Beyond the treatment: The role of race, sex, and education in health trajectories between cancer survivors and noncancer older adults.

INTRODUCTION: The number of older, long-term cancer survivors is increasing. However, little is known about how cancer and aging affect the health trajectories of older adults differently. In addition, the impact of race, sex, and education on the processes of aging and the cancer experience needs further investigation. The current study aims to address this knowledge gap by combining two National Cancer Institute (NIC)-funded longitudinal studies conducted in Cleveland from 1998 to 2010. MATERIALS AND METHODS: The unique cross-sequential design facilitates a comparison between the health changes in long-term (five years +) older cancer survivors (breast, prostate, and colorectal cancer) and demographically matched older adults without a history of cancer in the same geographic area within the same period. The study also captured comprehensive information on how socioeconomic status interacts with cancer and aging over time. General linear models were employed in the data analysis. RESULTS: The findings showed that early cancer experience did not affect long-term cancer survivors' health status in later life. Conversely, comorbidities, being an African American, being female, and having education less than a college degree significantly decreased the health trajectory in later life for all older adults. Moreover, compared to other groups, older African American cancer survivors reported a dramatic decrease in self-reported health after controlling for other conditions. DISCUSSION: Study findings can inform public policy and social services to offer comprehensive treatment plans and help individuals overcome their diseases and lead longer and healthier lives.

The Effects of Osteoarthritis on Depressive Symptomatology Among Older U.S. Military Veterans.

Osteoarthritis (OA) is a leading cause of disability among older adults. By 2050, approximately 60 million will suffer from arthritis adding up to a total societal cost of $65 billion. Chronic illnesses resulting in pain, and functional decline have been associated with depression in previous studies.A causal model was developed and tested using structural equation modeling that examined depression scores of 503 older (age 50-85), male Veterans with moderate to severe symptomatic OA of the knee\hip.The results of the structural equation modeling produced a final model of depressive symptomatology that fit the data well (Chi square = 12.23, DF = 11, p = .346; TLI = .99; CFI = 1.00; RMSEA = .02).The findings indicate the central role that OA severity (pain, stiffness, and functional difficulties) plays in the mental health of older Veterans in terms of the level of reported depressive symptoms.

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.

Life satisfaction among older adult, long-term cancer survivors: A comparison of Black with White survivors.

OBJECTIVE: This paper proposes and evaluates a model of the relative importance that cancer-related health factor along with other health factors have for the self-rated health and life satisfaction of older adult, long-term cancer survivors. The data are examined in the context of important racial differences in health and life satisfaction along with other covariates including gender and education. METHOD: This research utilizes regression-based path analysis to examine data from a sample of 321 older (age 60+), long-term (5+ years since diagnosis) cancer survivors. Respondents were randomly selected from the tumor registry of a major university hospital cancer center from among those with breast, prostate, or colorectal cancer. Blacks were oversampled to provide the analytic power to make racial comparisons among cancer survivors. RESULTS: Bivariate analysis indicates that there is a consistent pattern of Black/White differences in both cancer-related and general health characteristics as well as life satisfaction among older cancer survivors. Moreover, the results suggest that race is an important predictor of older survivors' health characteristics. These, in turn, explain significant variance in both self-rated health and life satisfaction, that is, attributed to Black/White differences in these predictors. CONCLUSIONS: Clinical health and social service providers need to be aware of the importance of both general health and cancer-related health factors when working with minority long-term cancer survivors as these have implications for their overall quality of life.

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.

Determinants of altered life perspectives among older-adult long-term cancer survivors.

BACKGROUND: In the recent literature on cancer survivorship, positive changes are emphasized in the aftermath of trauma. However, there is insufficient research on older-adult survivors and more complex transformations. OBJECTIVE: Consistent with nursing researchers' views about the duality of cancer survivor experiences, this research examined both positive and negative posttraumatic transformations (PTTs) among long-term survivors. Demographic, stress, and appraisal-related predictors of transformations were considered. METHODS: Using cross-sectional survey design, interviews were conducted with 288 survivors of breast, colorectal, and prostate cancer. The sample, obtained from a hospital tumor registry, was 58% female, 33% African American, and 67% white (mean age, 72.5 [SD, 7.6] years). Demographic characteristics, cumulative stress exposure, appraisals of stress, and self-reported PTTs were measured. RESULTS: Most respondents reported diverse transformations attributed to their illness experience. Demographic characteristics and stress appraisals were more strongly associated with PTT outcomes than was cumulative stress exposure. Appraisals of the cancer experience as stressful, as generating worry, and as stigmatizing were significantly associated with diverse PTT outcomes. CONCLUSION: Many long-term older cancer survivors report PTT reflecting altered perspectives on life. Posttraumatic transformations are related to the view that cancer is a continuing worrisome and stigmatizing experience. IMPLICATIONS FOR PRACTICE: Nurses have a unique opportunity to discuss with patients the potentially life-changing nature of the cancer experience in a manner that allows for understanding and acceptance of complex changes, incorporating benefit finding along with acknowledgement of loss and suffering. This type of discussion can enhance cancer survivors' mental health.

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.

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-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.