included self-reported difficulty conducting nine activities. Data were analyzed using age-stratified multivariate logistic regression (no limitation vs. limited in any way; minor limitation vs. major limitation) and are reported as covariate-adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). To gather insight on the influence of cancer, compared to aging without a history of cancer, on functional limitations, we also conducted exploratory regression analyses comparing all cancer by age groups to 18–44 year-olds without a cancer history.
Results
Cancer survivors (n = 12,518) were more likely to report a limitation than adults without cancer (n = 138,991). Age-stratified ORs for 1 + limitation were 2.75 (95% CI 1.98, 3.81) among 18–44 year-olds, 2.42 (95% CI 2.00, 2.93) among 45–64 year-olds, and 1.59 (95% CI 1.39, 1.82) among 65 + year-olds. Cancer survivors were more likely to report major limitations across multiple domains, with age-stratified ORs ranging from 1.18 (65 + year-olds, stooping limitation) to 2.28 (18–44 year-old, sitting limitation). ORs from exploratory analyses were lowest among 45–64 year-old adults without a cancer history (2.69–4.42) and highest among older adult cancer survivors (3.42–14.73).
Conclusions
Cancer was associated with limitations across age groups, with the highest age-stratified ORs observed among younger adults and for mobility and lower-extremity limitations. Stronger efforts to assess limitations as part of routine care and implement targeted interventions to address limitations are needed.
Implications for cancer survivors
Functional limitations have been linked with poorer aging trajectories and lower quality of life in cancer and non-cancer populations. Routine screening to identify and discuss functional limitations with cancer patients may help reduce the burden of such limitations on survivors.
Keywords: Cancer survivorship, Functional limitations, Accelerated aging, Physical function
Introduction
Advancements in cancer detection and treatment have led to a United States (US) cancer survivor population of over 18 million, which is expected to reach 26 million by 2040 [1, 2]. Across all age groups, 5-year survival has increased dramatically over the last half-century, with rates increasing among adults from 49% in the mid-1970s to 69% in 2019, among adolescents from 68 to 86%, and among children from 58 to 85% across this same time period [2]. Despite these significant reductions in cancer mortality, survivors often endure long-term health consequences [3] incommensurate with normal aging. Unfortunately, these consequences are often reflective of premature aging and can have significant and clinically meaningful impacts on survivors’ functional status, quality of life, independence, and successful aging [1, 4].
Defined as self-reported and perceived restrictions in the ability to perform physical functions, such as reaching over head, climbing stairs, stooping, or walking a short distance without assistance [5], functional limitations are a particular concern among cancer survivors. In a recent study utilizing the National Health Interview Survey (NHIS), Patel and colleagues reported that the prevalence of functional limitations among cancer survivors in the US increased from 57.0% in 1999 to 70.1% in 2018. This represents a 2.25-fold increase in the number of survivors with a functional limitation vs. a 1.34-fold increase in the number of limitation-free survivors [6]. In another analysis by Arem and colleagues [7], 67% of US adults with a history of cancer, vs. 35% of adults without a cancer history, reported at least one functional limitation in physical domains such as climbing steps, stooping down, or pushing large objects (Table 1). Although functional limitations in activities of daily living are well-documented in older adult cancer survivors [8], recent evidence suggests the impact of cancer on functional limitations in young adult cancer survivors, compared to their non-cancer peers, may be particularly salient [9–11]. In the study by Arem et al. [7], prevalence estimates of young adults (18–39 years-old) with a history of cancer were 2.6 times that of young adults without a cancer history, while estimates among middle-aged survivors were 1.6 times higher and, among older adults cancer survivors, 1.1 times higher than their non-cancer, age-matched counterparts. These data suggest functional limitations remain a persistent problem with limited solutions across age groups and may represent one marker of premature aging secondary to cancer, particularly among young adults. Indeed, studies report that young adults with a history of cancer often exhibit clinical signs of functional decline and frailty that may be indicative of accelerated aging and future, earlier onset of chronic morbidity [8, 12].
Table 1.
Functional limitation definitions
| Instrument variable label | Operational use |
|---|---|
| Limitation in walking 1/4 mile | Walk limitation |
| Limitation in climbing 10 steps | Climb limitation |
| Limitation in standing 2 h | Stand limitation |
| Limitation in sitting 2 h | Sit limitation |
| Limitation in stooping, bending, or kneeling | Stoop limitation |
| Limitation in reaching over head | Reach limitation |
| Limitation in grasping small objects | Grasp limitation |
| Limitation in lifting or carrying 10 lbs | Carry limitation |
| Limitation in pushing large objects | Push limitation |
Interview question was worded as follows: “By yourself, and without using any special equipment, how difficulty is it for you to…?”
Response options included 0 (not at all difficult), 1 (only a little difficult), 2 (somewhat difficult), 3 (very difficult), 4 (can not do at all), 6 (do not do this activity), 7 (refused), 8 (not ascertained), and 9 (do not know)
Despite increasing evidence on the prevalence of functional limitations among cancer survivors [6, 7], less is known what types of limitations survivors experience across the adult lifespan or the extent to which survivors experience more severe limitations. Enhanced understanding in this area may help healthcare providers identify targets for supportive care intervention, in addition to individuals most in need of intervention. Few studies, to our knowledge, have examined the prevalence, type, and severity of functional limitations across functional domains and across the adult lifespan between individuals with and without a history of cancer. Such evidence may better inform intervention and care strategies to reduce long-term clinical burden and improve quality of life in cancer survivors, of whom 69% live 5 or more years beyond their cancer diagnosis and 18% for 20 + years beyond their diagnosis [13].
Using the 2014 to 2018 National Health Interview Survey (NHIS), this study examined odds of reporting functional limitations across nine domains (Table 1) among cancer survivors versus those without a history of cancer. We hypothesized that cancer survivors, when compared with age-matched adults without a history of cancer, would be more likely to report a functional limitation in all nine domains and that, among those reporting a limitation for a given domain, cancer survivors would be more likely to report a major (vs. minor) limitation. We also conducted an exploratory analysis in which we compared all cancer by age groups (i.e., 18–44 year-olds with a cancer history, 45–64 year-olds without a cancer history, 45–64 year-olds with a cancer history, 65 + year-olds without a cancer history, 65 + year-olds with a cancer history) to a healthy, young adult reference group defined as 18–44 year-olds without a cancer history. Given the cross-sectional design of the NHIS, this analysis was exploratory in nature and designed to gather insight on how cancer, compared to aging in the absence of cancer, may influence odds of reporting a functional limitation across the nine domains.
Materials and methods
The data analyzed in this study were obtained from the NHIS, a continuous, cross-sectional household interview survey that uses a probability sampling design to calculate representative estimates on a variety of health topics from US households and non-institutionalized adults. One adult aged 18 years or older from each sampled family completed the interview. Sampling was continuous throughout each year, and the probability design permitted representative sampling of households. NHIS is conducted using a face-to-face interview format at the respondent’s home; therefore, survey planners used geographically clustered sampling techniques to select the sample of households and dwelling units interviewed, with the sample design stratified by state.
The present study includes data from individuals assessed between 2014 and 2018 NHIS. We combined data from the Sample Adult files in the Sample Adult Module and the Person files in the Family Module (publicly available at: https://www.cdc.gov/nchs/nhis/1997-2018.htm) to conduct the present analyses. These files include information on socio-demographic characteristics, health history, and lifestyle behaviors from the interviewed adult. Ethnicity sampling was modified in 2016 to account for the changing US population and to correct oversampling errors for African American, Hispanic, and Asian individuals. Although more recent data are available, data after 2018 were not used in the present study due to the redesign of the NHIS in 2019. Detailed information on the questionnaires and methods are available from the National Center for Health Statistics [14], and our procedures follow our previously published work [7, 15]. The final response rate for the Sample Adult File was 58.9% for 2014, 55.2% for 2015, 54.3% for 2016, 53.0% for 2017, and 53.1% for 2018, yielding an overall response rate of 55.1% across all years.
Participants
There were 155,556 adults in the combined sample from 2014 to 2018. Cancer was self-reported by participants from the question “Have you ever been told by a doctor or health professional that you had cancer or a malignancy of any kind?” Participants who answered “yes” to this question were asked to specify what type(s) of cancer and were allowed to specify up to three types of cancer. Individuals who reported non-melanoma skin cancer (n = 2810) or unknown skin cancer (n = 1104) were excluded from analyses. Individuals whose response regarding cancer history was refused, not ascertained, or unknown (n = 133) were also excluded from analyses. The final combined dataset from 2014 to 2018 included 12,518 individuals who reported at least one cancer diagnosis and 138,991 individuals with no history of cancer (N = 151,509).
Measures
We categorized demographic information and cancer diagnosis according to methods carried out in Arem et al. [7]. Demographic information was collected via various sections of the NHIS interview and included sex, race, ethnicity, age, marital status, education level, height and weight, and employment status. Cancer history was obtained in the Adult Conditions section via the following question: “Have you ever been told by a doctor you had cancer?” If the individual responded yes, they were asked what type of cancer(s) across 29 types and other and age when they were first diagnosed with each reported cancer. Additional medical conditions were assessed in this section, and engagement in physical activity was assessed in the Adult Health Behaviors section. Sample adults were asked about the frequency and duration of vigorous leisure-time physical activity, frequency and duration of light and moderate leisure-time physical activity, and frequency of strengthening activities. Respondents were permitted to describe the frequency of physical activity in any unit (e.g., times per week, times per month), and aerobic and strengthening activity variables were summarized as minutes per week.
Functional limitations were assessed as part of the Adult Health Status and Limitations of Activity Section of the NHIS, and individuals were asked about difficulties doing 12 activities [14]. For example, “By yourself, and without using any special equipment, how difficult is it for you to walk a quarter of a mile – about 3 city blocks?” Response options for each item were 0 (not at all difficult), 1 (only a little difficult), 2 (somewhat difficult), 3 (very difficult), 4 (can not do at all), 6 (do not do this activity), 7 (refused), and 9 (do not know). Responses of 6 to 9 were set to missing. For the present study, we excluded three items: going out to events, participating in social activities, and relaxing at home, resulting in nine total domains (Table 1).
Data analysis
Demographic and health characteristics of the survey respondents were summarized using descriptive statistics. We report the median and interquartile range (IQR) for continuous data and unweighted frequencies and weighted percentages for categorical data. To examine differences by cancer status, we employed the Rao-Scott chi-square test. Multivariate logistic regression was used for primary analyses. This included a cancer-age-stratified independent variable with six categories: 18–44 with a cancer history, 45–64 with a cancer history, 65 + with a cancer history, 18–44 without a cancer history, 45–64 without a cancer history, and 65 + without a cancer history. A binary variable was created to compare a response of 0 (not at all difficult; i.e., no limitation in the select domain) to 1–4 (only a little difficult to can not do at all; i.e., any limitation in the select domain). Hypothesis tests were performed on functional limitations, comparing cancer history vs. non-cancer history overall and for matched age groups (four comparisons of cancer against non-cancer for all ages and the age groups 18–44, 45–64, and 65 +), while controlling for other covariates. Next, among those who reported any limitation in a given domain, we examined the odds of reporting a major (vs. minor) limitation by cancer status for matched age groups, while controlling for covariates. Responses of 1–2 were modeled as a reference “minor limitation,” while responses of 3–4 were modeled as a “major limitation.” Finally, to explore functional limitations across domains as a marker of premature aging, we ran the multivariate logistic regression in which each cancer-age-stratified category (i.e., 18–44 year-olds with a cancer history, 45–64 year-olds without a cancer history, 45–64 year-olds with a cancer history, 65 + year-olds without a cancer history, 65 + year-olds with a cancer history) was compared to the reference group defined as 18–44 year-old adults without a history of cancer. We conducted these analyses first without covariates to mitigate any effects of age-related confounders and next with covariates.
A priori defined covariates that were assessed as part of the NHIS interview included the following: biological sex (male, female), race/ethnicity (non-Hispanic White, non-Hispanic Black, non-Hispanic Asian, Hispanic, other), education (< high school or high school graduate, 2-year degree or some college, bachelor’s degree or greater), body mass index (BMI) category (underweight (< 18.5 kg/m2), normal (18.5 to < 25 kg/m2), overweight (25.0 to < 30 kg/m2), obese (> 30.0 kg/m2)), number of comorbidities (0, 1–2, 3 + from arthritis, asthma, chronic obstructive pulmonary disease (COPD), heart attack, myocardial infarction, hypertension, stroke, type 2 diabetes), and meeting physical activity guidelines (not meeting guidelines, meeting aerobic + strength guidelines). Physical activity was calculated using methods previously described [7], and meeting guidelines were defined according to 2008 federal public health recommendations of 150 min per week of moderate-to-vigorous aerobic activity and 2 + days per week of muscle strengthening activity [16]. The 2008 guidelines were used in accordance with the survey years and the NHIS physical activity information website [17]. All data were analyzed in SAS version 9.4 (Cary, NC) using SAS SURVEY procedures following guidelines provided by the NHIS [18]. Results were considered significant at p < 0.05. The Tukey–Kramer method was used to adjust for multiple comparisons in all analyses. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs).
Results
Population
Cancer survivors’ median age was 65.7 years-old compared to 44.0 years-old among those without a history of cancer. A cancer diagnosis was reported by 1.9% (n = 1126) of 18–44 year-olds, 7.5% (n = 3844) of 45–64 year-olds, and 19.8% (n = 7548) of 65 + year-olds. Sample characteristics are provided in Table 2. Compared to adults without a history of cancer, a greater proportion of cancer survivors were female, non-Hispanic White, ever married, obese, reported other comorbidities, and did not meet combined physical activity guidelines. The distribution of cancer diagnoses among women was 40.4% breast cancer, 12.5% cervical cancer, 6.2% colon cancer, 9.1% uterine cancer, 8.1% melanoma, 5.2% ovarian cancer, 4.9% leukemia or lymphoma, 4.9% thyroid cancer, 3.5% lung cancer, and 16.6% other cancers. Among men, the distribution was 38.5% prostate cancer, 12.4% melanoma, 9.8% colon cancer, 9% leukemia or lymphoma, 6.4% bladder cancer, 4.5% lung cancer, 3.0% cancer of the testes, and 23.7% all other cancers.
Table 2.
Demographic and health characteristics of the adult population in the 2014–2018 NHIS by cancer history
| Characteristic | History of cancer | No history of cancer | Total | |||
|---|---|---|---|---|---|---|
| n = 12,518 | n = 138,991 | n = 151,509 | ||||
| n | % | n | % | n | % | |
| Age: median (IQR) | 65.7 | (55.4, 74.9) | 44.0 | (30.1, 58.3) | 45.6 | (31.0, 60.1) |
| Age group | ||||||
| 18–44 | 1126 | (10.7) | 61,330 | (50.0) | 62,456 | (47.8) |
| 45–64 | 3844 | (34.7) | 47,084 | (33.8) | 50,928 | (34.3) |
| 65 + | 7548 | (54.6) | 30,577 | (16.2) | 38,125 | (19.2) |
| Years since diagnosis (median (IQR)) | 6.7 | (2.1, 14.6) | N/A | N/A | N/A | N/A |
| Sex | ||||||
| Male | 4846 | (41.0) | 63,261 | (48.7) | 68,107 | (48.5) |
| Female | 7672 | (59.0) | 75,730 | (51.3) | 83,402 | (52.2) |
| Race/ethnicity | ||||||
| White, non-Hispanic | 10,161 | (81.2) | 89,886 | (63.0) | 100,047 | (65.3) |
| Black, non-Hispanic | 1090 | (8.0) | 18,133 | (12.8) | 19,223 | (13.0) |
| Asian, non-Hispanic | 317 | (2.9) | 8071 | (6.3) | 8388 | (6.4) |
| Hispanic | 812 | (7.0) | 20,968 | (16.8) | 21,780 | (17.0) |
| Non-Hispanic, other | 138 | (0.9) | 1933 | (1.1) | 2071 | (1.3) |
| Education | ||||||
| < High school/high school graduate/GED | 4921 | (42.2) | 52,439 | (40.9) | 57,360 | (41.6) |
| 2-year degree or some college | 3853 | (33.2) | 43,070 | (33.7) | 46,923 | (34.2) |
| Bachelor’s degree or more | 2576 | (24.6) | 31,007 | (25.3) | 33,583 | (25.9) |
| BMI | ||||||
| Underweight, < 18.5 | 277 | (2.1) | 2320 | (1.8) | 2597 | (1.9) |
| Normal, 18.5–24.9 | 3767 | (30.9) | 44,839 | (33.7) | 48,606 | (33.9) |
| Overweight, 25.0–29.9 | 4196 | (35.0) | 46,110 | (34.3) | 50,306 | (34.6) |
| Obese, 30.0 + | 3872 | (32.0) | 40,944 | (30.3) | 44,816 | (30.8) |
| Number of comorbiditiesa | ||||||
| 0 | 2792 | (24.6) | 74,209 | (57.9) | 77,001 | (56.0) |
| 1–2 | 6622 | (52.7) | 51,411 | (34.4) | 58,033 | (36.1) |
| 3 + | 3104 | (22.7) | 13,371 | (7.7) | 16,475 | (9.0) |
| Physical activity | ||||||
| Strength + aerobic | 331 | (6.9) | 5027 | (11.2) | 5358 | (11.4) |
| Aerobic only | 589 | (11.5) | 6613 | (14.2) | 7202 | (14.5) |
| Strength only | 264 | (4.2) | 1898 | (3.3) | 2162 | (3.6) |
| Insufficient | 4842 | (77.4) | 42,409 | (71.2) | 47,251 | (72.6) |
Sum of self-reported diagnosis of arthritis, asthma, chronic obstructive pulmonary disease (COPD), heart attack, myocardial infarction, hypertension, stroke, and type 2 diabetes
Functional limitations
Odds of functional limitations in the total sample
Across the sample, the odds of reporting at least one functional limitation were greater among women, individuals identifying as “other” race, individuals classified as under-weight or obese, and those reporting comorbidities (especially 3 + conditions). Conversely, the odds of reporting a limitation were lower among individuals with 2 + years of college and meeting combined physical activity guidelines. The effects of race and ethnicity were variable across functional domains; however, non-Hispanic Asian and Hispanic adults had lower odds of limitations in several domains. Data for the full sample and by covariates are provided in Supplementary Table 1.
Odds of functional limitations by cancer history and age
There were 9234 (67.8%) adults with a history of cancer and 51,107 (36.8%) adults without a history of cancer who reported at least one functional limitation. Across all age groups, individuals with a history of cancer were 2.20 times more likely to report at least one functional limitation across the nine domains compared to those without a history of cancer (95% CI 1.92, 2.52). Adjusted ORs for at least one functional limitation among cancer survivors by age were 2.75 (95% CI 1.98, 3.81) among 18–44 year-olds, 2.42 (95% CI 2.00, 2.93) among 45–64 year-olds, and 1.59 (95% CI 1.39, 1.82) among 65 + year-olds. Cancer survivors aged 18–44 years and 45–64 years were more likely to report a functional limitation in each of the nine domains when compared with their age-matched, non-cancer counterparts. Cancer survivors aged 65 + years were more likely to report a limitation in all domains except reaching over head. ORs and 95% CIs for each functional limitation are presented in Table 3.
Table 3.
Odds of functional limitations among cancer survivors vs. age-matched adults with no history of cancer
| Functional limitation | Age 18–44 | Age 45–64 | Age 65 + | Overall p | |||
|---|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | ||
| Walk limitation | 3.38 | (2.32, 4.93) | 1.96 | (1.63, 2.36) | 1.48 | (1.32, 1.67) | < 0.0001 |
| Climb limitation | 2.51 | (1.70, 3.70) | 1.79 | (1.51, 2.13) | 1.27 | (1.13, 1.43) | < 0.0001 |
| Stand limitation | 2.56 | (1.78, 3.69) | 1.98 | (1.68, 2.35) | 1.30 | (1.17, 1.46) | < 0.0001 |
| Sit limitation | 2.60 | (1.87, 3.62) | 1.46 | (1.24, 1.71) | 1.15 | (1.02, 1.29) | < 0.0001 |
| Stoop limitation | 2.03 | (1.49, 2.78) | 1.92 | (1.63, 2.27) | 1.31 | (1.17, 1.47) | < 0.0001 |
| Reach limitation | 3.39 | (2.33, 4.92) | 1.66 | (1.40, 1.96) | 1.10 | (0.98, 1.23) | < 0.0001 |
| Grasp limitation | 2.61 | (1.74, 3.91) | 1.67 | (1.41, 1.98) | 1.16 | (1.03, 1.31) | < 0.0001 |
| Carry limitation | 3.76 | (2.54, 5.55) | 2.00 | (1.69, 2.36) | 1.28 | (1.14, 1.43) | < 0.0001 |
| Pushing limitation | 2.79 | (1.92, 4.07) | 1.94 | (1.63, 2.31) | 1.44 | (1.29, 1.62) | < 0.0001 |
Data presented represent adjusted ORs controlling for the following covariates: sex, race/ethnicity, education, BMI group, comorbidities, and physical activity (reference variables defined in Supplementary Table 1). All ORs significant except reach limitation in age 65 +
OR odds ratio, 95% CI 95% confidence interval
Among individuals reporting a functional limitation for a given domain, the odds of reporting a major limitation (vs. minor limitation) were greater among cancer survivors. Among adults 18–44 years-old, cancer survivors had higher odds of reporting a major limitation in walking ¼ mile, standing for 2 h, sitting for 2 h, and stooping. Among adults 45–64 years-old, cancer survivors were more likely to report a major limitation in standing for 2 h, sitting for 2 h, stooping, reaching over head, carrying 10 lbs, and pushing large objects. Among adults 65 + years-old, cancer survivors had higher odds of a major limitation for walking ¼ mile, standing for 2 h, stooping, and carrying 10 lbs. Data on the odds of major functional limitations are presented in Table 4.
Table 4.
Odds of major functional limitations among cancer survivors vs. age-matched adults with no history of cancer
| Functional limitation | Age 18–44 | Age 45–64 | Age 65 + | |||
|---|---|---|---|---|---|---|
| OR | 95% CI | OR | 95% CI | OR | 95% CI | |
| Walk limitation (n = 16,385) | 1.97 | (1.15, 3.38) | 1.16 | (0.94, 1.43) | 1.19 | (1.05, 1.35) |
| Climb limitation (n = 13,621) | 1.34 | (0.76, 2.37) | 1.07 | (0.85, 1.36) | 1.15 | (0.99, 1.33) |
| Stand limitation (n = 18,064) | 1.96 | (1.13, 3.41) | 1.26 | (1.01, 1.57) | 1.35 | (1.18, 1.55) |
| Sit limitation (n = 9945) | 2.28 | (1.27, 4.07) | 1.30 | (1.02, 1.65) | 1.21 | (0.99, 1.48) |
| Stoop limitation (n = 20,958) | 1.74 | (1.06, 2.83) | 1.27 | (1.04, 1.56) | 1.18 | (1.05, 1.32) |
| Reach limitation (n = 8687) | 1.37 | (0.69, 2.70) | 1.39 | (1.07, 1.81) | 1.17 | (0.96, 1.42) |
| Grasp limitation (n = 8088) | 2.02 | (0.91, 4.48) | 1.03 | (0.76, 1.39) | 1.16 | (0.94, 1.43) |
| Carry limitation (n = 11,326) | 1.06 | (0.58, 1.93) | 1.36 | (1.08, 1.73) | 1.21 | (1.02, 1.42) |
| Pushing limitation (n = 13,692) | 1.57 | (0.92, 2.69) | 1.29 | (1.02, 1.62) | 1.15 | (0.99, 1.34) |
Data presented represent adjusted ORs controlling for covariates. Reference group for each OR is age-matched adults with no history of cancer reporting a functional limitation. Bolded values indicate statistically significant, p < 0.01
OR odds ratio, 95% CI 95% confidence interval
Exploratory: odds of functional limitations compared to reference group
When compared to 18–44 year-olds with no cancer history, all cancer by age groups had significantly higher odds of reporting a functional limitation in all nine domains. Although we did not test statistical equivalence as part of this exploratory analysis, ORs among those with a history of cancer approached or exceeded ORs of individuals one age group older without a history of cancer. For example, cancer survivors aged 18–44 years were 5.09 (4.18, 6.19) times more likely and individuals 45–64 years-old with no history of cancer were 4.02 (3.8, 4.24) times more likely to report a walking limitation when compared with the young adult, no cancer reference group. Similarly, cancer survivors aged 45–64 years were 8.14 (7.34, 9.03) times more likely and individuals 65 + years-old with no history of cancer were 7.84 (7.41, 8.28) times more likely to report a pushing limitation when compared with the young adult, no cancer reference group. Older adult cancer survivors had the greatest odds of reporting functional limitations, with ORs ranging from 3.42 (sitting) to 14.73 (walking ¼ mile) compared to the reference group. Further, older adult cancer survivors’ odds of limitations in walking, climbing, standing, stooping, grasping, carrying, and pushing were significantly higher than those of older adults without a history of cancer as observed in 95% CIs. Data from the exploratory analysis are illustrated in Fig. 1 and reported in Supplementary Table 2.
Fig. 1.
Odds of functional limitations by age and cancer history compared to 18–44 year-old adults with no history of cancer. Notes. aReference group is 18–44 year-old adults without a history of cancer. Red line = reference group odds ratio (OR) of 1.0. Orange circle = individuals without a history of cancer in the age group. Blue circle = individuals with a history of cancer in the age group. A ORs for 18–44 year-old adults; B ORs for 45–64 year-old adults; C 65 + year-old adults. Full statistics are available in Supplementary Table 2
Similar, but attenuated effects were observed with the addition of covariates to the exploratory model (not reported). Significant covariates attenuating associations among cancer, aging, and functional limitations included number of comorbidities and meeting vs. not meeting physical activity guidelines. As presented in Supplementary Table 1, 3 + comorbid conditions, compared to no comorbid conditions, were associated with higher odds of reporting a functional limitation across the sample, ranging from 8.43 (sit limitation) to 16.87 (walk limitation). Alternately, meeting combined aerobic + strength physical activity guidelines, compared to not meeting guidelines, was associated with lower odds of reporting a functional limitation, ranging from 0.59 (sit limitation) to 0.23 (climb limitation).
Discussion
Major findings indicate greater prevalence of both major and minor functional limitations among adult cancer survivors of all ages, with the largest age-stratified odds observed among young adults. These data suggest that young adult cancer survivors may experience greater age-inappropriate limitations and may be functionally older than their non-cancer counterparts. However, despite attenuated effects of aging on cancer’s association with functional limitations, older cancer survivors had the highest overall odds of reporting a functional limitation in all nine domains. Overall, functional limitations may represent one marker of premature aging secondary to cancer that may have significant healthcare and quality of life implications and in need of systematic clinical evaluation. For young adults, these limitations may have significant late and long-term consequences to social relationships, career development, independence from parents, and psychosocial health, in addition to physical health status inconsistent with their age [11, 19]. Among older adults, the interaction between aging and cancer may pose a particularly significant risk to older adult cancer survivors’ independence and successful aging [20].
Consistent with previous evidence, cancer survivors in this study, regardless of age, were more likely to report at least one functional limitation. A recent investigation by Patel and colleagues [6] indicated that 70.1% of cancer survivors sampled in the 2018 NHIS reported at least one functional limitation, representing a 2.25-fold increase from 1999. Likewise, Arem and colleagues [7], in an update on cancer survivor health behaviors from 2001 to 2017, noted an increase in functional limitations of 4.7% among 18–39 year-olds, 9.9% among 40–64 year-olds, and 2.9% among 65 + year-olds. Data from the present study add to this previous evidence and indicate that certain functional domains may be most impacted by cancer within and across age groups. Among younger adults, cancer survivors were most likely to report limitations in reaching over head, walking ¼ mile, and lifting/carrying 10 lbs. Among middle-aged adults, cancer survivors were most likely to report limitations in lifting/carrying 10 lbs, standing 2 h, and walking ¼ mile. Finally, among older adults, cancer survivors were most likely to report limitations in walking ¼ mile, pushing large objects, and stooping/bending/kneeling. Previous population-level data on young adults with a history of cancer found that 88% reported at least one physical concern related to their cancer and 40% struggled to cope with the challenges of everyday life [21]. In a study of middle-aged and older adults, cancer survivors were more likely to report severe physical functioning limitations, and increasing limitation was associated with increased psychological distress and poorer self-rated health and quality of life [10]. However, compared to the present study, previous studies provide little insight into the types of functional limitations survivors experience. Consistently observed limitations across age groups in the present study included those related to mobility (e.g., walking ¼ mile) and lower-extremity function (e.g., standing 2 h, stooping/bending/kneeling). The increasing prevalence of these limitations and their considerable impact on survivors’ quality of life warrant efforts to more systematically identify and manage functional limitations [22, 23].
In our analysis, the odds of reporting at least one limitation were greatest among younger adult survivors, followed by middle-aged survivors (when compared with age-matched, non-cancer counterparts). Further, younger survivors were 1.74 to 2.28 times more likely and middle-aged survivors were 1.26 to 1.39 times more likely to report a major limitation in multiple domains. This is consistent with a recent study in Australia in which cancer was more strongly associated with physical functioning limitations in younger compared to older adults [10]. In a recent commentary, Nekhlyudov and colleagues [24] emphasized the workforce implications that functional limitations can have for survivors who are still employed, many of whom are < 65 years. Specifically, younger survivors are more likely to suffer functional impairments that lead to social and financial consequences, such as lower educational attainment, less likely to marry, and more likely to make changes to their employment or be unemployed. As such, functional limitations can lead to significant socioeconomic toxicities for patients (and the healthcare system) and be associated with increased long-term and late symptom clusters in other areas, such as emotional health [24]. To this end, some researchers argue that younger cancer survivors may be at highest risk for adverse survivorship outcomes [25] and have high clinical demands into older adulthood [26]. Although older adult cancer survivors have been a priority focus for research and intervention due to greater population size and comorbidity [27], our findings reinforce the need for efforts to assess and treat functional decline in younger and middle-aged cancer survivors—many of whom will eventually become older survivors with an earlier trajectory of functional aging.
Of critical importance is also the finding from our exploratory analysis that odds of limitations among cancer survivors, when compared to 18–44 year-old adults without a history of cancer, were similar to or greater than those of individuals one age group older without a history of cancer. This suggests functional limitations as one indicator of premature aging due to cancer. Results are similar to previous research in which morbidity burden in 24-year-old survivors of childhood cancer was the same as 50-year-old siblings without a history of cancer [26]. Unfortunately, as survivors aged, the incidence of morbidity increased further, with cancer survivors 5 times more likely to develop 2 + chronic conditions and at a younger age. In our sample, comorbidities, especially reporting 3 or more, were the strongest determinant of functional limitations across the sample and explained a large amount of variance in functional limitations. While the burden of chronic disease is generally well-characterized in older adult survivors, research to define phenotypes of premature aging in younger cancer survivors is only emerging [28]. Nearly one-quarter of all cancer survivors are less than 65, and 5-year survival rates of childhood and adolescent cancers now exceed 85% [9, 13, 29]. Amid this growth, clinicians and scientists are increasingly recognizing the need to specifically address younger survivor long-term health trajectories [11, 19].
Despite these findings, adults aged 65 + years, regardless of cancer status, had the highest odds of functional limitations, which is consistent with well-documented evidence of the effects of age and age-related factors (e.g., increased comorbidities, decreased physical activity) on functional outcomes [8, 27]. Yet, ORs in most domains (i.e., walking, climbing, standing, stooping, grasping, carrying pushing) were statistically higher among older adult cancer survivors than those of older adults without a history of cancer in both unadjusted (Supplementary Table 2) and adjusted models. These data support well-documented evidence indicating greater self-reported mobility limitations, lower self-reported physical function, and worse performance on objective measures of physical function in older adult cancer survivors compared to similarly aged adults without a history of cancer [30, 31]. However, our findings also indicate an attenuated effect of cancer on functional limitations amid aging. Adults aged 65 + years with a history of cancer had 19–35% increased risk of functional limitations compared to 65 + year-old adults without a history of cancer, while 18–44 year-olds with a history of cancer had 74–128% increased risk among compared to their non-cancer counterparts. These data, while indicating a need to ameliorate limitations in older adults with cancer, emphasize a need to characterize and intervene upon functional limitations in younger cancer populations as well.
Of further interest are results revealing covariates that were associated with higher risk of functional limitations, such as number of other chronic conditions and physical inactivity. In the present sample, the prevalence of comorbidities among cancer survivors (across ages) was almost double that of adults without a history of cancer (80% vs. 42%). This is consistent with previous research, which indicates that up to 92% of cancer survivors have at least one comorbid condition and up to 62% have an activity limitation due to their comorbidity [32]. Previous NHIS data from 2013 to 2017 reported that only 14.2% of cancer survivors compared to 21.1% of adults without a history of cancer met physical activity guidelines of 150 min per week of aerobic activity and 2 + days per week of strength training [7]. Similarly, 39.2% of cancer survivors vs. 31.2% of adults without a history of cancer reported no physical activity. Differences were greatest among younger adults (22% of cancer survivors vs. 28.6% without cancer compared to 11.6% of cancer survivors vs. 11.1% without cancer in the 65 + age group). The American College of Sports Medicine recommends at least 3 days per week for 30–60 min of moderate-to-vigorous physical activity or 2–3 days per week of resistance training to improve physical function among cancer survivors [33]. However, more work is needed in this area. Evidence on physical activity and fall risk remains limited, and targeted strategies addressing functional needs by age group are untested [33, 34]. Additionally, non-modifiable factors associated with increased risk in the present study and warranting consideration for clinical assessment in relation to functional limitations in cancer survivors included female sex, “other” race, and high school education or lower.
Strengths and limitations
Key strengths of this study include the large, nationally representative sample of American adults across 5 years. We also identified differences in specific functional limitations by age and cancer status to inform future investigations and intervention targets. Despite these strengths, limitations inherent to the NHIS include reliance upon self-report, cross-sectional design, and no availability of items on treatment or certain lifestyle behaviors. Further, cancer status is the history of cancer, not current cancer. Finally, the present analysis did not consider time since diagnosis or the distribution of types of cancer across age groups, precluding conclusions regarding the effects of age vs. cancer type on functional limitations within individuals with a history of cancer.
Conclusions
The cancer survivor population is expected to grow exponentially in the coming decades; however, the quality of survivors’ extended years may be impacted by cancer-related consequences, such as increased risk of functional limitations. Our findings indicate that young adult, middle-aged, and older adult cancer survivors alike experience more functional limitations than their non-cancer counterparts, especially in lower extremity functions such as walking short distances, standing for extended periods of time, stooping, carrying or lifting 10 lbs, and pushing large objects. Increased focus on younger and middle-aged cancer populations is critically needed, as the likelihood of reporting a limitation, after controlling for relevant covariates, was greatest in these age groups. Functional limitations may represent one marker of accelerated aging with potentially significant impacts on long-term health trajectories. Stronger efforts to assess limitations as part of routine care and to design and implement targeted interventions to address limitations are needed across survivor age groups.
Supplementary Material
Funding
This work was funded by the University of Nebraska Medical Center College of Medicine biostatistical support program (DKE, JM) and the TREC Training Workshop (DKE, SKM, HA; R25CA203650 [PI: M. Irwin]).
Footnotes
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/s11764-024-01638-8.
Conflict of interest The authors declare no competing interests.
References
- 1.Shapiro CL. Cancer survivorship. N Engl J Med. 2018;379:2438–50. 10.1056/NEJMra1712502. [DOI] [PubMed] [Google Scholar]
- 2.Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin. 2024;74:12–49. 10.3322/caac.21820. [DOI] [PubMed] [Google Scholar]
- 3.Weaver KE, Forsythe LP, Reeve BB, Alfano CM, Rodriguez JL, Sabatino SA, et al. Mental and physical health–related quality of life among U.S. cancer survivors: population estimates from the 2010 National Health Interview Survey. Cancer Epidemiol Biomarkers Prev. 2012;21:2108–17. 10.1158/1055-9965.EPI-12-0740. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Gegechkori N, Haines L, Lin JJ. Long-term and latent side effects of specific cancer types. Med Clin North Am. 2017;101:1053–73. 10.1016/j.mcna.2017.06.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.McAuley E, Konopack JF, Morris KS, Motl RW, Hu L, Doerksen SE, et al. Physical activity and functional limitations in older women: influence of self-efficacy. J Gerontol B Psychol Sci Soc Sci. 2006;61:P270–7. 10.1093/geronb/61.5.P270. [DOI] [PubMed] [Google Scholar]
- 6.Patel VR, Hussaini SMQ, Blaes AH, Morgans AK, Haynes AB, Adamson AS, et al. Trends in the prevalence of functional limitations among US cancer survivors, 1999–2018. JAMA Oncol. 2023. 10.1001/jamaoncol.2023.1180. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Arem H, Mama SK, Duan X, Rowland JH, Bellizzi KM, Ehlers DK. Prevalence of healthy behaviors among cancer survivors in the United States: how far have we come? Cancer Epidemiol Biomarkers Prev. 2020;29:1179–87. 10.1158/1055-9965.EPI-19-1318. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hurria A, Jones L, Muss HB. Cancer treatment as an accelerated aging process: assessment, biomarkers, and interventions. Am Soc Clin Oncol Educ Book Am Soc Clin Oncol Annu Meet. 2016;35:e516–522. 10.1200/EDBK_156160. [DOI] [PubMed] [Google Scholar]
- 9.Miller KD, Fidler-Benaoudia M, Keegan TH, Hipp HS, Jemal A, Siegel RL. Cancer statistics for adolescents and young adults, 2020. CA Cancer J Clin. 2020;70:443–59. 10.3322/caac.21637. [DOI] [PubMed] [Google Scholar]
- 10.Joshy G, Thandrayen J, Koczwara B, Butow P, Laidsaar-Powell R, Rankin N, et al. Disability, psychological distress and quality of life in relation to cancer diagnosis and cancer type: population-based Australian study of 22,505 cancer survivors and 244,000 people without cancer. BMC Med. 2020;18:372. 10.1186/s12916-020-01830-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Robison LL, Hudson MM. Survivors of childhood and adolescent cancer: life-long risks and responsibilities. Nat Rev Cancer. 2014;14:61–70. 10.1038/nrc3634. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Galán S, de la Vega R, Miró J. Needs of adolescents and young adults after cancer treatment: a systematic review. Eur J Cancer Care (Engl). 2018;27:e12558. 10.1111/ecc.12558. [DOI] [PubMed] [Google Scholar]
- 13.Miller KD, Nogueira L, Devasia T, Mariotto AB, Yabroff KR, Jemal A, et al. Cancer treatment and survivorship statistics, 2022. CA Cancer J Clin. 2022;72:409–36. 10.3322/caac.21731. [DOI] [PubMed] [Google Scholar]
- 14.Centers for Disease Control and Prevention. National health interview survey methods: National Center for Health Statistics, Centers for Disease Control and Prevention. 2019. https://www.cdc.gov/nchs/nhis/methods.htm. Accessed 14 May 2023. [Google Scholar]
- 15.Arem H, Duan X, Ehlers DK, Lyon ME, Rowland JH, Mama SK. Provider discussion about lifestyle by cancer history: a nationally representative survey. Cancer Epidemiol Biomarkers Prev. 2021;30:278–85. 10.1158/1055-9965.EPI-20-1268. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.United States Department of Health and Human Services. 2008 physical activity guidelines for Americans. Washington, D.C.: 2008. https://health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines. Accessed 9 Jul 2024. [Google Scholar]
- 17.National Center for Health Statistics. NHIS - adult physical activity - leisure-time physical activity recodes 2021. https://www.cdc.gov/nchs/nhis/physical_activity/pa_recodes.htm. Accessed 22 Apr 2024.
- 18.Centers for Diseae Control and Prevention. Variance estimation guidance, NHIS 2016–2017. 2018. https://www.cdc.gov/nchs/data/nhis/2016var.pdf. Accessed 17 Jul 17 2023.
- 19.Hudson MM, Bhatia S, Casillas J, Landier W, Rogers ZR, Allen C, et al. Long-term follow-up care for childhood, adolescent, and young adult cancer survivors. Pediatrics. 2021;148:e2021053127. 10.1542/peds.2021-053127. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Chavan PP, Kedia SK, Yu X. Physical and functional limitations in US older cancer survivors. J Palliat Care Med 2017;07. 10.4172/2165-7386.1000312. [DOI] [Google Scholar]
- 21.Jones JM, Fitch M, Bongard J, Maganti M, Gupta A, D’Agostino N, et al. The needs and experiences of post-treatment adolescent and young adult cancer survivors. J Clin Med. 2020;9:1444. 10.3390/jcm9051444. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer statistics, 2022. CA Cancer J Clin. 2022;72:7–33. 10.3322/caac.21708. [DOI] [PubMed] [Google Scholar]
- 23.Lagergren P, Schandl A, Aaronson NK, Adami H-O, de Lorenzo F, Denis L, et al. Cancer survivorship: an integral part of Europe’s research agenda. Mol Oncol. 2019;13:624–35. 10.1002/1878-0261.12428. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Nekhlyudov L, Campbell GB, Schmitz KH, Brooks GA, Kumar AJ, Ganz PA, et al. Cancer-related impairments and functional limitations among long-term cancer survivors: gaps and opportunities for clinical practice. Cancer. 2022;128:222–9. 10.1002/cncr.33913. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Zhang A, Wang K, Zebrack B, Tan CY, Walling E, Chugh R. Psychosocial, behavioral, and supportive interventions for pediatric, adolescent, and young adult cancer survivors: a systematic review and meta-analysis. Crit Rev Oncol Hematol. 2021;160:103291. 10.1016/j.critrevonc.2021.103291. [DOI] [PubMed] [Google Scholar]
- 26.Armstrong GT, Kawashima T, Leisenring W, Stratton K, Stovall M, Hudson MM, et al. Aging and risk of severe, disabling, life-threatening, and fatal events in the childhood cancer survivor study. J Clin Oncol. 2014;32:1218–27. 10.1200/JCO.2013.51.1055. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Kobayashi LC, Westrick AC, Doshi A, Ellis KR, Jones CR, LaPensee E, et al. New directions in cancer and aging: state of the science and recommendations to improve the quality of evidence on the intersection of aging with cancer control. Cancer. 2022;128:1730–7. 10.1002/cncr.34143. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Armenian SH, Gibson CJ, Rockne RC, Ness KK. Premature aging in young cancer survivors. JNCI J Natl Cancer Inst. 2019;111:226–32. 10.1093/jnci/djy229. [DOI] [PubMed] [Google Scholar]
- 29.American Cancer Society. Childhood and adolescent cancer: at a glance. Am Cancer Soc Cancer Facts Stat 2022. https://cancerstatisticscenter.cancer.org/#!/childhood-cancer. Accessed 26 Jul 2023.
- 30.Keating NL, Nørredam M, Landrum MB, Huskamp HA, Meara E. Physical and mental health status of older long-term cancer survivors. J Am Geriatr Soc. 2005;53:2145–52. 10.1111/j.1532-5415.2005.00507.x. [DOI] [PubMed] [Google Scholar]
- 31.Winters-Stone KM, Medysky ME, Savin M. Patient-reported and objectively measured physical function in older breast cancer survivors and cancer-free controls. J Geriatr Oncol. 2019;10:311–6. 10.1016/j.jgo.2018.10.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32.Williams GR, Deal AM, Lund JL, Chang Y, Muss HB, Pergolotti M, et al. Patient-reported comorbidity and survival in older adults with cancer. Oncologist. 2018;23:433–9. 10.1634/theoncologist.2017-0404. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33.Campbell KL, Winters-Stone KM, Wiskemann J, May AM, Schwartz AL, Courneya KS, et al. Exercise guidelines for cancer survivors: consensus statement from International Multidisciplinary Roundtable. Med Sci Sports Exerc. 2019;51:2375. 10.1249/MSS.0000000000002116. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Sturgeon KM, Kok DE, Kleckner IR, Guertin KA, McNeil J, Parry TL, et al. Updated systematic review of the effects of exercise on understudied health outcomes in cancer survivors. Cancer Med. 2023;12:22278–92. 10.1002/cam4.6753. [DOI] [PMC free article] [PubMed] [Google Scholar]
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