The Landscape of Perception: Racial Differences in How Disability Is Viewed Among Older-Adult Cancer Survivors.

This paper compares disability perceptions of Black with white older cancer survivors' to document racial disparities in these perceptions and the factors that contribute to them. The data are from a randomly selected tumor registry sample of 321 older adult cancer survivors from an NCI funded study. OLS regression models of disability perceptions, nested by race, examined the effects cancer and non-cancer health factors along with important covariates. Black older adult cancer survivors perceived themselves to be more disabled than did white survivors. Multivariate analyses showed a strong relationship between functional difficulties and disability perceptions for both Black and white survivors. However cancer-related factors such as continuing symptoms of the illness or treatment were relatively more important for Blacks. The findings suggest that race and cancer are both important factors in our understanding of disability in later life. These findings can then inform clinical best practices among minority older adults.

Factors Affecting Perceptions of Disability and Self-Rated Health Among Older Adult, Long-Term Cancer Survivors.

OBJECTIVE: This article examines the relative importance of cancer-related and noncancer illness factors as they predict the health quality of life among older adult, long-term cancer survivors. Specifically, it examines the effects that continuing cancer symptoms and comorbidities have on functional difficulties and how they in turn affect perceptions of disability and self-rated health. METHOD: Data from an National Cancer Institute (NCI)-funded, tumor registry-based 10-year study of 321 older adult (age 60+), long-term (5+years post diagnosis) survivors of breast colorectal and prostate cancer are examined using regression analyses. RESULTS: The analyses documented the independent effects of both cancer-related and age-related health factors as they contribute to explaining functional difficulties, perceptions of disability and self-rated health. Gender and racial differences in health quality of life were also identified. DISCUSSION: The findings suggest that geriatricians, geriatric nurses, and clinical gerontologists who work with cancer survivorsneed to be aware of the ways in which both cancer and noncancer illness factors work together in producing threats to health quality of life through the extent and nature of functional impairments.

The relative importance of cancer-related and general health worries and distress among older adult, long-term cancer survivors.

OBJECTIVE: This research examines the relative importance that cancer-related and non-cancer illness factors play in generating general health worries and/or cancer-related worries. The analysis also examines how these in turn impact anxiety and depression among older adult, long-term cancer survivors. METHODS: Data from a longitudinal study of 245 older-adult (age 60+ years), long-term survivors (5 or more years after diagnosis) of breast, prostate, and colorectal cancer are examined to identify the measurement properties and structure of general health and cancer-related health worries. Based on that measurement analysis, structural equation models (SEM) are used to estimate the relative importance of cancer-related and other illness predictors on cancer-related worry and general health worry and how these two forms of worry affect both anxiety (POMS) and depression (CES-D). RESULTS: The results from the exploratory and confirmatory factor analysis of health worries identify two relatively independent measures of health worry, one of general health worry and a second of cancer-related worries that includes fears of recurrence, new cancers, and follow-up testing. SEM analyses identified the importance of current cancer-related symptoms and comorbidities on cancer-related worry. It also documents the primacy of non-cancer symptoms and general health worry as predictors of anxiety and depression among older survivors. CONCLUSIONS: The fact that cancer-related symptoms continue to be associated with cancer-related worries years after diagnosis speaks to the significance of these continuing sequelae. While the findings suggest the relative independence of cancer-related worries and general health worries, both are correlated with anxiety and depression. This may be particularly problematic as survivors age and symptoms related to new health problems increase, while cancer-related symptoms persist. Copyright © 2015 John Wiley & Sons, Ltd.

Personality and psychological distress among older adult, long-term cancer survivors.

This research examines a model of how personality (Five-Factor Model) is related to adjustment to cancer in later life in terms of the presence of continuing cancer-related worry and depression among older adult, long-term cancer survivors. Data from an NCI-funded study with 275 older adult (age 60+), long-term (5+ years) survivors of breast, prostate, and colorectal cancer were examined. Regression analyses identified neuroticism as the strongest predictor of cancer-related worry along with continuing cancer-related symptoms. For depression, three personality dimensions (neuroticism, conscientiousness, and agreeableness) were significant predictors. Findings suggest the importance of considering the central role that survivors' personality characteristics play in understanding cancer-related worries and depression. Understanding these dispositional characteristics is key for social workers and health-care practitioners in counseling survivors experiencing these common mental health effects.

Correlated and Coupled Trajectories of Cancer-Related Worries and Depressive Symptoms among Long-Term Cancer Survivors.

The quality of life over time of long-term survivors has become an important part of both cancer and aging research. This paper examines individual differences in trajectories of cancer-related worries and depressive symptoms of 179 participants who completed four waves of annual interviews. Cancer-related worries were significantly associated with both initial level and trajectories of depressive symptoms. In a parallel process growth curve model, the initial level of depressive symptoms was significantly correlated with both the initial level and rate of change in cancer-related worry over time. Our findings indicate that cancer survivors are never completely removed from cancer's threats to quality of life, even as they survive into later life. These findings also suggest that older adults face the dual vulnerability of aging with its growing number of comorbidities and related symptoms along with the vulnerability conferred by cancer-related sequelae and the possibility of recurrence or new cancers.

Primary care physicians' involvement in the cancer care of older long-term survivors.

OBJECTIVE: This study investigated survivors' reports of primary care physicians' (PCPs) involvement in three key cancer survivorship activities: discussing cancer history, whether the PCP initiated discussions, and whether discussions led to tests/procedures. METHOD: The sample included 215 older survivors whose health care was maintained in primary care. Logistic regression explored predictors of the three activities, including demographics, cancer characteristics, survivor/PCP association characteristics, health characteristics, and psychosocial well-being. RESULTS: Nearly two thirds of survivors indicated discussing cancer history; most said discussions were PCP initiated and nearly half said discussions resulted in tests/procedures. Predictors of discussing cancer history were African American race and more comorbid conditions. PCP-initiated discussions were related to older age, surviving breast cancer, more years in the PCP's practice, and having less general health worry. The tests/procedures model was not significant. CONCLUSIONS: As older survivors focused more on other health concerns, PCPs remained attentive to cancer issues, prompting discussions about history and ordering tests.

Functioning of older, long-term cancer survivors: the role of cancer and comorbidities.

OBJECTIVES: To examine the relative effect of comorbidities, noncancer symptoms, and cancer-related factors on the functioning of older adult long-term survivors of breast, colorectal, and prostate cancers. DESIGN: Data from in-person interviews with survivors of a tumor registry-based stratified random sample were used to test a multivariate model using ordinary least-squares regression. SETTING: Survivors were identified in the tumor registry of a National Cancer Institute-designated Comprehensive Cancer Center in Cleveland, Ohio. PARTICIPANTS: Three hundred twenty-one older (>or=60), long-term (>or=5 years) cancer survivors. MEASUREMENTS: The primary outcome measure, functional difficulty, was measured using Nagi's Performance Limitations Index. Predictors included a number of indicators of survivors' personal characteristics, age-related health characteristics, and cancer-related characteristics. RESULTS: The model explained 44% of the variance in functional difficulties between the cancer survivors in this sample. The strongest predictors were symptoms not attributed to cancer (beta=0.28) and comorbidities (beta=0.22), although cancer-related factors explained an additional 8% of the variance over that explained by demographic and noncancer health factors, with current cancer-related symptoms being a significant predictor (beta=0.14). CONCLUSION: These findings indicate the importance of monitoring cancer-related characteristics along with comorbidities and noncancer symptoms in long-term survivors because they jointly affect overall physical functioning. Special attention needs to be given to women and minority cancer survivors as well.

Cancer survivorship and aging.

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 survivors are aged > or =65 years. Given these large numbers and the potential vulnerability 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 > or =65 years. The second part reviewed the research regarding long-term (> or =5 years) cancer survivors 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 provided. In particular, prospective studies with measures of functioning before cancer diagnosis and treatment, comparisons with age-matched noncancer populations, and interventions to reduce the impact of cancer on functioning are needed.

The effects of cancer-related pain and fatigue on functioning of older adult, long-term cancer survivors.

This research examines the fatigue and pain reported by a sample of long-term (5 years), older adult (>or=60 years) survivors of breast, prostate, and colorectal cancer. It also examines the importance of cancer and age-related factors as correlates of pain and fatigue as well as the relationship between pain and fatigue and functional difficulty. Data were derived from 321 in-person interviews with a sample of survivors randomly selected from a tumor registry at a comprehensive cancer center. The results of multivariate analysis indicate that the pain, energy level, and weakness reported by older adult cancer survivors are more strongly related to age-related factors than they are to cancer-related factors. Age-related factors accounted for 14% of the variance in pain compared with 2% for cancer-related factors. For energy level, age-related factors explained 4% of the variance, whereas cancer-related factors account for 2%. Age-related factors accounted for 9% of the variance in weakness compared with 6% for cancer-related factors. Furthermore, pain, energy, and weakness are all statistically significant predictors of functional difficulties (beta = .20, -.16, and .11, respectively). Age-related factors explained 21% of the total variance, whereas cancer-related factors contributed 6%. This research points to the fact that both cancer and age-related factors contribute to the pain and fatigue of older adult survivors, although factors such as comorbidities and noncancer symptoms appear to be relatively more important. Because it is not unusual for those providing health care to older adults to be unaware of their cancer history and treatments, the role that cancer may play in symptoms such pain and fatigue may go unassessed and unadressed.

Cancer survivorship and identity among long-term survivors.

This article examines the concept of survivorship and the adoption of the "survivor identity" by those who have been treated for cancer. First, we review recent and growing theoretical and empirical literatures on cancer and identity and identity transformation. With that review as background, we present our own research findings from 2 separate studies on survivorship and identity. Our data suggest that most older adults who have survived cancer for at least 5 years, identify as cancer survivors and/or as ex-patients rather than as victims or patients. Most also view being a survivor as an important part of who they are, do not see themselves as less whole, and are not overly concerned about how others view them. To the degree that a survivor orientation is associated with better mental health outcomes and encourages health promotion and appropriate symptom monitoring, it can reinforce the effects of the quality medical care provided by clinical staff. The support of clinicians encouraging this orientation, where it is appropriate, may further enhance the quality of life of individuals who living with a history of cancer.

Functioning and activity participation restrictions among older adult, long-term cancer survivors.

This research examines how cancer and treatment sequelae combine with comorbidities to influence the physical functioning and activity participation restrictions reported by older adult (> or =60), long-term survivors (5+ years) of breast, prostate, and colorectal cancer. The number of current comorbidities was the best predictor of functional difficulties and also a significant predictor of participation restrictions. Cancer stage at diagnosis and continuing cancer symptoms had direct effects on functional difficulties, and indirect effects through functional difficulties on participation restrictions. Clinicians working with older adult survivors need to be aware of the interplay between cancer and other health problems as they affect quality of life after cancer.

Older adults in the Emergency Department: predicting physicians' burden levels.

The aging of the U.S population will have impact on hospital Emergency Departments (ED) nationwide. To date, ED research has focused on utilization rates and acuity without considering issues of burden and stress that emergency physicians may experience caring for the increasing numbers of older adult patients. Results of a survey of Emergency Medicine residents and their attendings indicates that physicians overestimate the percentage of their patient load aged 65 years and older, have less confidence managing older patients, and desire more geriatric Emergency Medicine training. Based on regression analysis, several factors predict higher levels of emergency physician burden including training level, experiences, patient census estimate gaps, and relational issues with patients. Findings suggest the need to systematically address how the profession of Emergency Medicine is responding to its growing older adult patient population.

Appraisal of the cancer experience by family members and survivors in long-term survivorship.

This study assessed the appraisal of the stressfulness of the cancer experience and its correlates for family members and older survivors living in the long-term survivorship phase of the disease. On average, family members appraised the cancer experience as more stressful than their surviving relatives. Beliefs about the effect of the diagnosis and treatment on family members were important correlates for both family members and survivors in the appraisal process. Cancer characteristics were not related to appraisal for survivors, but stage at diagnosis was associated with a more stressful appraisal for family members. Demographic characteristics were unrelated to appraisal for family members, but being African-American was linked to a less stressful appraisal for survivors. These findings highlight the stressful impact of the cancer experience on family members and can help guide health care interventions which include family members from African-American and White ethnicities.

Cancer-related health worries and psychological distress among older adult, long-term cancer survivors.

While long-term survivors (5 years+) do not face the stressors of diagnosis and treatment, they continue to face the uncertainties that survivorship brings: recurrence, other cancers, late effects of treatment, and the potential of a shortened life expectancy. This research focuses on the cancer-related health worries of older adult, long-term cancer survivors, the factors that predict these worries, and their link to traditional measures of psychological distress. Specifically, a model is proposed that identifies the personal (including race and gender) and illness/treatment characteristics of survivors that are significantly associated with cancer-related health worries and their effects on anxiety and depression. Descriptive and multivariate analyses of a random sample of 321 long-term survivors in a major cancer center tumor registry are used to address these issues. About one-third of survivors continue to report worries about recurrence, worries about a second cancer, and worries that symptoms they experience may be from cancer. The regression analyses show that cancer-related health worries is a significant predictor of both depression (beta=0.36) and anxiety (beta=0.21). Race is a significant predictor; being African American is related to fewer cancer-related health worries (beta=-0.22). Having more symptoms during treatment is also a predictor of having more cancer-related health worries (beta=0.20). The most consistent predictor of psychosocial distress is dispositional optimism/pessimism, with more optimistic individuals reporting fewer cancer-related health worries (beta=-0.27), lower levels of both anxiety (beta=-0.16) and depression (beta=-0.23). Overall, for many older adult, long-term survivors, the legacy of cancer continues in terms of cancer-related health worries. In spite of these, for most survivors, their quality of life is not dramatically compromised either physically or psychologically.

Coping among older-adult, long-term cancer survivors.

This research focuses on the coping behavior of older adult, long-term cancer survivors. Specifically, it identifies the personal (including race and gender) and illness/treatment characteristics of survivors that are significantly associated with the use of specific coping styles: planning, acceptance, venting, denial and seeking social support. It also examines the mediating role that these forms of coping play in terms of psychological distress: anxiety, depression and cancer-related worries. Multivariate analysis of data from a random sample of 321 long-term survivors in a major cancer center tumor registry is used to address the above issues. The most prominent forms of coping used by long-term survivors were planning and acceptance; least used were venting and denial. Increased age was associated with lower use of all forms of coping, but cancer type was not. Denial as a form of coping was associated with higher anxiety, depression and cancer-related worries. While race was not found to be a significant predictor of coping style, it was a significant predictor of three dimensions of psychological distress, anxiety, depression and cancer-related worries, with African Americans exhibiting lower levels of distress than Whites. The relevance of these findings for health and social service practitioners is discussed.

Cancer in the elderly.

As the population expands, over the period from 2000 to 2050, the number and percentage of Americans over age 65 is expected to double. This population expansion will be accompanied by a marked increase in patients requiring care for disorders with high prevalence in the elderly. Since cancer incidence increases exponentially with advancing age, it is expected that there will be a surge in older cancer patients that will challenge both healthcare institutions and healthcare professionals. In anticipation of this challenge, researchers at the Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio are conducting a series of investigations focused on the intersection of aging and cancer. Studies will be addressed in the high priority research areas of 1) Treatment Efficacy and Tolerance, 2) Effects of Comorbidities, 3) Psychosocial Issues, and 4) Biology of Aging Cancer.

The health of older-adult, long-term cancer survivors.

Research indicates that cancer-related health problems persist for decades among survivors. The combination of late effects of cancer or its treatment and age-related health problems may add to the vulnerability of older survivors. This research reports on the health and functioning of a sample of long-term (5+ years), older-adult (>60 years) survivors of breast, prostate, and colorectal cancer. Data were derived from 321 in-person interviews with a sample randomly selected from a tumor registry at a comprehensive cancer center. Descriptive data analyzed comorbid health conditions and continued cancer symptoms reported by survivors. Correlational analysis examined the association among demographic cancer-related factors and a range of health quality-of-life outcomes, including functioning and illness impact. Nearly 40% of respondents have at least 1 symptom attributed to cancer/treatment. Pain was the most commonly reported symptom, with 21% attributing it to cancer. More than 40% of breast cancer survivors and nearly 20% of prostate cancer survivors reported pain. Being African American or female was significantly associated with more current symptoms and greater functional difficulty. Survivors who had chemotherapy and survivors with more types of treatment reported significantly more symptoms both during treatment and currently. Many older-adult survivors are more vulnerable due to both cancer-related symptoms and comorbid health conditions. Women and African Americans are at special risk. This combined vulnerability is an important factor for clinicians treating long-term survivors.

Families of long-term cancer survivors: health maintenance advocacy and practice.

Research on cancer and aging has addressed health maintenance issues for older adults in long-term cancer survivorship, but not their family members. The current study focused on two aspects of health maintenance for families: advocacy and practice. Regression analyses explored the effects of demographic characteristics and perceptions during diagnoses and treatments on family members' health maintenance in long-term survivorship. Family members were acting as health maintenance advocates for their surviving relatives. Advocacy was related to being a caregiver during diagnosis and treatment. In terms of their own health, family members were practicing a high number of health maintenance activities. Practice was associated with being a caregiver during diagnosis and treatment and with being older and White. Implications for interventions and future research with family members are discussed.

Appraisal of the cancer experience by older long-term survivors.

Cancer survivorship is best viewed as a process that continues across the life span. Appraisals of cancer change over time and may not be explicit until long after treatment completion. The current study, using the Lazarus and Folkman (1984) stress-appraisal-coping framework, explored factors related to both a stressful and an irrelevant appraisal of the cancer experience by older long-term survivors. Hierarchical regression analysis investigated the individual and cumulative effects of person factors (survivors' demographic characteristics, beliefs about the effect of cancer on family members) and situation factors (characteristics of cancer) on survivors' appraisals that cancer was a stressful life event. The strongest correlates of the stress appraisal were person factors. A more stressful appraisal was associated with: (1). the belief that diagnosis/treatment caused greater family distress, (2). being younger, and (3). being White. The irrelevant appraisal had a marginally significant correlate in bivariate analysis and was not included in regression analysis. Implications for health-care professionals and patient/family interventions are discussed.