Cancer survivorship and aging

Cancer and Aging: Challenges and Opportunitiesacross the Cancer Control Continuum

Supplement to Cancer

Cancer Survivorship and Aging

Nancy E. Avis, PhD1

Gary T. Deimling, PhD2

1 Department of Social Sciences and HealthPolicy, Division of Public Health Sciences, WakeForest University School of Medicine, Winston-Salem, North Carolina.

2 Department of Sociology, Case WesternReserve University, Cleveland, Ohio.

Cancer is primarily a disease of the elderly. Greater than 60% of new cancers

occur in people aged >65 years, and 60% of the current 10 million cancer survi-

vors are aged �65 years. Given these large numbers and the potential vulnerabil-

ity of older adults, older cancer survivors have become an especially important

group to study. This article discusses published research on the physical and

mental functioning of older cancer survivors. In the first part, the authors

reviewed studies of those who are newly diagnosed at the age of �65 years. The

second part reviewed the research regarding long-term (�5 years) cancer survi-

vors who are aged >65 years, but may have been diagnosed at a younger age.

Older survivors are likely to be more affected by cancer in terms of physical than

psychologic function. However, comparisons with individuals without a history of

cancer suggest that older cancer survivors may be faring worse physically and

psychologically than noncancer comparison groups. For older cancer survivors,

cancer occurs against a background of other chronic conditions and normal aging,

and comorbidities and symptoms are important factors to consider. Limitations of

the research were discussed, and recommendations for future research were pro-

vided. In particular, prospective studies with measures of functioning before can-

cer diagnosis and treatment, comparisons with age-matched noncancer

populations, and interventions to reduce the impact of cancer on functioning are

needed. Cancer 2008;113(12 suppl):3519–29. � 2008 American Cancer Society.

KEYWORDS: aging, elderly, oncology, cancer survivors, quality of life.

C ancer is primarily a disease of the elderly. Greater than 60% of

new cancers occur in people aged >65 years.1 The incidence

rate for all sites triples in persons ages 60 years to 70 years, com-

pared with individuals aged 40 to 59 years.2 Moreover, as the pro-

portion of the US population aged �65 years increases, even greater

numbers of older individuals will be diagnosed with cancer.3,4

Improved early detection and treatment have also increased the

number of people who have cancer for an extended period of time.

Of the current 10 million cancer survivors, 60% are aged �65 years,

and >16% of US adults aged �65 years are cancer survivors.5 Given

these large numbers and the potential vulnerability of older adults,

older cancer survivors have become an especially important group

to study.

Survivorship represents a relatively new way of thinking about

cancer as it is experienced by those who are diagnosed and treated

for this disease. In the past, poor survival rates for the majority of

cancers resulted in thinking of cancer as a ‘‘death sentence.’’ How-

ever, improved survival rates have made a survivorship orientation

Sponsored by the National Cancer Institute’sOffice of Cancer Survivorship.

Presented at the Society of Behavioral Medicinepreconference entitled ‘‘Cancer and Aging: Chal-lenges and Opportunities across the Cancer Con-trol Continuum,’’ Washington, DC, March 21,2007.

Address for reprints: Nancy E. Avis, PhD, Divisionof Public Health Sciences, Department of SocialSciences and Health Policy, Wake Forest Univer-sity School of Medicine, Piedmont Plaza II, Sec-ond Floor, Winston-Salem, NC 27157-1063; Fax:(336) 716-7554; E-mail: [email protected]

Received November 7, 2007; accepted January2, 2008.

ª 2008 American Cancer SocietyDOI 10.1002/cncr.23941Published online 3 December 2008 in Wiley InterScience (www.interscience.wiley.com).

3519

more realistic. This, along with the perspective of

cancer as a chronic disease,5,6 has resulted in survi-

vorship becoming a new focus for both the clinicians

who treat cancer patients and the scientists who

study them.

The term ‘‘survivor’’ now refers not only to those

who have lived for an extended period of time after

treatment, but also includes newly diagnosed indivi-

duals as well as those who are in treatment, have

completed treatment, or are in remission. This

change in orientation and language has been

adopted and promoted by the American Cancer Soci-

ety and the National Coalition of Cancer Survivors.

In fact, the National Cancer Institute’s Office of Can-

cer Survivorship defines a survivor as anyone who

has been diagnosed with cancer.7 Taken together, the

definition of a cancer survivor now includes a range

of individuals beginning with those newly diagnosed

to those who have been free of cancer for decades.

This article discusses the physical and mental

functioning of older cancer survivors across a tempo-

ral continuum. The first part reviewed research on

survivors age �65 years who are relatively newly

diagnosed (�3 years) with cancer. The second part

reviewed research on older survivors who represent

long-term survivors. In reviewing the research, we

focused on published research based on samples of

cancer survivors aged >60 years only or research

that specifically compared survivors of different age

categories. We began our search with recently pub-

lished articles identified through PubMed and added

articles cited in these publications. This article did

not attempt to provide an exhaustive review of all

published research on older cancer survivors, but

rather to present a sense of what is currently known

regarding older cancer survivors, the limitations of

this research, and directions for future research.

We should mention several factors that make

comparisons across studies particularly challenging.

One challenge is differing age distributions and cut-

points across studies. The most common cutpoint

for older survivors is 65 years of age, but this is not

used uniformly. Second, samples differ in their time

since diagnosis. Some smaller studies have samples

comprised of survivors with very explicit time inter-

vals from diagnosis (eg, 3 months, 1 year), whereas

other large cohort studies may have wider ranges

(eg, any cancer survivor). Third, some studies control

for important covariates, and others do not. As seen

in this review, these covariates (particularly comor-

bidities and symptoms) are important considerations

in studying older survivors. Fourth, studies involve

different cancer sites. The majority of studies focus

on breast cancer survivors, but others include survi-

vors of multiple cancer sites. As seen in these stu-

dies, quality of life (QOL) issues vary by cancer site.

Despite these challenges, there are some consistent

patterns to the findings, and those patterns are the

focus of this article.

Studies of Newly Diagnosed Older PatientsAlthough many studies have examined the physical

and mental status of newly diagnosed cancer

patients, to our knowledge few have focused specifi-

cally on older patients or on age-related compari-

sons. Even fewer provide comparisons with a general

population. We classified these studies into 2 cate-

gories: 1) those that include older cancer survivors

only or compare older and younger survivors, and 2)

those that provide a comparison between older can-

cer patients with the general population.

Newly diagnosed older survivors (no comparison group)Given et al8,9 and Ganz et al10 have conducted what

to our knowledge are the largest studies published to

date focusing specifically on older cancer survivors

during the first year after diagnosis (Table 1). The

primary aim of these studies was to examine the tra-

jectory of functioning in the year after diagnosis and

factors related to better functioning. Both studies

assessed functioning with the Medical Outcomes

Study 36-item Short Form (MOS SF-36), but found

somewhat different results in terms of the trajectory

of functioning over time.

Given et al studied 907 newly diagnosed breast,

colon, lung, and prostate cancer patients aged �65

years and found that physical functioning improved

over 1 year8 and that symptoms of depression

decreased over 1 year.9 Ganz et al10 followed 691

newly diagnosed breast cancer patients aged �65

years for 15 months and found that both physical

functioning and mental health on the SF-36 declined

over time. It is difficult to determine why these stu-

dies found different patterns of functioning using the

same instrument and similar timeframes. Differences

cannot be explained by cancer site, because Given

et al found improvement among all cancer sites.

Interestingly, Ganz et al found improvement over

time on a cancer-specific psychosocial instrument

(Cancer Rehabilitation Evaluation System). Both stu-

dies, however, found that the number of comorbid

conditions was a significant predictor of changes in

physical and mental health. Given et al8,9 also found

that improvement in physical function was corre-

lated with cancer site, being female, and having

fewer symptoms; a decrease in depressive symptom-

atology was found to be correlated with cancer site,

3520 CANCER Supplement December 15, 2008 / Volume 113 / Number 12

TABLE

1Stud

iesof

Older

Can

cerSu

rvivor

sDiagn

osed

Withinth

ePa

stYe

ar(N

oCom

pariso

nSa

mple)

Stud

ySa

mple

Timeframe

Out

comes

Cov

ariates

Results

Given

etal

2000

8New

lydiag

nosedbrea

st,

colon,

lung

,and

pros

tate

canc

er;

N590

7;alla

ged�6

5y

6-8,

12-16,

26-30,

and52

wkafterdiag

nosis

SF-36ph

ysical

func

tion

subs

cale

No.

ofco

morbid

cond

ition

s,ca

ncer

site,

andsex

Physical

func

tionim

prov

edov

ertim

e;pred

ictors

ofworse

physical

func

tion:

site,a

ge,fem

alesex,

comorbidity,a

ndsymptom

s.

Stom

mel

etal

2004

9Sa

mesampleas

Given

etal

2000

8Dep

ressive

symptom

atolog

y

(CES

D)

Sex,

marita

lstatus,

educ

ation,

race

/

ethn

icity

,can

cersite,

stag

e,co

morbiditie

s,

physical

func

tion,

and

symptom

s

Dep

ressivesymptom

atolog

yde

clined

over

time;

pred

ictors:c

ance

r

site,s

tage

,com

orbiditie

s,ed

ucation,

physical

func

tioning

,and

symptom

seve

rity;a

gewas

NS.

Gan

zet

al20

0310

New

lydiag

nosedbrea

st

canc

er;N

569

1;ag

ed

65-69y,

70-74y,

and

�80y

3,6,

and15

mon

thsafter

surgery

SF-36ph

ysical

func

tion

andmen

talh

ealth

;

CAR

ES-SFca

ncer-

spec

ificps

ycho

social

summary,

med

ical

interaction,

andself-

ratedhe

alth

Baselin

eQOL,

social

supp

ort,marita

lstatus,

educ

ation,

no.o

f

comorbidco

ndition

s,

type

ofsu

rgery,

trea

tmen

t,ethn

icity

,

Med

icaid,

anddisease

stag

e

Physical

func

tionde

clined

over

time;

pred

ictors:n

o.of

comorbid

cond

ition

s,ch

emothe

rapy

,Med

icaid,

BCSwith

outradiation.

Men

talh

ealth

declined

over

time(smalla

mou

nt);pred

ictors:n

o.

ofco

morbidco

ndition

s,Med

icaid,

andmarried

.CAR

ES

psyc

hoso

cial

scoreim

prov

edov

ertim

e;pred

ictors:s

ocials

uppo

rt

andbe

tter

interactionwith

healthca

reprov

iders.

Perceive

dhe

alth

at15

mo;

pred

ictors:b

aselineph

ysical

func

tion,

men

talh

ealth

,

andso

cial

supp

ort.Ag

eno

trelatedto

anyou

tcom

e.Note:

low

resp

onse

rate

(50%

).

Vino

kuret

al19

9014

Brea

stca

ncer;N

527

4;

stag

esIan

dII;a

ged

<60

yan

d�6

0y

4moan

d10

moafter

diag

nosis

Men

talh

ealth

(man

y

mea

sures)

physical

func

tion

Youn

gerag

erelatedto

worse

men

talh

ealth

;older

ageexac

erba

ted

impa

ctof

moreextens

ivesu

rgeryon

symptom

s.

Wen

zele

tal

1999

15Br

east

canc

er;s

tage

sI,II,

andIIIA;a

ged�5

0y

(n516

1),a

ged>50

y

(n514

3);N

530

4

<2moaftertrea

tmen

tFA

CT,

CES

D,s

exua

l

func

tioning

Trea

tmen

t

(che

mothe

rapy

,

reco

nstruc

tion)

Youn

gerpa

tientsrepo

rted

sign

ifica

ntly

worse

emotiona

lwell-be

ing,

brea

stca

ncer

conc

erns

,globa

lQOL,

andde

pression

.Noag

e

diffe

renc

eno

tedin

physical

orfunc

tiona

lwell-be

ing,

sexu

al

func

tioning

.

Mor

etal

1994

13New

lydiag

nosedbrea

st

canc

erpa

tients;

aged

24-54y(n514

3),a

ged

�55y(n511

9)

Beginn

ingch

emothe

rapy

orradiation

SF-36MHI-5

Dem

ograph

ics,

extent

of

disease,

trea

tmen

t,

social

supp

ort

Youn

gerpa

tientsrepo

rted

lower

emotiona

lwell-be

ing.

Other

pred

ictors:�

high

scho

oled

ucation,

symptom

s,an

dlower

social

supp

ort.

King

etal

2000

12Ea

rly-stag

ebrea

stca

ncer;

aged

25-39y(n529

),

aged

40-49y(n586

),

aged

50-59y(n593

),

ages

60-81y(n595

)

3moan

d12

moafter

surgery

EORT

CQLQ

-C30

Educ

ationan

dmarita

l

status

Older

patie

ntsrepo

rted

better

social,e

motiona

lfun

ctioning

,less

pain,few

ersymptom

s,bu

tworse

physical

func

tioning

.

SF-36indica

tesMed

ical

Outco

mes

Stud

y36

-item

ShortFo

rm;C

ESD,C

enterforEp

idem

iologica

lStudies-D

epressionSc

ale;

NS,

notsign

ifica

nt;C

ARES

-SF,

Canc

erRe

habilitation

Evalua

tion

System

,Sho

rtFo

rm;Q

OL,

quality

oflife;

BCS,

brea

stco

nserva

tionsu

rgery;

FACT

,Fun

c-

tiona

lAssessm

ento

fCan

cerTh

erap

y;MHI-5,

Men

talH

ealth

Inve

ntory;

EORT

CQLQ

-C30

,Europ

eanOrgan

izationforRe

search

andTrea

tmen

tofC

ance

rqu

ality

oflifequ

estio

nnaire.

Cancer Survivorship and Aging/Avis and Deimling 3521

stage, physical functioning, and symptom severity.

Age was found to be related to worse physical func-

tion in the study by Given et al,8,9 but was unrelated

to outcomes in the report by Ganz et al.10

Several studies have compared older and

younger cancer survivors (Table 1). By using various

outcome measures, these studies consistently found

greater psychologic morbidity among younger cancer

patients compared with older survivors.11–15 Possible

explanations for this include cancer being an off-

time event for younger women (most of these studies

focused on breast cancer patients) and younger

women having more family responsibilities, greater

interference with work, more concerns about the

impact of treatment on fertility, and fewer coping or

financial resources.13 Although older cancer patients

may experience less psychologic effects of cancer

than younger survivors, older patients report worse

physical functioning.11,14,16 Despite the consistency

of findings, these studies were limited by the lack of

adjustment for age-related differences in treatment.

It is well established that younger cancer patients

receive more aggressive cancer treatments, which

could have a negative impact on their functioning.17

Cancer Patients Compared With the General PopulationThe studies reviewed above all lacked a comparison

group of similarly aged individuals who had not

been diagnosed with cancer and were unable to dis-

tinguish between age-linked effects resulting from

the impact of cancer and those that are the result of

aging. This distinction is especially important given

that older patients are likely to have several comor-

bidities and other functional limitations. Two studies

addressed this limitation by providing explicit com-

parisons of older cancer survivors with the general

population (Table 2). In a study conducted in Ger-

many, Arndt et al11 compared scores on the Euro-

pean Organization for Research and Treatment of

Cancer QOL questionnaire (QLQ-C30) of cancer sur-

vivors who were 1 year after diagnosis with scores

from a general adult population. They found differ-

ences between cancer patients and the general popu-

lation among a younger cohort of patients, but not

the older age group. Consistent with other studies,

they found that among cancer survivors, age was

correlated with better emotional and social function-

ing, but also poorer physical functioning.

Kroenke et al18 used data from the Nurses’

Health Study (NHS) and NHS 2 to analyze change in

function among women diagnosed with breast can-

cer within a 4-year period compared with an age-

matched group of women who remained healthy

over the same time period. A strength of this study TABLE

2Stud

iesof

New

lyDiagn

osed

Can

cerPa

tien

tsAge

d‡6

5Ye

arsWithCom

pariso

nSa

mples

Stud

ySa

mple

Com

pariso

nGro

upTimeframe

Out

comes

Cov

ariates

Results

Arnd

tet

al20

0411

Brea

stca

ncer

patie

nts;

N538

7;ag

ed30

-80y;

mea

nag

e,57

y;ag

ed

30-49y(n588

),ag

ed

50-59y(n585

),ag

ed

60-69y(n587

),ag

ed

70-80y(n554

)

German

femalead

ult

popu

latio

nag

es

16-92y;

N511

39

1yafterdiag

nosis

EORT

CQLQ

-C30

Non

erepo

rted

Agerelatedto

lower

physical

func

tionan

dglob

al

QOL.

Older

patie

ntsrepo

rted

better

emotiona

l,

cogn

itive

,and

social

func

tioning

.Differen

ces

betw

eenca

ncer

patie

ntsan

dreferenc

egrou

p

was

largestforyo

unge

rpa

tients;

olde

rpa

tients

didno

tdiffe

rsign

ifica

ntly

from

gene

ral

popu

latio

n.

Kroe

nkeet

al20

0418

Nurse’sHea

lthStud

yan

d

Nurse’sHea

lthStud

y2;

wom

endiag

nosed

with

brea

stca

ncer

(N510

82);ag

ed�4

0y,

aged

41-64y,

andag

ed

�65y

Age-match

edwom

en

with

outbrea

stca

ncer

Pred

iagn

osis

andup

to

4yafterdiag

nosis

SF-36

Baselin

efunc

tiona

l

status

,smok

ing,

alco

hol,ph

ysical

activ

ity,B

MI,

comorbiditie

s,

men

opau

sals

tatus,

andho

rmon

eus

e

Allw

omen

with

brea

stca

ncer

show

edgrea

ter

func

tiona

ldec

lines

compa

redwith

controls,b

ut

thediffe

renc

ewas

grea

test

foryo

unge

rwom

en.

EORT

CQLQ

-C30

indica

tesEu

rope

anOrgan

izationforRe

search

andTrea

tmen

tofC

ance

rqu

ality

oflifequ

estio

nnaire;Q

OL,

quality

oflife;

SF-36,

Med

ical

Outco

mes

Stud

y36

-item

ShortF

orm;B

MI,bo

dymassinde

x.


was the availability of SF-36 scores before diagnosis,

which enabled researchers to compare change in SF-

36 scores from before to after diagnosis. Controlling

for baseline functional status, smoking, alcohol,

physical activity, body mass index, comorbidities,

menopausal status, and hormone use, they found

that all women with breast cancer demonstrated

greater functional declines than the controls. How-

ever, young women who developed breast cancer

demonstrated greater absolute and relative functional

losses in physical role function, bodily pain, social

function, and mental health compared with middle-

aged or older women with breast cancer. Results

showed substantial physical declines in older women

both with and without breast cancer, suggesting that

much of this decline is related to age, rather than

disease or treatment. This research highlights the im-

portance of obtaining functional measures before

treatment.

SummaryTaken as a whole, research on newly diagnosed older

cancer patients suggests that for older cancer survi-

vors, cancer affects physical functioning more than

psychologic functioning. Whereas older cancer

patients may demonstrate some psychologic impact

of cancer, this tends to be relatively short-lived and

less detrimental than for younger patients. Although

several hypotheses have been put forward as to why

younger cancer survivors have greater psychologic

morbidity, these hypotheses need to be explored fur-

ther and tested. Conversely, older cancer patients

may be more affected by cancer in terms of physical

function. The presence of comorbidities is especially

important and needs to be considered in any study

of older cancer survivors.

Studies of Long-term Cancer SurvivorsThis section focuses specifically on the physical and

psychosocial QOL of older-adult long-term survivors

of cancer (�5 years). The diversity of older adults

included in these studies in terms of age at diagno-

sis, current age, and length of survivorship makes

this literature difficult to synthesize. Studies often

include individuals who range from ages 60 years to

90 years at the time of the study, but may have sur-

vived cancer for �25 years. This results in the inclu-

sion of very different survivor subgroups. As in the

previous section, studies of long-term cancer survi-

vors can be categorized as: 1) those that include only

cancer survivors and 2) those that compare cancer

survivors to those without cancer. We reviewed each

category separately.

Older adult long-term survivors only (no comparison group)Many of the long-term survivorship studies that

included older adults did not include a comparison

group of similarly aged individuals without a history

of cancer. As with other studies of survivors, the ma-

jority focused on breast cancer survivors. Our review

(Table 3) reflects this pattern.

In a study of 316 breast cancer survivors aged

>65 years who were followed for 5 years after diag-

nosis, Clough-Gorr et al19 reported that mental

health did not change for the majority of survivors.

Those survivors who did demonstrate a decline in

mental health had poorer physical function at base-

line. Ganz et al20 found that age was positively

related to general health, and that older breast can-

cer survivors reported less of an impact of cancer on

their lives, a finding also reported by Stava et al.21

Cimprich et al22 compared long-term (�5 years)

breast cancer survivors diagnosed at different ages

(<45 years, 45 to 64 years, and �65 years) and found

that survivors diagnosed at an older age (aged �65

years) reported significantly poorer QOL in the physi-

cal domain, whereas those diagnosed at a younger

age (aged <45 years) demonstrated worse QOL in

the social domain.

Two groups of researchers have conducted stu-

dies focusing on long-term survivors of multiple

types of cancers. Avis et al23,24 studied 242 long-term

(�5 years) survivors of breast, bladder, prostate, col-

orectal, head and neck, or gynecologic cancer.

Approximately Eighty-five percent of this sample was

aged >60 years, and 65% was aged >70 years. The

mean time since diagnosis was 12.6 years. This study

was conducted in the context of developing a QOL

instrument specific to adult cancer survivors, the

Quality of Life in Adult Cancer Survivors (QLACS)

scale. The biggest problems cited by survivors were

sexual problems, fatigue, and family-related concerns

surrounding disease recurrence.23 QOL varied by

cancer site, with prostate and colorectal cancer survi-

vors reporting the best QOL and head and neck and

bladder cancer survivors the worst QOL.

Deimling et al25–30 also conducted a study of

long-term breast, colorectal, and prostate survivors

that specifically examined QOL issues. They studied

321 survivors aged >60 years who were at least 5

years after diagnosis. Their results demonstrated that

nearly 40% of older survivors had at least 1 continu-

ing symptom attributed to cancer or its treatment.

Survivors who had chemotherapy and/or more types

of treatment reported significantly more symptoms

both during treatment and currently. Being African

American or female was found to be significantly

associated with more current symptoms and greater


TABLE

3Stud

iesof

Long

-term

Can

cerSu

rvivor

sAge

d‡6

5Ye

ars(N

oCom

pariso

nSa

mple)

Stud

ySa

mple

Timeframe

Out

comes

Cov

ariates

Results

Cim

prichet

al20

0222

Brea

stca

ncer;N

510

5;ag

ed<45

y

(n542

),ag

ed45

-65y(n535

),

aged

>65

y(n528

);mea

nag

e,

64.5

y

�5yafterdiag

nosis;

rang

e,5-50

y;mea

n,

11.5

y

QOL-CS;

domains

:phy

sica

lwell-

being,

psyc

hologicwell-be

ing,

social

well-be

ing,

andsp

iritu

al

well-be

ing.

ysinc

ediag

nosis,

marita

lstatus,

educ

ation,

type

ofsu

rgery,

chem

othe

rapy

,rad

iatio

n,an

d

antie

stroge

ntherap

y

Wom

endiag

nosedat

anolde

rag

erepo

rted

lower

physical

well-be

ing;

wom

endiag

nosedat

ayo

unge

r

agerepo

rted

lower

social

well-be

ing.

Gan

zet

al20

0220

Mea

nag

e,55

.6yat

baselin

e;

follo

w-upoc

curred

4ylater

5-9.5yafterdiag

nosis;

mea

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adde

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ation,

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cial

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talh

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ofsu

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tch

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;

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men

talh

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ofdisability,

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aged

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Symptom

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5),a

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nosis

Pain,e

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wea

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func

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of

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nergy,

andwea

kness.

QOL-CS

indica

tesQua

lityof

Life

Canc

erSu

rvivorsscale;

SF-36,

Med

ical

Outco

mes

Stud

y36

-item

ShortFo

rm;M

HI-5,

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talH

ealth

Inve

ntory;

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ance

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stem

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rtFo

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dies

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stress

diso

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functional difficulty, but this was related to having

more comorbidities and not to cancer-related factors

such as cancer stage at diagnosis or treatment com-

plexity.

In terms of specific symptoms, pain was the

most commonly reported symptom, with 21% attri-

buting this current symptom to their past cancer or

its treatment.27 Although cancer-related factors were

significant correlates of pain, comorbidities and non-

cancer symptoms were stronger correlates. Greater

than 40% of breast cancer survivors and nearly 20%

of prostate cancer survivors reported pain, with breast

cancer survivors reporting the highest levels of pain.

Race was also a significant correlate of pain, with Afri-

can–American women having the highest scores.

Greater than 40% of survivors reported feeling

weakness or lack of energy within the past week,26

with approximately 25% attributing it to cancer.

However, as with other symptoms, the lack of energy

and weakness reported by these older adult survivors

was found to be more strongly related to age-related

factors such as the number of other health problems

rather than cancer.

This study also found important psychosocial

outcomes of cancer. Nearly half of the older adult

long-term survivors reported a range of cancer-

related worries such as fears of disease recurrence,

fears of a new cancer, and fears that symptoms they

experience may represent cancer. Furthermore, these

fears were correlated with the number of cancer-

related symptoms experienced during treatment as

well as current cancer-related or treatment-related

symptoms. Importantly, cancer-related worries were

found to be significant predictors of more general

levels of distress such as anxiety and depression.

Comparison of long-term survivors to those without acancer historyMost of the long-term physical and mental effects of

cancer reported above are from studies that included

only cancer survivors. To fully understand the impact

of cancer on older persons, it is important to compare

long-term survivors with individuals who have never

had cancer. These studies are presented in Table 4.

In a study focusing specifically on older adult,

long-term survivors from the Health and Retirement

study, Keating et al31 compared cancer survivors with

a population-based noncancer comparison group

from this same study. Cancer survivors had higher

rates of specific comorbidities such as lung disease,

heart disease, arthritis, incontinence, frequent pain,

and obesity compared with controls. Controlling for

these comorbidities, survivors were still less likely to

report being in excellent health and had more mobil-

ity and activity limitations than those without a his-

tory of cancer. Older long-term cancer survivors did

not exhibit more psychiatric disease or depression,

nor did they exhibit poorer cognitive functioning

compared with those who never had cancer.

Robb et al32 compared SF-36 scores and meas-

ures of psychologic well-being from a sample of

older-adult breast cancer survivors aged �70 years

with the scores of women who had never had cancer.

Their analysis found that cancer survivors reported

poorer physical functioning, bodily pain, more days

per week with fatigue, and worse psychologic well-

being than the comparison group. However, the

comparison group was a sample of women enrolled

in a longitudinal study of healthy aging, and there-

fore may have been particularly healthy.

Using data from the large Health Outcomes

Study, Baker et al33 compared SF-36 scores between

those participants who had a history of cancer with

age-matched participants who did not. They found

that cancer survivors had poorer QOL on all sub-

scales of the SF-36, but the effect sizes were small.

Those who were currently in treatment for lung can-

cer or had >1 cancer were worse off. Comorbidities

were found to be significantly related to health–

related QOL. In what to our knowledge was 1 of the

few studies that further broke down the group of

patients aged >65 years, they found that the patients

ages 65 years to 74 years reported better QOL than

those who were aged >75 years.

Hewitt et al5,34 used data from the National

Health Interview Survey to compare participants

with a history of cancer with those without such a

history. Analyses included survivors ranging from <2

years to those who had survived >20 years. Cancer

survivors had more comorbidities and were more

likely to report poorer overall health and limitations

in activities of daily living. Survivors reported greater

use of mental health services in general; this was

noted particularly for younger women, who also

reported greater psychologic problems. Although

these analyses include both short-term and long-

term survivors, 83% of the sample had been diag-

nosed >2 years previously.

Two studies were able to take advantage of exist-

ing large cohorts in which data were available before

a cancer diagnosis. Sweeney et al35 compared the

functional limitations of female older–adult cancer

survivors (ages 66 years-79 years) from the Iowa

Women’s Health Study with study participants who

had never had cancer. Controlling for baseline char-

acteristics (obesity, smoking, and diabetes) and

comorbidities, they found that 5-year survivors, com-

pared with those without a cancer history, were sig-


TABLE

4Stud

iesCom

paring

Long

-term

Survivor

sWithCon

trols

Stud

ySa

mple

Com

pariso

nGro

upTimeframe

Out

comes

Cov

ariates

Results

Arnd

tet

al20

0411

Aged

30-49y(n567

),ag

ed50

-59y

(n566

),ag

ed60

-69y(n575

),

aged

�70y(n543

)

German

gene

ral

popu

latio

nthat

was

age-stan

dardized

3yafterdiag

nosis

EORT

CQLQ

-C30

Non

erepo

rted

Differen

cesbe

twee

nca

ncer

patie

ntsan

dge

neral

popu

latio

nweregrea

test

foryo

unge

rpa

tients.

Robb

etal

2007

32Br

east

canc

er;N

512

7;ag

ed�7

0y;

mea

nag

e,78

y

Wom

enin

epidem

iologic

stud

yof

aging;

N511

9;

mea

nag

e,77

.6y

>1yafterdiag

nosis;

mea

n,5.1y

SF-36ps

ycho

logicwell-

being

Did

notad

just

Brea

stca

ncer

survivorsrepo

rted

worse

QOLan

d

someps

ycho

logicwell-be

ing(com

pariso

ngrou

p

may

have

been

particularly

healthy);s

urvivo

rs

hadmoreco

morbiditie

s.

Bake

ret

al20

0333

Hea

lthCareFina

ncing

Administration’sHea

lth

Outco

meSu

rvey

;N522

,747

;

aged

65-74y(n510

,969

),ag

ed

�75y(n510

,716

)

Age-match

edno

ncan

cer

patie

nts

Anytim

epo

stdiag

nosis

SF-36

Age,

sex,

race

,Hispa

nic,

inco

me,

marita

lstatus,

educ

ation,

med

ical

cond

ition

,treatmen

t

status

,can

cersite

Can

cersu

rvivorsha

dpo

orer

QOLthan

compa

riso

n

grou

pon

alls

ubscales,b

uteffect

sizeswere

small;thos

ein

trea

tmen

tforlung

canc

eror

>1

canc

erwereworse;c

omorbiditie

salso

sign

ifica

ntly

relatedto

HRQ

OL;

65-74grou

pha

d

high

erscores.

Swee

neyet

al20

0635

IowaWom

en’sHea

lthStud

y;ag

ed

55-69yin

1986

;age

d66

-79y

in19

97;m

eanag

e,72

y;ca

ncer

survivors;

N522

18

Stud

ypa

rticipan

ts

with

outca

ncer;

N523

,501

>2yafterdiag

nosis,

2-5yafterdiag

nosis,

�5yafterdiag

nosis

Func

tiona

llim

itatio

nsSm

oking,

BMI,

comorbiditie

s,ph

ysical

activ

ity,a

nded

ucation

Can

cersu

rvivorsrepo

rted

morefunc

tiona

l

limita

tions

;differen

cegrea

test

forpa

tients

surviving�2

y.

Garman

etal

2003

36Duk

eestablishe

dpo

pulatio

nsfor

epidem

iologicstud

iesof

the

elde

rlyca

ncer

patie

nts;

N537

6;

alla

ged�6

5y,

mea

nag

e,

73.6

y

Participan

tsne

ver

diag

nosedwith

canc

er;

N537

84

Patie

ntsdiag

nosed0-4y

prev

ious

ly(n513

2),

diag

nosed5-15

y

prev

ious

ly(n511

7),

anddiag

nosed>15

y

prev

ious

ly(n512

7)

Katz

activ

ities

ofda

ily

living,

Rosow-B

reslau

Nag

isca

le,

instrumen

tala

ctivities

ofda

ilyliv

ing

Com

orbidity

scoreof

0or

1vs

�2;p

redictors

wereag

e,sex,

race,

marita

lstatus,

educ

ation,

depression

,

andco

gnitive

status

Durationof

canc

ersu

rvivorsh

ipwas

foun

dto

be

unrelatedto

func

tioning

;com

orbidity

was

foun

d

tobe

sign

ifica

ntly

relatedto

func

tion.

Keatinget

al20

0531

Hea

lthan

dRe

tirem

entStud

y

canc

ersu

rvivors;

N596

4;all

aged

�55y;

mea

nag

e,68

.3y

Participan

tswho

didno

t

repo

rtha

ving

canc

er;

N514

,333

�4yafterdiag

nosis

Self-assessed

health,

ADLs

,and

depression

Com

orbiditie

sSu

rvivorsha

dworse

physical

health;n

odiffe

renc

e

notedwith

rega

rdto

men

talh

ealth

.Com

men

t:

Analysis

used

prop

ensity

scoreweigh

ts.

Hew

ittan

dRo

wland

2002

34Nationa

lHea

lthInterview

Survey

;

aged

18-44y,

aged

45-64y,

aged

�65y;

canc

ersu

rvivors;

N548

78

Participan

tswith

outa

historyof

canc

er;

N590

,737

Anytim

eafterdiag

nosis;

83%

ofsamplewas

>2yafterdiag

nosis

Use

ofmen

talh

ealth

services

Sociod

emog

raph

icsan

d

health

charac

teristics

Can

cersu

rvivorsrepo

rted

grea

terus

eof

men

tal

health

services;m

entalh

ealth

serviceus

egrea

ter

amon

gthos

eag

ed<65

yan

ddiag

nosedat

youn

gerag

e,an

dmoreco

morbiditie

s,form

erly

married

.

Hew

ittet

al20

035

Nationa

lHea

lthInterview

Survey

;

aged

18-44y,

aged

45-64y,

aged

�65y,

canc

ersu

rvivors,

N548

78

Participan

tswith

outa

historyof

canc

er;

N590

,737

Anytim

eafterdiag

nosis;

83%

ofsamplewas

>2yafterdiag

nosis

Gen

eral

health

status

,

psyc

hologicdisability,

limita

tions

inAD

Ls,

physical

func

tioning

Sociod

emog

raph

ics,

comorbiditie

s,ca

ncer

site,a

ge,a

ndag

eat

diag

nosis

Can

cersu

rvivorsha

dmoreco

morbiditie

san

dwere

morelik

elyto

repo

rtpo

orer

health,p

sych

olog

ic

prob

lems,

limita

tions

ofAD

Lsan

dIADLs

,and

func

tiona

llim

itatio

ns.A

mon

gca

ncer

survivors,

youn

gersu

rvivorsrepo

rted

grea

terps

ycho

logic

prob

lems.

EORT

CQLQ

-C30

indica

tesEu

rope

anOrgan

izationforRe

search

andTrea

tmen

tofC

ance

rqu

ality

oflifequ

estio

nnaire;S

F-36

,Med

ical

Outco

mes

Stud

y36

-item

ShortF

orm;Q

OL,

quality

oflife;

HRQ

OL,

health-related

quality

oflife;

BMI,bo

dymassinde

x;AD

Ls,a

ctivities

ofda

ily

living;

IADLs

,ins

trum

entala

ctivities

ofda

ilyliv

ing.


nificantly more likely to report functional limitations

such as an inability to do housework, walk a half

mile, or walk up/down stairs. Using data from the

Duke Established Populations for Epidemiologic stu-

dies of the Elderly, Garman at al36 found that func-

tion decline was significantly correlated with the

presence of comorbidities rather than cancer per se

among participants aged �65 years.

SummaryThe research regarding long-term cancer survivors is

noteworthy for the consistency of findings that can-

cer survivors have more comorbidities and poorer

functioning (independent of comorbidities) than

noncancer survivors. The consistency of this research

is in contrast to that of newly diagnosed older

patients, in whom the effects of cancer due to age

are not as apparent. It thus appears that age-related

differences may arise over time. This may be the

result of the late effects of cancer and its treatment,

consequences of underlying risk factors for cancer

(eg, smoking and diet), or the interaction of cancer

and aging. This highlights the importance of studying

the late effects of cancer and developing interven-

tions to prevent loss of functioning with age.

Summary and Future Research DirectionsThe literature suggests that older cancer survivors

are likely to be more affected by cancer in terms of

physical compared with psychologic function. Physi-

cal domains also may be more important to older

persons, for whom impairments in mobility may

mean the difference between independent and

assisted living. The literature has consistently shown

that older breast cancer survivors are less likely to

have psychologic morbidity than younger survivors.

However, comparisons with noncancer patients in

some studies suggest that older cancer survivors may

be faring worse psychologically than noncancer sur-

vivors. In the context of older cancer survivors, it is

important to consider the impact of an acute cancer

episode on a background of other chronic conditions

and deterioration in physical functioning that is part

of normal aging. To our knowledge, very few studies

to date have measures of functioning before a cancer

diagnosis and treatment, thus making it difficult to

determine the direct impact of cancer.

Limitations of ResearchThe majority of studies reviewed herein focused on

breast cancer survivors. This is largely a result of the

large numbers of long-term breast cancer survivors.

However, the extent to which these findings can be

generalized to men, cancers that progress more

quickly, and cancers with different patterns of treat-

ment is unknown. Another limitation is that most

studies do not report effect sizes, which is particu-

larly important for some of the studies that deter-

mined statistical significance with large sample sizes.

Studies comparing older and younger cancer sur-

vivors do not take treatment characteristics beyond

type of surgery or adjuvant therapy into account.

This is an important consideration because older per-

sons tend to receive less aggressive treatment because

of the greater likelihood of estrogen receptor–positive

tumors, the presence of comorbid conditions, and

lower functional status,17 and more aggressive treat-

ment may impact QOL. To truly understand the impact

of age on cancer survivorship, it is important to control

for type of treatment received.

Although many studies control for comorbidities,

others do not. The long-term effects of cancers that

are common among older adults often coexist along

with other health problems associated with aging.

Thus, older adults may experience this dual vulner-

ability. Over a decade ago, Havlik et al37 identified

comorbidities as a significant issue among cancer

survivors and found them to increase with advancing

age. Recently, others have also identified the pre-

sence of comorbidities among older survivors as 1 of

the key issues to be addressed by research on cancer

and aging.38

Finally, it should be noted that few articles report

effect sizes, but in those that do, the effect size is of-

ten modest. This is noted especially in studies with

large sample sizes, in which small effects can be sta-

tistically significant.

The following approaches to futureresearch are suggested:

� Any study of older cancer survivors needs to con-

sider comorbidities and their interaction with a

cancer diagnosis. As observed in the studies

described herein, comorbidities are important

determinants of QOL.

� Comparisons with age-matched noncancer popula-

tions are critical for understanding the impact of

cancer on older persons. These comparisons are

particularly important in the context of other func-

tional declines that occur with aging and are not

attributable to cancer.

� Prospective studies that measure physical and

mental health functioning before treatment are

needed to assess changes in functioning resulting

from treatment.

� Age groupings of older survivors need to be broken

down further into young-old and old-old. To our


knowledge, the majority of research published to

date combined all survivors aged >65 years. How-

ever, some research has shown age differences

even among those aged �60 years.8,29,33 The gen-

eral gerontologic literature would recommend

separating the young-old from the old-old, because

research has shown that there are important

health, functioning, and psychosocial differences

among age groupings of older adults.

� It is important to identify subgroups of older survi-

vors at greatest risk. This may include those who

have poor functioning at the time of diagnosis, low

social support, or comorbidities. Cancer site and

type of treatment may also be important.

� Greater emphasis is needed on recruiting older

persons into clinical trials. Relatively few elderly

persons are accrued to clinical trials because of

concerns that older patients cannot tolerate or will

not benefit from treatment17or restrictive inclu-

sion/exclusion criteria.39 These criteria need to be

carefully evaluated to ensure that older persons are

not excluded unnecessarily.

� Interventions are needed to reduce the impact of

cancer on functioning. Existing behavioral inter-

ventions that have shown benefits among cancer

survivors in general need to be applied to older

patients. In some instances, this may mean adjust-

ing the modality or specifics of the intervention

(eg, exercise).

A more detailed discussion of the implications

for future research is provided in the article by Bel-

lizzi et al in this issue.40

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Cancer survivorship and aging