Abstract
Background: The aim of this prospective study was to report the quality of life (QoL) of older cancer patients during the first year after diagnosis and factors influencing QoL.
Patients and methods: Newly diagnosed patients aged ≥65 years were recruited for a pilot prospective cohort study at the Jewish General Hospital, Montreal, Canada. Participants were interviewed at baseline, and at 1.5, 3, 4.5, 6, and 12 months. QoL was assessed at each interview using the European Organization for the Research and Treatment of Cancer Quality of Life Core Questionnaire with 30 items. Logistic regression was conducted to determine which sociodemographic, health, and functional status characteristics were associated with decline in global health status/QoL between baseline and 12-month follow-up.
Results: There were 112 participants at baseline (response rate 72%), median age of 74.1, and 70% were women. Between baseline and 12-month follow-up (n = 78), 18 participants (23.1%) declined ≥10 points in global health status/QoL, while 34 participants (43.6%) remained stable and 23 participants (33.3%) improved ≥10 points. None of the sociodemographic, health, and functional status variables were associated with decline in logistic regression analyses.
Conclusion: Almost 25% of older adults experienced clinically relevant decline in their QoL. Further research is needed on which factors influence decline in QoL in older adults.
Keywords: cancer treatment, frail elderly, functional status, geriatric oncology, QoL
introduction
Cancer is a significant health problem in older persons [1, 2]. It is estimated that 43% of all incident cases and >60% of mortality due to cancer occur in persons aged ≥70 years [3].
Quality of life (QoL) is included as an end point in many clinical trials but only recently for older patients [4]. Older adults have reportedly given preference to maintenance or improvement of QoL rather than an increase in survival [5]. Older persons with cancer, especially frail older persons with comorbidities, are underrepresented in clinical trials [6–10]. Older adults tend to receive less aggressive treatment and less extensive staging of their disease [11–18]. With older age, the risk of complications of treatment may increase; therefore, preservation or improvement of QoL should be an important aim of treatment of older patients, especially for older adults undergoing treatment with a non-curative approach [4].
Most of the QoL studies have not focused on newly diagnosed older patients [19]. Knowledge about what influences QoL and how it changes over time during treatment is important for the oncology treatment team and patients and may help to identify areas where interventions can be useful to improve QoL in older adults.
The aim of the analyses reported in this paper is to report on the QoL of older newly diagnosed cancer patients during the first year after diagnosis and examine which sociodemographic, health, and functional status characteristics influence QoL.
patients and methods
study sample
Patients were recruited as part of a pilot study to assess health and vulnerability in older newly diagnosed cancer patients (for more detail, see [20]). The inclusion criteria were patients aged ≥65 years, referred to the Segal Cancer Centre of the Jewish General Hospital, a new diagnosis of solid tumor (breast, colorectal, or lung cancer) or hematological malignancy (lymphoma and myeloma), and not having received cancer treatment in the previous 5 years. Exclusion criteria were not able to speak English or French, estimated life expectancy <3 months, and unable to give informed consent due to cognitive impairment.
Recruitment took place between 1 March 2007 and 31 January 2008 except for colorectal cancer recruitment which ended on 1 May 2008. Among the 156 eligible patients, 112 (71.8%) participated. Four (2.6%) patients who agreed to participate had to be excluded (already treated for interview/change in diagnosis/died before interview) and 40 (25.6%) refused to participate. More details on recruitment have been published elsewhere [21]. Of the 40 patients who refused, 16 reported that they felt overwhelmed/sad by the diagnosis, 5 patients did not feel well enough, 5 patients had no time, 2 patients felt too healthy, 10 persons were not interested, 1 patient refused due to study burden and 1 refused due to denial of the cancer diagnosis. The only statistically significant difference between those who participated and those who refused was that participants were less often married/living common law (P = 0.006).
The baseline interview took place before the start of treatment and the patients were followed for 1 year with face-to-face follow-up interviews at 3 and 6 months and telephone interviews at 1.5, 4.5, and 12 months. The study was approved by the Research Ethics Committee of the Jewish General Hospital, Montreal, Canada. All participants provided written consent.
sociodemographic, health, and functional status
Information on patient age, sex, marital status, and educational level was collected during the baseline interview.
The cancer diagnosis, stage, and treatment received were obtained from the medical chart. The tumor node metastasis staging system of the American Joint Committee on Cancer was used for the solid tumors [21]. For lymphoma, the Ann Arbor staging was used [22]. For multiple myeloma, the classification according to Durie and Salmon [23] was used. For the analyses, stages were grouped into two categories: early disease (stage 0–2) or advanced disease (stage 3–4). For lymphoma, stage 1 or 2 was classified as early disease and stage 3 and 4 were classified as advanced disease. For the four participants with multiple myeloma, stage 1A (n = 2) was classified as early disease and stage 3B (n = 2) was classified as advanced disease. There were no participants with multiple myeloma stage 1B, 2, or 3A.
Treatment received was classified as extensive treatment (yes/no) based on the classification of Johansson et al. [24]. For breast cancer, extensive treatment included surgery plus radiation therapy plus chemotherapy, and for colorectal cancer, extensive treatment included surgery plus chemotherapy. For lung cancer, extensive treatment included double agent chemotherapy or concurrent radiation and chemotherapy. For lymphoma, extensive treatment included a regimen consisting of multiple chemotherapy agents. For multiple myeloma, extensive treatment included therapy consisting of melphalan, thalidomide, and prednisone.
The Functional Comorbidity Index which includes 18 questions on diseases/chronic conditions with answer categories yes/no was used to assess comorbidity [25, 26].
The seven Nagi Items were used [27] to measure functional limitations and they were defined as a lot of difficulty or unable to do one or more items. Instrumental activities of daily living (IADL) were measured with the Older American Resources and Services [28] (seven items) and IADL disability was defined as needing help or unable to perform one or more activities.
Disability in activities of daily living (ADL) was measured with the Katz index [29] (six items) and ADL disability was defined as not able to do one or more activities. The Eastern Cooperative Oncology Group performance status (ECOG PS) [27] was used to describe functional status.
Mood disturbance was assessed using the Hospital Anxiety and Depression scale [30, 31] which consists of an anxiety and a depression subscale and for both scores range from 0 to 21 points. For each subscale, a score of ≥10 indicates probable disorder. Mood disturbance was defined as a score of ≥10 on either subscale.
outcome measure
QoL was measured at each interview with the European Organization for the Research and Treatment of Cancer Quality of Life Core Questionnaire with 30 items (EORTC QLQ-C30) [32]. This QoL scale includes a global health status/QoL scale, five functional scales (emotional, physical, role, cognitive, and social functioning), and symptom scales (fatigue, nausea–vomiting, pain, dyspnea, insomnia, appetite loss, constipation, diarrhea, and financial problems). Calculation of scores was carried out according to the EORTC QLQ-C30 manual.
A difference of ≥10 points in each scale indicates clinically important change [33].
statistical analysis
We used means, medians, frequencies, and proportions to describe the characteristics of the sample. At each follow-up, we determined how many older adults declined or improved (a change of ≥10 points compared with the previous interview) in the functional scales or the global health status/QoL scale.
We compared the baseline sociodemographic, health, and functional status and QoL scores of those who were lost to follow-up and those who participated at the 12-month interviews using Mann–Whitney U tests for continuous variables and chi-square tests for categorical variables.
We grouped the global health status/QoL scale in three groups; those who declined, those who improved, or those who remained stable between baseline and 12-month follow-up in. We used one-way analysis of variance (ANOVA) and chi-square tests to compare the three groups in terms of age, sex, living situation, social support, number of comorbid conditions, diagnosis, stage of disease, extensive treatment received, and functional status.
Subsequently, we examined which sociodemographic, health, and functional status variables were associated with decline in global health status/QoL versus stable/improved between baseline and 12-month follow-up using logistic regression analysis adjusting for age and sex. Analyses were carried out with SPSS version 16.0.
results
The characteristics of the sample are shown in Table 1. The median age was 74.1 and the majority were women (69.6%). The most common diagnosis was breast cancer (n = 44).
Table 1.
Characteristics of the study sample
| Characteristics of study sample | N = 112 (%) |
| Median age at baseline (range) | 74.1 (65, 93) |
| 65–74 years | 66 (58.9) |
| ≥75 years | 46 (41.1) |
| Sex women | 78 (69.6) |
| Country of birth | |
| Canada | 65 (58.0) |
| Europe | 28 (25.9) |
| Africa | 6 (4.5) |
| South America/Caribbean | 6 (4.5) |
| Other | 7 (7.1) |
| Marital status | |
| Married/common-law | 62 (55.4) |
| Widowed | 25 (22.3) |
| Divorced/separated | 19 (17.0) |
| Single | 6 (5.4) |
| Level of education | |
| 0–4 years | 5 (4.5) |
| 5–8 years | 19 (17.0) |
| 9–12 years | 41 (36.6) |
| ≥13 years | 47 (42.0) |
| Living situation | |
| At home | 108 (96.4) |
| Residence | 3 (2.7) |
| Other | 1 (0.9) |
| Living alone | 45 (40.2) |
| Not living alone | 67 (59.8) |
| Social support available | 82 (73.2) |
| Who? (N = 82) | |
| Spouse | 50 (61.0) |
| Child(ren) | 20 (24.4) |
| Other | 12 (14.6) |
| Cancer diagnosis | |
| Lung | 27 (24.1) |
| Breast | 44 (39.3) |
| Colorectal | 20 (17.8) |
| Non-Hodgkin lymphoma | 17 (15.2) |
| Multiple myeloma | 4 (3.6) |
| Cancer diagnosis is | |
| First cancer diagnosis | 101 (90.2) |
| Recurrence | 2 (1.8) |
| New diagnosis, has been diagnosed in the past | 9 (8.0) |
| Stage of disease | |
| Stage 0–2 | 63 (56.2) |
| Stage 3–4 | 49 (43.8) |
| Extensive treatment received | 45 (40.2) |
| Number of comorbid conditions at baseline | |
| None | 23 (20.5) |
| 1 | 27 (24.1) |
| 2 | 27 (24.1) |
| 3 | 13 (11.6) |
| 4+ (max 8) | 22 (19.7) |
| ECOG PS at baseline | |
| 0 Fully active | 72 (64.3) |
| 1 Restricted in physically strenuous activities | 22 (19.6) |
| 2 Ambulatory and capable of all self-care but unable to carry out any work activities | 12 (10.7) |
| 3 Capable of only limited self-care | 6 (5.4) |
| 4 Completely disabled | 0 |
| Presence of functional limitations at baseline | 38 (33.9) |
| Presence of IADL disability at baseline | 39 (34.8) |
| Presence of ADL disability at baseline | 12 (10.7) |
| Presence of mood disturbance at baseline | 26 (23.2) |
ADL, activities of daily living; ECOG PS, Eastern Cooperative Oncology Group performance status; IADL, instrumental activities of daily living.
Of the 112 included at baseline, 78 participants also have data on global health status/QoL at the 12-month follow-up (69.6%), 10 (8.9%) refused follow-up, 22 (19.6%) died, and 2 participants (1.8%) had missing data.
The characteristics of those who completed have the global health status/QoL scale at 12 months and those who did not complete the global health status/QoL scale are shown in Table 2. Those who did not complete the global health status/QoL scale at 12 months had more often advanced disease at baseline (67.6% versus 33.3%), more often lung cancer (35.3% versus 19.2%) and had more often IADL disability at baseline (50.0% versus 28.2%). There were no differences between those who completed the study and who did not complete the global health status/QoL scale in terms of age at baseline, sex, ADL disability, or extensive treatment received. With regard to the global health status/QoL, functional scales, and symptom scales, there was a statistically significant difference only in terms of physical functioning and nausea–vomiting. Specifically, those who were lost to follow-up had lower physical functioning at baseline and reported nausea–vomiting more often.
Table 2.
Characteristics of those who completed the global health status/QoL at 12 months and those who did not complete the global health status/QoL scale at 12 months
| Characteristics | No global health status/QoL at 12 months, N = 34 (%) | Global health status/QoL at 12 months, N = 78 (%) |
| Median age at baseline (interquartile range) | 74.6 (70.9, 78.5) | 73.8 (69.1, 77.6) |
| Sex % women | 20 (58.8) | 58 (74.4) |
| Born in Canada | 22 (64.7) | 43 (55.1) |
| Married/common law | 21 (61.8) | 41 (52.6) |
| Level of education | ||
| 0–4 years | 1 (2.9) | 4 (5.1) |
| 5–8 years | 6 (17.6) | 13 (16.7) |
| 9–12 years | 13 (38.2) | 28 (35.9) |
| ≥13 years | 14 (41.2) | 33 (42.3) |
| Living alone | 14 (41.2) | 31 (39.7) |
| Social support available | 26 (76.5) | 56 (71.8) |
| Cancer diagnosis | ||
| Lung | 12 (35.3) | 15 (19.2)* |
| Breast | 4 (11.8) | 40 (51.3) |
| Colorectal | 7 (20.6) | 14 (17.9) |
| Hematological malignancy | 11 (32.4) | 9 (11.5) |
| Cancer diagnosis is: | ||
| First cancer diagnosis | 32 (94.1) | 68 (87.2) |
| Recurrence | 0 | 2 (2.6) |
| New diagnosis, has been diagnosed in the past | 2 (5.9) | 8 (10.3) |
| Advanced stage of disease (stage 3–4) | 23 (67.6) | 26 (33.3)* |
| Extensive treatment received | 15 (44.1) | 30 (38.5) |
| Median number of comorbid conditions at baseline (interquartile range) | 2.0 (1, 4) | 2.0 (1, 3) |
| ECOG PS at baseline | ||
| 0 | 14 (41.2) | 58 (74.4)* |
| 1 | 10 (29.4) | 12 (15.4) |
| ≥2 | 10 (29.4) | 8 (10.3) |
| Presence of functional limitations at baseline | 16 (47.1) | 22 (28.2) |
| Presence of IADL disability at baseline | 17 (50.0) | 22 (28.2)* |
| Presence of ADL disability at baseline | 6 (17.6) | 6 (7.7) |
| Presence of mood disturbance at baseline | 9 (30.0) | 17 (22.1) |
| EORTC QLQ-C30 scores | ||
| Global health status/QoL (interquartile range)a | 66.7 (5, 83.3) | 66.7 (58.3, 83.3) |
| Functional scalesa | ||
| Emotional functioning (interquartile range) | 75 (52.1, 89.6) | 83.3 (66.7, 91.7) |
| Physical functioning (Interquartile range) | 80 (55, 93.3) | 93.3 (76.7, 100)* |
| Role functioning (interquartile range) | 100 (66.7, 100) | 100 (83.3, 100) |
| Cognitive functioning (interquartile range) | 83.3 (66.7, 100) | 100 (83.3, 100) |
| Social functioning (interquartile range) | 100 (66.7, 100) | 100 (83.3, 100) |
| Symptom scalesb | ||
| Fatigue (interquartile range) | 22.2 (0, 55.6) | 22.2 (11.1, 33.3) |
| Nausea–vomiting (interquartile range) | 0 (0, 16.7) | 0 (0, 0)* |
| Pain (interquartile range) | 16.7 (0, 50) | 16.7 (0, 16.7) |
| Dyspnea (interquartile range) | 0 (0, 33.3) | 0 (0, 33.3) |
| Insomnia (interquartile range) | 33.3 (8.3, 66.7) | 33.3 (0, 33.3) |
| Appetite loss (interquartile range) | 0 (0, 33.3) | 0 (0, 33.3) |
| Constipation (interquartile range) | 0 (0, 33.3) | 0 (0, 0) |
| Diarrhea (interquartile range) | 0 (0, 0) | 0 (0, 0) |
| Financial problems (interquartile range) | 0 (0, 0) | 0 (0, 0) |
ADL, activities of daily living; ECOG PS, Eastern Cooperative Oncology Group performance status; EORTC QLQ-C30, European Organization for the Research and Treatment of Cancer Quality of Life Core Questionnaire with 30 items; IADL, instrumental activities of daily living; QoL, quality of life.
For the global health status/QoL and functional scales, 0 = poor functioning and 100 = highest level of functioning.
Symptom scales 0 = no symptoms and 100 = maximum symptomatology.
P < 0.05.
In Table 3, the changes over time can be seen. Overall, there was little change in median scores of the global health status/QoL scale, the functional scales, and symptom scales over time for both the groups aged 65–74 years or for those aged 75 years and older.
Table 3.
QoL over time and changes over time by age groupa
| Median (interquartile range) | Baseline | 1.5 months | 3 months | 4.5 months | 6 months | 12 months |
| N = 112 | N = 101 | N = 97 | N = 93 | N = 91 | N = 78 | |
| Global health status/QoLb | 66.7 (50–83.3) | 66.7 (50–83.3) | 66.7 (50.0–83.3) | 66.7 (50–83.3) | 75.0 (50–91.7) | 75.0 (58.3–83.3) |
| 65- to 74-year olds | 75.0 (58.3–91.7) | 66.7 (50.0–83.3) | 66.7 (50.0–83.3) | 66.7 (50–83.3) | 66.7 (50.0–91.7) | 75.0 (58.3–91.7) |
| 75 and older | 66.7 (50–83.3) | 66.7 (50–83.3) | 66.7 (50.0–83.3) | 66.7 (50–83.3) | 75.0 (54.2–83.3) | 75.0 (58.3–83.3) |
| Functional scalesb | ||||||
| Emotional functioning | 80.6 (66.7–91.7) | 83.3 (66.7–91.7) | 83.3 (66.7–100) | 83.3 (66.7–100) | 91.7 (66.7–100) | 91.7 (75.0–100) |
| 65- to 74-year olds | 83.3 (62.5–91.7) | 83.3 (66.7–91.7) | 83.3 (66.7–100) | 83.3 (66.7–100) | 91.7 (75.0–100) | 91.7 (75.0–100) |
| 75 and older | 77.8 (66.7–95.8) | 83.3 (66.7–91.7) | 75.0 (66.7–100) | 79.2 (66.7–100) | 87.5 (66.7–100) | 83.3 (75.0–100) |
| Physical functioning | 93.3 (70–100) | 86.7 (66.7–93.3) | 86.7 (73.3–100) | 86.7 (66.7–100) | 86.7 (73.3–100) | 93.3 (80.0–100) |
| 65- to 74-year olds | 93.3 (80–100) | 86.7 (66.7–93.3) | 86.7 (78.3–95.0) | 86.7 (70.0–96.7) | 93.3 (73.3–100) | 90 (80.0–100) |
| 75 and older | 86.7 (61.7–100) | 86.7 (70.0–93.3) | 86.7 (60.0–100) | 86.7 (66.7–100) | 86.7 (75.0–100) | 93.3 (66.7–100) |
| Role functioning | 100 (83.3–100) | 83.3 (66.7–100) | 100 (66.7–100) | 100 (66.7–100) | 100 (66.7–100) | 100 (83.3–100) |
| 65- to 74-year olds | 100 (83.3–100) | 83.3 (66.7–100) | 100 (66.7–100) | 83.3 (66.7–100) | 100 (66.7–100) | 100 (66.7–100) |
| 75 and older | 100 (66.7–100) | 83.3 (66.7–100) | 100 (66.7–100) | 100 (66.7–100) | 100 (83.3–100) | 100 (83.3–100) |
| Cognitive functioning | 100 (83.3–100) | 83.3 (83.3–100) | 91.7 (83.3–100) | 100 (83.3–100) | 100 (83.3–100) | 100 (83.3–100) |
| 65- to 74-year olds | 100 (75.0–100) | 91.7 (83.3–100) | 83.3 (75.0–100) | 100 (83.3–100) | 100 (83.3–100) | 83.3 (83.3–100) |
| 75 and older | 91.7 (83.3–100) | 83.3 (66.7–100) | 100 (83.3–100) | 100 (83.3–100) | 83.3 (83.3–100) | 100 (83.3–100) |
| Social functioning | 100 (83.3–100) | 83.3 (58.3–100) | 100 (66.7–100) | 100 (66.7–100) | 100 (83.3–100) | 100 (83.3–100) |
| 65- to 74-year olds | 100 (83.3–100) | 83.3 (50.0–100) | 100 (66.7–100) | 83.3 (66.7–100) | 100 (66.7–100) | 100 (83.3–100) |
| 75 and older | 100 (83.3–100) | 83.3 (66.7–100) | 100 (66.7–100) | 100 (66.7–100) | 100 (83.3–100) | 100 (83.3–100) |
| Symptom scalesc | ||||||
| Fatigue | 22.2 (11.1–38.9) | 33.3 (22.2–55.6) | 33.3 (11.1–44.4) | 22.2 (11.1–44.4) | 22.2 (11.1–33.3) | 22.2 (0–33.3) |
| 65- to 74-year olds | 22.2 (0–33.3) | 27.8 (11.1–55.6) | 33.3 (11.1–44.4) | 22.2 (11.1–44.4) | 22.2 (11.1–44.4) | 22.2 (0–33.3) |
| 75 and older | 22.2 (11.1–44.4) | 33.3 (22.2–55.6) | 33.3 (22.2–44.4) | 27.8 (11.1–52.8) | 22.2 (11.1–33.3) | 22.2 (0–44.4) |
| Nausea–vomiting | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) |
| 65- to 74-year olds | 0 (0–0) | 0 (0–16.7) | 0 (0–0) | 0 (0–16.7) | 0 (0–0) | 0 (0–0) |
| 75 and older | 0 (0–0) | 0 (0–0) | 0 (0–16.7) | 0 (0–0) | 0 (0–0) | 0 (0–0) |
| Pain | 16.7 (0–33.3) | 16.7 (0–33.3) | 16.7 (0–33.3) | 16.7 (0–33.3) | 0 (0–33.3) | 16.7 (0–33.3) |
| 65- to 74-year olds | 16.7 (0–25.0) | 16.7 (0–33.3) | 16.7 (0–33.3) | 16.7 (0–33.3) | 16.7 (0–33.3) | 16.7 (0–33.3) |
| 75 and older | 8.3 (0–33.3) | 16.7 (0–33.3) | 16.7 (0–33.3) | 0 (0–33.3) | 0 (0–29.2) | 16.7 (0–33.3) |
| Dyspnoea | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) |
| 65- to 74-year olds | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 33.3 (0–33.3) | 0 (0–33.3) |
| 75 and older | 0 (0–33.3) | 33.3 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) |
| Insomnia | 33.3 (0–50) | 33.3 (0–33.3) | 33.3 (0–33.3) | 33.3 (0–33.3) | 0 (0–33.3) | 33.3 (0–33.3) |
| 65- to 74-year olds | 33.3 (0–33.3) | 33.3 (0–33.3) | 33.3 (0–33.3) | 33.3 (0–33.3) | 33.3 (0–33.3) | 33.3 (0–33.3) |
| 75 and older | 33.3 (0–66.7) | 33.3 (0–33.3) | 33.3 (0–66.7) | 16.7 (0–33.3) | 0 (0–66.7) | 0 (0–33.3) |
| Appetite loss | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) |
| 65- to 74-year olds | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) |
| 75 and older | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–25.0) | 0 (0–33.3) |
| Constipation | 0 (0–33.3) | 0 (0–33.3) | 0 (0–0) | 0 (0–33.3) | 0 (0–0) | 0 (0–33.3) |
| 65- to 74-year olds | 0 (0–0) | 0 (0–33.3) | 0 (0–0) | 0 (0–33.3) | 0 (0–0) | 0 (0–0) |
| 75 and older | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) | 0 (0–33.3) |
| Diarrhea | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) |
| 65- to 74-year olds | 0 (0–0) | 0 (0–0) | 0 (0–33.3) | 0 (0–0) | 0 (0–0) | 0 (0–0) |
| 75 and older | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) |
| Financial problems | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) |
| 65- to 74-year olds | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) |
| 75 and older | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) | 0 (0–0) |
QoL, quality of life.
At baseline, there were sixty-five 65- to 74-year olds and forty-five ≥75 years, and at 12 months there were forty-eight 65- to 74-year olds and thirty-one ≥75 years.
For the global health status/QoL and functional scales, 0 = poor functioning and 100 = highest level of functioning.
Symptom scales 0 = no symptoms and 100 = maximum symptomatology.
Table 4 describes the number and proportion of participants who were classified as exhibiting no change, improvement, or decline over time using the cutoff for clinically relevant change. Of all the different functional scales, most changes over time occurred in global health status/QoL scale and the least change over time occurred in the physical function scale.
Table 4.
Clinically relevant change in functional scales between two subsequent data collection cycles
| EORTC QLQ-C30 scalesa | 0–1.5 months | 1.5–3 months | 3–4.5 months | 4.5–6 months | 6–12 months |
| Global health status/QoL | |||||
| Decline, n (%) | 39 (39.4) | 23 (23.7) | 21 (22.6) | 18 (20.0) | 17 (21.5) |
| No change, n (%) | 38 (38.4) | 43 (44.3) | 55 (81.7) | 49 (54.4) | 42 (53.2) |
| Improvement, n (%) | 22 (22.2) | 31 (32.0) | 17 (18.3) | 23 (25.6) | 20 (25.3) |
| Emotional function | |||||
| Decline, n (%) | 19 (19.2) | 17 (17.5) | 20 (21.5) | 7 (7.8) | 11 (13.9) |
| No change, n (%) | 58 (58.6) | 62 (63.9) | 59 (63.4) | 68 (75.6) | 55 (69.9) |
| Improvement, n (%) | 22 (22.2) | 18 (18.6) | 14 (15.1) | 15 (16.7) | 13 (16.5) |
| Physical function | |||||
| Decline, n (%) | 25 (25.8) | 12 (12.5) | 13 (14.0) | 9 (10.0) | 12 (15.2) |
| No change, n (%) | 61 (62.9) | 68 (70.8) | 72 (77.4) | 70 (77.8) | 59 (74.7) |
| Improvement, n (%) | 11 (11.3) | 16 (16.7) | 8 (8.6) | 11 (12.2) | 8 (10.1) |
| Role function | |||||
| Decline, n (%) | 40 (41.7) | 16 (16.7) | 29 (31.2) | 20 (22.2) | 16 (20.3) |
| No change, n (%) | 41 (42.7) | 40 (41.7) | 48 (51.6) | 42 (46.7) | 47 (59.5) |
| Improvement, n (%) | 15 (15.6) | 40 (41.7) | 16 (17.2) | 28 (31.1) | 16 (20.3) |
| Cognitive function | |||||
| Decline, n (%) | 29 (29.3) | 20 (20.8) | 16 (17.4) | 23 (25.6) | 16 (20.5) |
| No change, n (%) | 49 (49.5) | 52 (54.8) | 51 (55.4) | 53 (58.9) | 43 (55.1) |
| Improvement, n (%) | 21 (21.2) | 24 (25.0) | 25 (27.2) | 14 (15.6) | 19 (24.4) |
| Social function | |||||
| Decline, n (%) | 38 (40.0) | 17 (18.1) | 26 (28.0) | 12 (13.3) | 14 (17.2) |
| No change, n (%) | 41 (43.2) | 42 (44.7) | 52 (55.9) | 53 (58.9) | 48 (60.8) |
| Improvement, n (%) | 16 (16.8) | 35 (37.2) | 15 (16.1) | 25 (27.8) | 17 (21.5) |
Clinically relevant decline or improvement is change >10 points compared with previous interview. EORTC QLQ-C30, European Organization for the Research and Treatment of Cancer Quality of Life Core Questionnaire with 30 items; QoL, quality of life.
Due to missing items, for some participants we were unable to calculate the scale score; therefore, the number of participants with no change/improvement or decline may vary for the different functional and symptom scales.
Between baseline and 12-month follow-up (n = 78), 18 participants (23.1%) declined >10 points in global health status/QoL scale, while 34 participants (43.6%) remained stable and 23 participants (33.3%) improved ≥10 points. In the age group 65–74, 11 participants declined (23.4%), 21 did not change (44.7%), and 15 (31.9%) improved, whereas in the age group ≥75, 7 declined (22.6%), 13 did not change (41.9%), and 11 improved (35.5%). When we compared the three groups with regard to health and functional status using one-way ANOVA and chi-square tests, we found no statistically significant differences in age at baseline, sex, the living situation, social support, number of comorbid conditions at baseline, the number of persons with one or more functional limitations, the number of persons with one or more ADL/IADL disabilities, the number of persons with a mood disturbance, ECOG PS (0 versus >0), the number of persons with lung cancer versus other diagnoses, or extensive treatment received (yes/no), see Table 5. The only statistically significant difference was that those who declined (6.33%) or improved (14.58%) more often had advanced disease compared with the no change group (6.17%).
Table 5.
Description of Characteristics at baseline of those who declined, stable, or improved in global health status/QoL between baseline and 12 months
| Characteristics at baseline | Decline, N = 18 (%) | No change, N = 34 (%) | Improvement, N = 26 (%) |
| Median age at baseline (interquartile range) | 73.2 (68.1, 76.2) | 73.3 (69.1, 77.6) | 74.5 (69.1, 78.9) |
| Sex % women | 16 (88.9) | 26 (76.5) | 16 (61.5) |
| Living alone | 8 (44.4) | 11 (32.4) | 12 (46.2) |
| Social support available | 11 (61.1) | 27 (79.4) | 18 (71.8) |
| Lung cancer diagnosis versus other | 2 (11.1) | 6 (17.6) | 7 (26.9) |
| Advanced stage of disease (stage 3–4) | 6 (33.3) | 6 (17.5) | 14 (58.3)* |
| Extensive treatment received during first 6 months after diagnosis | 8 (44.4) | 9 (26.5) | 13 (50.0) |
| Median number of comorbid conditions (interquartile range) | 1.5 (0, 3) | 2.0 (1, 3) | 1.5 (0, 3) |
| ECOG PS ≥ 1 | 2 (11.1) | 8 (23.5) | 10 (38.5) |
| Presence of functional limitations | 6 (33.3) | 9 (26.5) | 7 (26.9) |
| Presence of IADL disability | 3 (16.7) | 8 (23.5) | 11 (42.5) |
| Presence of ADL disability | 2 (11.1) | 1 (2.9) | 3 (11.5) |
| Presence of mood disturbance | 1 (5.6) | 8 (24.2) | 8 (30.8) |
ADL, activities of daily living; ECOG PS, Eastern Cooperative Oncology Group performance status; IADL, instrumental activities of daily living; QoL, quality of life.
P < 0.05.
The results of the logistic regression analysis showed that none of the sociodemographic, health, and functional status variables were statistically significant associated with decline in global health status/QoL scale. All models were adjusted for age and sex (results not shown but available on request).
conclusions and discussion
We examined changes in QoL in older persons diagnosed with cancer in the first year after diagnosis. Our results show that while almost a quarter of older persons experienced clinically relevant decline in their QoL during the first year, a third of the sample experienced a clinically relevant improvement in their QoL despite undergoing cancer treatments. The remaining 40% experienced no clinically relevant change in their QoL. There was no difference between the younger and older participants in this study. Furthermore, none of the sociodemographic, health, or functional status variables were associated with decline in QoL during the first year after diagnosis.
Our results are in agreement with the results of Esbensen et al. [34] who found that 30% of study participants deteriorated in global health status/QoL scale of >10 points in the first 6 months after diagnosis using the same measurement instrument and with only a slightly older sample (mean age 75.4 versus 74.2 in our study). When we compared our scores on the functional and symptom scales to those of a general population (the general German population aged 70 years and older [35]), the men in our study had slightly lower functional scale scores (indicating poorer functioning) and slightly higher symptom scale scores (indicating more symptoms) whereas the women in our study had slightly higher functional scale scores (indicating better functioning) and slightly lower symptom scale scores (indicating less symptoms). However, our sample is small, there were few men, and therefore, the results should be replicated in a larger study. Furthermore, there is the possibility that a proportion of the 40% of participants we observed who neither decline nor improve was due to ceiling effects. In this study, the scores for the physical, role, social, and cognitive scales (indicating good functioning) and for most symptoms were very low (indicating few symptoms) and therefore these scores could not have improved very much. Hurria et al. [36] have reported no change in QoL during the first year in older adults with breast cancer receiving adjuvant treatment despite significant treatment toxicity using the Functional Assessment of Cancer Treatment and in a younger population (median age 68) with few women aged ≥75 years. The sample of Hurria et al. only included 49 patients, which might have led to non-significant findings. Wedding et al. [37, 38] have reported that before the start of chemotherapy depression, functional impairment and comorbid conditions were associated with poor QoL using the global health status/QoL scale of the EORTC QLQ-C3-30. In our study, mood impairment, functional impairment, and the number of comorbid conditions assessed before the start of treatment were not associated with decline in QoL during the course of treatment. Wedding et al. also observed no differences between elderly with cancer and without cancer; in both groups, severe disease requiring hospitalization led to a reduction in QoL. The participants in their study were all inpatients, whereas in our study they were outpatients, and thus less severely ill. This may explain the difference in findings.
It is important to understand the impact of cancer and its treatment on the QoL in older adults. It has been reported previously that older cancer survivors do worse in terms of functional status and QoL compared with older adults without cancer [39–41] but there are very few published studies that have examined this. There is currently limited research on QoL in older newly diagnosed cancer patients [42]. Although QoL is considered as an important end point in clinical trials, there are few older adults enrolled in clinical trials. A quality of life module for the Assessment of QoL in the Elderly patient with Cancer (QLQ-ELD-15) has been developed and will undergo further validation http://groups.eortc.be/qol/qolg_projects.htm#elderly.
In this study, we examined a variety of sociodemographic, health, and functional status variables. Nevertheless, there may be other causes of decline in QoL in older adults, such as aging, having the disease, or complications of the disease and treatment. Further studies with larger samples are needed to evaluate which factors influence changes in QoL after the diagnosis during cancer treatment in older adults. This knowledge will aid in the development of interventions improving QoL for older cancer patients during cancer treatment.
A limitation of our study was our small relatively heterogeneous sample with regard to cancer diagnosis, stage, and treatment received as it was designed as a pilot study and recruitment took place in only one cancer treatment center. A strength of our study on the other hand is that we measured QoL every 6 weeks for the first 6 months as well as at 12 months, allowing us to examine the changes over time during the first year after diagnosis during cancer treatment. Due to the small numbers in each of the groups, we could not conduct statistical analysis examining if changes over time were different between groups. Due to the small sample, we could not examine the effect of each of the different modalities of cancer treatment separately and we have used a rather cruder measure to indicate who had received extensive treatment or not. Another limitation is our loss to follow-up and this loss to follow-up was mostly due to mortality. This might have led to an underestimate of the number of older cancer patients with a clinically relevant decline in QoL as they scored at baseline on the physical functioning scale.
In conclusion, almost a quarter of newly diagnosed older adults experienced clinically relevant decline in their QoL. Decline in QoL might be a consequence of aging, cancer itself, the treatment, or the complications of treatment. More research is needed on which factors influence decline in QoL in older adults undergoing cancer treatment.
funding
Canadian Cancer Society/National Cancer Institute of Canada to M.T.E.P; McGill University/Université de Montreal Solidage Research Group on Frailty and Aging and the McGill Dr Joseph Kaufman Chair in Geriatric Medicine. Postdoctoral research fellowship of the M. Puts from the Canadian Cancer Society/National Cancer Institute of Canada.
disclosure
The authors declare no conflict of interest.
Acknowledgments
We thank all of the participants who gave of their time during a very difficult period of their life to participate in our study. In addition, we very much appreciate the support of staff and volunteers of the Segal Cancer Centre.
References
- 1.Smith BD, Smith GL, Hurria A, et al. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol. 2009;27(17):2758–2765. doi: 10.1200/JCO.2008.20.8983. [DOI] [PubMed] [Google Scholar]
- 2.Canadian Cancer Society/National Cancer Institute of Canada. Canadian Cancer Statistics 2008. Toronto, Canada: Canadian Cancer Society: 2008. [Google Scholar]
- 3.Canadian Cancer Society's Steering Committee. Canadian Cancer Statistics 2009. Toronto, Canada: Canadian Cancer Society; 2009. [Google Scholar]
- 4.Pasetto LM, Lise M, Monfardini S. Preoperative assessment of elderly cancer patients. Crit Rev Oncol Hematol. 2007;64(1):10–18. doi: 10.1016/j.critrevonc.2007.08.001. [DOI] [PubMed] [Google Scholar]
- 5.Wedding U, Pientka L, Hoffken K. Quality-of-life in elderly patients with cancer: a short review. Eur J Cancer. 2007;43(15):2203–2210. doi: 10.1016/j.ejca.2007.06.001. [DOI] [PubMed] [Google Scholar]
- 6.Jennens RR, Giles GG, Fox RM. Increasing under representation of elderly patients with advanced colorectal or non-small-cell lung cancer in chemotherapy trials. Intern Med J. 2006;36(4):216–220. doi: 10.1111/j.1445-5994.2006.01033.x. [DOI] [PubMed] [Google Scholar]
- 7.Hutchins LF, Unger JM, Crowley JJ, et al. Under representation of patients 65 years of age or older in cancer-treatment trials. N Engl J Med. 1999;341(27):2061–2067. doi: 10.1056/NEJM199912303412706. [DOI] [PubMed] [Google Scholar]
- 8.Meropol NJ, Buzaglo JS, Millard J, et al. Barriers to clinical trial participation as perceived by oncologists and patients. J Natl Compr Canc Netw. 2007;5(8):655–664. doi: 10.6004/jnccn.2007.0067. [DOI] [PubMed] [Google Scholar]
- 9.Sateren WB, Trimble EL, Abrams J, et al. How sociodemographics, presence of oncology specialists, and hospital cancer programs affect accrual to cancer treatment trials. J Clin Oncol. 2002;20(8):2109–2117. doi: 10.1200/JCO.2002.08.056. [DOI] [PubMed] [Google Scholar]
- 10.Townsley CA, Selby R, Siu LL. Systematic review of barriers to the recruitment of older patients with cancer onto clinical trials. J Clin Oncol. 2005;23(13):3112–3124. doi: 10.1200/JCO.2005.00.141. [DOI] [PubMed] [Google Scholar]
- 11.Balducci L. Aging, frailty, and chemotherapy. Cancer Control. 2007;14(1):7–12. doi: 10.1177/107327480701400102. [DOI] [PubMed] [Google Scholar]
- 12.Bouchardy C, Rapiti E, Blagojevic S, et al. Older female cancer patients: importance, causes, and consequences of undertreatment. J Clin Oncol. 2007;25(14):1858–1869. doi: 10.1200/JCO.2006.10.4208. [DOI] [PubMed] [Google Scholar]
- 13.Velanovich V, Gabel M, Walker EM, et al. Causes for the undertreatment of elderly breast cancer patients: tailoring treatments to individual patients. J Am Coll Surg. 2002;194(1):8–13. doi: 10.1016/s1072-7515(01)01132-2. [DOI] [PubMed] [Google Scholar]
- 14.Olaya W, Wong JH, Morgan JW, et al. Disparities in the surgical management of women with stage I breast cancer. Am Surg. 2009;75(10):869–872. [PubMed] [Google Scholar]
- 15.Smith GL, Xu Y, Shih YC, et al. Breast-conserving surgery in older patients with invasive breast cancer: current patterns of treatment across the United States. J Am Coll Surg. 2009;209(4):425–433. doi: 10.1016/j.jamcollsurg.2009.06.363. e2. [DOI] [PubMed] [Google Scholar]
- 16.Wang J, Kollias J, Boult M, et al. Patterns of surgical treatment for women with breast cancer in relation to age. Eur J Cancer. 2010;16(1):60–65. doi: 10.1111/j.1524-4741.2009.00828.x. [DOI] [PubMed] [Google Scholar]
- 17.Langer CJ. Neglected and underrepresented subpopulations: elderly and performance status 2 patients with advanced-stage non-small-cell lung cancer. Clin Lung Cancer. 2006;7(Suppl 4):S126–S137. doi: 10.3816/clc.2006.s.004. [DOI] [PubMed] [Google Scholar]
- 18.Jagsi R, Abrahamse P, Morrow M, et al. Postmastectomy radiotherapy for breast cancer: patterns, correlates, communication, and insights into the decision process. Cancer. 2009;115:1185–1193. doi: 10.1002/cncr.24164. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Pasetto LM, Falci C, Compostella A, et al. Quality of life in elderly cancer patients. Eur J Cancer. 2007;43(10):1508–1513. doi: 10.1016/j.ejca.2006.11.023. [DOI] [PubMed] [Google Scholar]
- 20.Puts MT, Monette J, Girre V, et al. Participation of older newly-diagnosed cancer patients in an observational prospective pilot study: an example of recruitment and retention. BMC Cancer. 2009;9(1):277. doi: 10.1186/1471-2407-9-277. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Collaborative Staging Task Force of the American Joint Committee on Cancer. Collaborative staging manual and coding instructions, version 01.04.00. Report No.: NIH Publication Number 04–5496. Chicago, IL: American Joint Committee on Cancer 2004. [Google Scholar]
- 22.Carbone PP, Kaplan HS, Musshoff K, et al. Report of the committee on Hodgkin's disease staging classification. Cancer Res. 1971;31(11):1860–1861. [PubMed] [Google Scholar]
- 23.Durie BG, Salmon SE. A clinical staging system for multiple myeloma. Correlation of measured myeloma cell mass with presenting clinical features, response to treatment, and survival. Cancer. 1975;36(3):842–854. doi: 10.1002/1097-0142(197509)36:3<842::aid-cncr2820360303>3.0.co;2-u. [DOI] [PubMed] [Google Scholar]
- 24.Johansson BB, Holmberg L, Berglund IG, et al. Determinants of cancer patients' utilization of hospital care within two years after diagnosis. Acta Oncol. 2004;43(6):536–544. doi: 10.1080/02841860410015631. [DOI] [PubMed] [Google Scholar]
- 25.Groll DL, Heyland DK, Caeser M, Wright JG. Assessment of long-term physical function in acute respiratory distress syndrome (ARDS) patients: comparison of the Charlson comorbidity index and the functional comorbidity index. Am J Phys Med Rehabil. 2006;85(7):574–581. doi: 10.1097/01.phm.0000223220.91914.61. [DOI] [PubMed] [Google Scholar]
- 26.Groll DL, To T, Bombardier C, Wright JG. The development of a comorbidity index with physical function as the outcome. J Clin Epidemiol. 2005;58(6):595–602. doi: 10.1016/j.jclinepi.2004.10.018. [DOI] [PubMed] [Google Scholar]
- 27.Oken MM, Creech RH, Tormey DC, et al. Toxicity and response criteria of the eastern cooperative oncology group. Am J Clin Oncol. 1982;5(6):649–655. [PubMed] [Google Scholar]
- 28.Fillenbaum GG, Smyer MA. The development, validity, and reliability of the OARS multidimensional functional assessment questionnaire. J Gerontol. 1981;36(4):428–434. doi: 10.1093/geronj/36.4.428. [DOI] [PubMed] [Google Scholar]
- 29.Katz S. Assessing self-maintenance: activities of daily living, mobility, and instrumental activities of daily living. J Am Geriatr Soc. 1983;31(12):721–727. doi: 10.1111/j.1532-5415.1983.tb03391.x. [DOI] [PubMed] [Google Scholar]
- 30.Zigmond AS, Snaith RP. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983;67:361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x. [DOI] [PubMed] [Google Scholar]
- 31.Hermann C. International experience with the hospital anxiety and depression scale-a review of validation data and clinical results. J Psychom Res. 1997;42:17–41. doi: 10.1016/s0022-3999(96)00216-4. [DOI] [PubMed] [Google Scholar]
- 32.Aaronson NK, Ahmedzai S, Bergman B, et al. The European organization for research and treatment of cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst. 1993;85(5):365–376. doi: 10.1093/jnci/85.5.365. [DOI] [PubMed] [Google Scholar]
- 33.Osoba D, Rodrigues G, Myles J, et al. Interpreting the significance of changes in health-related quality-of-life scores. J Clin Oncol. 1998;16(1):139–144. doi: 10.1200/JCO.1998.16.1.139. [DOI] [PubMed] [Google Scholar]
- 34.Esbensen BA, Osterlind K, Hallberg IR. Quality of life of elderly persons with cancer: a 6-month follow-up. Scand J Caring Sci. 2007;21(2):178–190. doi: 10.1111/j.1471-6712.2007.00454.x. [DOI] [PubMed] [Google Scholar]
- 35.Schwarz R, Hinz A. Reference data for the quality of life questionnaire EORTC QLQ-C30 in the general German population. Eur J Cancer. 2001;37(11):1345–1351. doi: 10.1016/s0959-8049(00)00447-0. [DOI] [PubMed] [Google Scholar]
- 36.Hurria A, Hurria A, Zuckerman E, et al. A prospective, longitudinal study of the functional status and quality of life of older patients with breast cancer receiving adjuvant chemotherapy. J Am Geriatr Soc. 2006;54:1119–1124. doi: 10.1111/j.1532-5415.2006.00789.x. [DOI] [PubMed] [Google Scholar]
- 37.Wedding U, Koch A, Rohrig B, et al. Depression and functional impairment independently contribute to decreased quality of life in cancer patients prior to chemotherapy. Acta Oncol. 2008;47(1):56–62. doi: 10.1080/02841860701460541. [DOI] [PubMed] [Google Scholar]
- 38.Wedding U, Rohrig B, Klippstein A, et al. Co-morbidity and functional deficits independently contribute to quality of life before chemotherapy in elderly cancer patients. Support Care Cancer. 2007;15(9):1097–1104. doi: 10.1007/s00520-007-0228-9. [DOI] [PubMed] [Google Scholar]
- 39.Reeve BB, Potosky AL, Smith AW, et al. Impact of cancer on health-related quality of life of older Americans. J Natl Cancer Inst. 2009;101:860–868. doi: 10.1093/jnci/djp123. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Baumann R, Putz C, Rohrig B, et al. Health-related quality of life in elderly cancer patients, elderly non-cancer patients and an elderly general population. Eur J Cancer Care. 2009;18:457–465. doi: 10.1111/j.1365-2354.2008.00975.x. [DOI] [PubMed] [Google Scholar]
- 41.Thome B, Dykes AK, Hallberg IR. Quality of life in old people with and without cancer. Qual Life Res. 2004;13(6):1067–1080. doi: 10.1023/B:QURE.0000031342.11869.2f. [DOI] [PubMed] [Google Scholar]
- 42.Given B, Given CW. Cancer treatment in older adults: implications for psychosocial research. Breast J. 2009;57(Suppl 2):S283–S285. doi: 10.1111/j.1532-5415.2009.02513.x. [DOI] [PubMed] [Google Scholar]