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Geriatr Gerontol Int 2015; 15: 983–990
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Factors affecting quality of life of older adults with cancer in Korea Hyunsook Yoon,1 Yojin Kim,1 Yeon Ok Lim,2 Hyun Joo Lee3 and Kyoungwon Choi1 1 Department of Social Welfare, 2Institute of Aging, Hallym University, and 3Department of Social Welfare, Hallym Polytechnic University, Chuncheon-si, Korea
Aim: The main objective of the present study was to examine the quality of life of older adults with cancer and investigate factors associated with it. Some practical problems experienced by older adults with cancer are introduced, such as changes in work situation, availability of caregivers and financial difficulties relative to medical expenditures. Methods: A total of 339 patients aged 65 years or older who were treated for five major cancer diseases – colorectal, stomach, lung, liver or kidney cancer – participated in the present study. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire was used to measure the quality of life. Performance status (physical functioning) was assigned according to the Eastern Cooperative Oncology Group classification. The Life Orientation Test-Revised was used to assess future expectations. The multiple linear regression analysis was used to identify predictors of the quality of life of older persons with cancer. Results: The results showed that physical functioning and optimism were significant predictors of all four functions (physical, role, emotional and social function) and global quality of life of older adults with cancer. Nearly 60% experienced changes in work situation and had financial burden on medical costs. Conclusions: The findings suggest that efforts to assess physical functioning with more attention and enhance optimism should be emphasized in interventions for older adults with cancer. Geriatr Gerontol Int 2015; 15: 983–990. Keywords: cancer, older adults, optimism, performance status, quality of life.
Introduction Cancer has special significance for the health of older adults because of the greater likelihood of its occurrence in old age, and because of the expected increase of cancer survivors among older adult cohorts in current aging societies. Over half of all cancers occur in individuals aged over 65 years, and the incidence of stomach, lung, liver and colorectal cancers increases gradually with age.1 The 5-year survival rate of Korean older people diagnosed with cancer between 2006 and 2010 reached 64.1%, 10.4% points higher than that of people diagnosed with the disease between 2000 and 2005. The 10-year survival rate also increased from
Accepted for publication 27 July 2014. Correspondence: Dr Yojin Kim PhD, Department of Social Welfare, Hallym University, 39 Hallymdaehak-gil, Chuncheon-si, Gangwon-do, 200-702, Korea. Email: [email protected]
© 2014 Japan Geriatrics Society
40.6% to 49.4% over the same period in Korea.2 Considering the current rate of growth in the number of people aged 65 years and older, the proportion of cancer survivors in older adult cohorts is sure to continue to expand. As a result of the symptoms caused by the disease, the toxicity of treatment and the treatment approach, quality of life has become a major concern for older adults with cancer, their caregivers and healthcare providers. A model by Taylor,3 which is derived from Cohen and Lazarus’s4 coping process paradigm, might help us understand the experiences and the quality of life of older adults with cancer. In this model, Taylor presented the paths of how people cope with stressful events, which involve internal and external resources/ impediments that influence how people manage stress.3 Psychosocial resources help people to appraise and cope with stressors, and foster resilience in the face of stressful events.5 Characteristics of cancer and its treatment (cancer stage at diagnosis, number of treatments received and recurrence) as well as performance status doi: 10.1111/ggi.12378
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represent stressors or stressful events. Optimism and cancer-related health worries are the internal resources/ impediments that modify the effect the stressor has on quality of life. The external resources/impediments include social support, other life stressors and financial burden on medical costs. Optimism is a relatively stable personality trait characterized by the expectancy that in general, future events in one’s life will be of a positive nature.6 During diagnostic and initial treatment periods, optimism was associated with lower distress and better health-related quality of life in cancer patients undergoing chemotherapy.7 Cross-sectional and longitudinal studies of cancer survivors or cancer patients have found that optimism is a significant predictor of emotional wellbeing, social functioning, better health-related quality of life or depression.8–13 Cancer-related health worries can persist into the chronic stage of survivorship.14 After diagnosis, cancer patients’ concerns are most likely to focus on the treatability of the disease and prognosis for survival. However, once treatment begins, patients’ concerns might shift to the potential risks of invasive procedures and the often adverse effects of treatment. After treatment, concerns about recurrence are likely to be predominant. With the passage of time, worries about recurrence might be reduced to some degree, whereas other cancer-related health worries, such as concerns about another cancer resulting from radiation or chemotherapy, could occur.15 Deimling et al. reported that approximately one-third of the older, long-term cancer survivors (≥5 years) continued to report worries about recurrence, worries about a second cancer and worries that symptoms that they experience might be from cancer.9 As suggested by the stress-buffering hypothesis,16 social support has been shown to modify adverse physical and mental consequences associated with stress.17,18 It can also assist individuals in effectively coping with cancer by offering a better understanding of the problem and by increasing motivation to take more adaptive action. Sound social support has also been found to partially explain trajectories of psychological adjustment in cancer patients.19 Diverse sources of social support from family, friends and health professionals might be helpful in obtaining benefits of supportive care services, reducing psychological distress and enhancing quality of life. The main objective of the present study was to examine the quality of life of older adults with cancer, and investigate factors associated with it. In addition, to help improve understanding of the problem, some of the practical problems experienced by older adults with cancer are introduced, such as changes in work situation, availability of caregivers and financial difficulties relative to medical expenditures. 984 |
Methods Participants The present study was a baseline survey of a 5-year longitudinal study about the quality of life of older adults with cancer. The sample was selected from 600 persons with cancer aged 55 years or older who were treated at three sites of Hallym University Medical Center, Samsung Medical Center and Ajou University Hospital. A total of 339 participants were selected by the following criteria: (i) patients who were aged 65 years or older; (ii) patients who had been treated for five major cancer diseases in Korea – colorectal, stomach, lung, liver or kidney cancer; (iii) patients with prostate cancer and breast cancer were excluded to balance sex effects; and (iv) patients with any cognitive debilitating comorbidity were screened and excluded. Clinical personnel introduced participants who met the selection criteria to research staff during admission or scheduled hospital visits. Research staff provided information about the study and acquired informed consent. Patients completed a questionnaire by oneself or with assistance from the research staff. The present study was approved by the institutional review board of Hallym University (HIRB-2011-0089), Samsung Medical Center (SMCIRB-2012-2005-006) and Ajou University Hospital (AJIRB-MED-SUR-11– 404).
Measures of study variables Some of the instruments only in English had to be first translated into Korean and then back-translated into English. They were reviewed and revised by three experts who were proficient in both Korean and English. The questionnaire was first tested with seven cancer survivors. The revised questionnaire was shown to be valid by face and content validity tests. Internal consistency of each translated scale was assessed by the reliability coefficient Cronbach’s alpha, and results of internal consistency analysis showed that no major differences were found to exist as a result of the language of administration.
Quality of life The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQC30), a questionnaire developed to assess the quality of life of cancer patients, was used to measure the quality of life of the participants.20,21 The quality of life in the present study was measured with four function subscales of QLQ-C30 including physical function, role function, emotional function and social function, and one global quality of life scale. The Korean version has © 2014 Japan Geriatrics Society
Quality of life of older adults with cancer
been validated.22,23 Alpha internal consistency coefficients for each Korean subscale were 0.83 (physical function), 0.85 (role function), 0.87 (emotional function), 0.81 (social function) and 0.86 (global quality of life).
Cancer/treatment characteristics All the information on cancer and treatment characteristics (type of cancer, stage at diagnosis, types of treatment received and recurrence of cancer) was extracted from the medical records at hospitals. The types of treatment included surgery, chemotherapy, radiation and/or other. Each type was coded as a dichotomous variable (0 = did not receive, 1 = received).
scored on a five-point continuum from “1 = strongly agree” to “5 = strongly disagree”.9 The alpha reliability coefficient was 0.89.
Social support The Multidimensional Scale of Perceived Social Support (MSPSS) by Zimet, Dahlem, Zimet and Farley was modified to measure social support from three types of providers including family, friends and medical professionals. Each type was composed of two items to measure a participant’s perception of the level of support.29 Each item was rated on a five-point scale (from 1 = strongly disagree to 5 = strongly agree). Reliability analysis reached satisfactory levels of alpha above 0.70 for all types of providers.
Performance status Performance status as an indicator of physical functioning was assigned according to the Eastern Cooperative Oncology Group performance status classification as follows: grade 0 for patients fully active, able to carry on all predisease activities without restriction; grade 1 for patients restricted in physically strenuous activity, but ambulatory and able to carry out work of a light or sedentary nature; for example, light house work or office work; grade 2 for patients ambulatory and capable of all self-care, but unable to carry out any work activities, up and about more than 50% of waking hours; grade 3 for patients capable of only limited self-care, confined to bed or chair more than 50% of waking hours; and grade 4 for patients completely disabled, who cannot carry out any self-care and are totally confined to bed or chair.24
Optimism The Life Orientation Test-Revised (LOT-R)25 is a 10-item revision of the original LOT,26 in which Likert responses (from 1 = strongly disagree to 5 = strongly agree) are used to assess future expectations (e.g. “In certain times, I usually expect the best”). The internal consistency of the LOT-R was 0.65.
Analysis Descriptive statistics was used to describe the sociodemographic and cancer/treatment characteristics of the participants, and practical problems. Pearson’s correlation analysis was used to examine the association between the study variables and the quality of life. We used multiple linear regressions to identify predictors of the quality of life of the respondents. Predictor variables used in the regression analyses included sociodemographic factors (sex, age, education and living with spouse), cancer/treatment factors (stage of cancer, number of treatments received, recurrence and performance status), internal resources (optimism and cancerrelated health worries) and external resources (social support, other life stressors and financial burden on medical cost). These variables were entered into the regression model simultaneously, thereby allowing the effect of each independent variable to be examined while taking into account the rest of the variables in the model. Both the unstandardized and standardized coefficients are reported. All P-values are two tailed, and P < 0.05 was considered to be significant.
Results
Cancer-related health worries
Characteristics of participants and descriptions of study variables
Cancer-related health worries were conceptualized and measured based on the work of Gotay and Muraoka,27 which had been previously used by Deimling et al.9 and Bowman et al.28 to study appraisal of the cancer experience by older adults. Four items that tap this domain were included in this research: “I worry about my cancer coming back,” “I am sometimes concerned that symptoms I experience may indicate the recurrence of cancer,” “I worry about future diagnostic tests” and “I worry about another type of cancer.” Responses were
The sociodemographic and cancer/treatment characteristics of the participants are provided in Tables 1 and 2. The level of association between sociodemographic characteristics, cancer/treatment characteristics, internal resources (optimism and health related worries), external resources (social support, other stressors and financial burden on medical cost) and quality of life are shown in Table 3. Optimism was inversely associated with cancer-related health worries. Social supports from family, friends and medical professionals were positively
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Table 1 Sociodemographic characteristics of the participants
Table 2 Cancer/treatment characteristics of the participants n (%)†
n (%) Sex Men Women Age (years) Mean (SD) 65–69 70–74 75–79 ≥80 Education Mean (SD) Less than primary school Primary school Junior school High school College or more Living with spouse With spouse Without Spouse
217 (64.0) 122 (36.0) 71.8 (4.5) 116 (34.2) 132 (38.9) 71 (20.9) 20 (5.9) 8.0 (4.9) 42 (12.4) 104 (30.7) 59 (17.4) 75 (22.1) 59 (17.4) 241 (71.1) 98 (28.9)
associated with optimism, but inversely associated with cancer-related health worries. Four functions (physical function, role function, emotional function and social function) and global quality of life were positively interrelated. All four functions and global quality of life were positively associated with optimism, but negatively associated with cancer-related health worries and financial burden on medical costs. Emotional function, social function and global quality of life were inversely associated with other stressors, but positively associated with support from friends. Physical function, role function, emotional function and global quality of life were positively associated with support from medical professionals.
Factors affecting the quality of life of older adults with cancer Although the correlation coefficients provide a preliminary picture of the factors that explain the quality of life of older adults with cancer, the multivariate approach that regression provides makes it possible to identify the net effects (controlling for other predictors/ covariates) of each predictor. Table 4 provides the standardized regression coefficient (beta), along with the unstandardized coefficients (b), and the related P-values for each of the four functions and global quality of life. With regard to physical function, being a man (b = 8.88), higher education (b = 0.61) and being opti986 |
Cancer diagnosis Lung Stomach Colorectal Liver/pancreas Kidney/bladder Stage of the cancer at diagnosis Stage I Stage II Stage III Stage IV Cancer therapy received Surgery Radiation therapy Chemotherapy Surgery + radiation Surgery + chemotherapy Surgery + radiation + chemotherapy Radiation + chemotherapy Recurrence of cancer Recurrence No recurrence ECOG performance status Fully active Restricted in physically strenuous activity Ambulatory and capable of all self-care Capable of only limited self-care Completely disabled
36 (10.6) 106 (31.3) 160 (47.2) 20 (5.9) 17 (5.0) 85 (25.8) 88 (26.7) 91 (27.7) 64 (19.5) 76 (22.4) 5 (1.5) 42 (12.4) 4 (1.2) 174 (51.3) 30 (8.8) 8 (2.4) 38 (11.2) 301 (88.8) 13 (3.8) 17 (50.1) 138 (40.7) 12 (3.5) 6 (1.8)
†
Missing responses are not presented. ECOG, Eastern Cooperative Oncology Group.
mistic (b = 6.76) were significantly related to higher physical function. Older adults with more advanced cancer stage at diagnosis (b = −3.23) and poorer performance status (b = −9.00) had significantly lower physical function. The model explained 34% of the variance in physical function of older adults with cancer. Factors with significant influences on role function were education (b = 1.18), optimism (b = 8.57), cancer stage at diagnosis (b = −3.79) and performance status (b = −13.05). Although having more education and being optimistic were significantly related to higher role function, having more advanced cancer stage at diagnosis and having poorer performance status were significantly related to lower role function. The model explained 27% of the variance in role function. Education (b = 0.82), optimism (b = 7.56), performance status (b = −5.08) and other life stressors (b = −11.08) were significant factors influencing © 2014 Japan Geriatrics Society
© 2014 Japan Geriatrics Society
Sex Age Education Living with spouse Stage of the cancer at diagnosis No. treatments Recurrence of cancer ECOG performance status Optimism Health worries Support from family Support from friends Support from medical staff Other life stressors Financial burden on medical costs QoL-Physical function Qol-Role function QoL-Emotional function QoL-Social function QoL-Global Quality of life
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 1 0.162** 0.038 −0.126* 0.086 0.093 0.139* 0.227** 0.151**
12
11
1 −0.033 0.027 0.201** 0.210** −0.061 −0.049 −0.292** −0.238** −0.245**
1 −0.155** −0.180** 0.034 −0.130* 0.033 0.153** −0.092 −0.129* 0.027 −0.142** 0.049 0.094 0.000 −0.159** −0.096 0.036 −0.007 0.063
1 −0.046 0.487** 0.404** −0.085 0.112* 0.013 −0.089 −0.080 −0.058 −0.022 0.009 −0.018 −0.049 −0.040 0.263** 0.156** 0.127* 0.038 0.106*
2
.1 −0.027 −0.040 0.192** 0.152** 0.149** 0.083 0.233**
13
1 0.307** −0.037 0.080 0.012 −0.123* 0.111* −0.090 0.106 0.126* −0.022 0.034 −0.111* 0.289** 0.248** 0.237** 0.154** 0.211**
3
1 .092 .026 .037 .026 −0.008 .104
14
1 −0.084 0.081 −0.019 −0.116* 0.015 −0.091 0.118* 0.059 0.004 −0.089 −0.003 0.167** 0.060 0.146** 0.037 0.079
4
*P < 0.05, **P < 0.01, ***P < 0.001. ECOG, Eastern Cooperative Oncology Group; QoL, quality of life.
Sex Age Education Living with spouse Stage of the cancer at diagnosis No. treatments Recurrence of cancer ECOG performance status Optimism Health worries Support from family Support from friends Support from medical staff Other life stressors Financial burden on medical costs QoL-Physical function Qol-Role function QoL-Emotional function QoL-Social function QoL-Global Quality of life
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
1
Table 3 Correlations among study variables
1 −0.142** −0.127* −0.209** −0.367** −0.258**
15
1 −0.030 −0.020 0.112* −0.038 0.151** 0.015 −0.031 0.009 0.087 0.071 −0.238** −0.209** −0.118* −0.170** −0.096
5
1 0.669** 0.467** 0.497** 0.452**
16
1 0.211** −0.005 −0.066 0.042 0.060 0.052 −0.026 0.027 −0.019 −0.008 −0.018 0.055 −0.029 −0.017
6
1 0.491** 0.464** 0.464**
17
1 −0.080 0.082 −0.021 0.019 0.074 0.068 0.057 −0.120* 0.126* 0.059 0.120* 0.081 0.091
7
1 0.518** 0.532**
18
1 −0.120* 0.183** −0.055 −0.251** −0.048 −0.009 0.075 −0.406** −0.377** −0.252** −0.238** −0.352**
8
1 0.452**
19
1 −0.166** 0.240** 0.240** 0.205** 0.139* −0.126* 0.256** 0.272** 0.311** 0.282** 0.360**
9
1
20
1 −0.116* −0.112* −0.155** −0.127* 0.222** −0.181** −0.149** −0.257** −0.227** −0.234**
10
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Table 4 Regression analyses of quality of life of older adults with cancer Physical function B (beta) Sex Age Education Living with spouse Stage of the cancer at diagnosis No. treatments Recurrence of cancer ECOG performance status Optimism Health worries Support from family Support from friends Support from medical staff Other life stressors Financial burden on medical costs F R2
Role function B (beta)
Emotional function B (beta)
Social function B (beta)
Global Quality of life B (beta)
8.88 (0.19)** −0.49 (−0.10) 0.61 (0.13)* −1.14 (−0.02) −3.23 (−0.16)**
5.40 (0.09) −0.13 (−0.02) 1.18 (0.19)** −5.24 (−0.08) −3.79 (−0.14)**
0.18 (0.00) 0.45 (0.09) 0.82 (0.17)** 3.96 (0.08) −1.93 (−0.09)
0.72 (0.01) −0.25 (−0.04) 0.56 (0.10) −2.87 (−0.05) −2.67 (−0.11)*
1.22 (0.03) 0.65 (0.14)* 0.56 (0.12)* 1.96 (0.04) −0.87 (−0.04)
3.14 (0.09) −0.24 (−0.00) −9.00 (−0.28)***
1.62 (0.03) −0.09 (−0.00) −13.05 (−0.31)***
3.80 (0.10) 1.66 (0.02) −5.08 (−0.15)**
1.94 (0.05) −2.30 (−0.03) −4.96 (−0.13)*
0.54 (0.02) −3.22 (−0.05) −8.84 (−0.28)***
6.76 (0.19)*** −1.11 (−0.05) 0.83 (0.02) 0.53 (0.02) −2.25 (−0.05)
8.57 (0.18)** 0.10 (0.00) 0.43 (0.01) 0.304 (0.007) −1.67 (−0.03)
7.56 (0.20)*** −2.07 (−0.09) −1.64 (−0.04) 0.79 (0.02) −1.60 (−0.03)
6.84 (0.16)** −2.24 (−0.09) 5.93 (0.12)* −3.28 (−0.09) −3.62 (−0.06)
7.87 (0.22)*** −1.36 (−0.07) −1.98 (−0.05) 3.37 (0.10) 0.73 (0.02)
0.67 (0.01) −0.39 (−0.02)
−0.53 (−0.01) −1.07 (−0.04)
−11.08 (−0.22)*** −1.58 (−0.08)
−6.09 (−0.11)* −4.91 (−0.23)***
−7.66 (−0.16)** −2.59 (−0.14)**
9.81*** 0.34
6.90*** 0.27
7.11*** 0.27
6.47*** 0.26
8.86*** 0.32
*P < 0.05, **P < 0.01, ***P < 0.001. ECOG, Eastern Cooperative Oncology Group.
emotional function. Higher emotional function was significantly related to higher education and being optimistic. Older adults with poorer performance status and more daily hassles showed significantly lower emotional function. The model explained 27% of the variance in emotional function. In the multiple linear regression model to predict social function, 26% of the variance was predicted by cancer stage at diagnosis, performance status, optimism, support from family and financial burden on medical costs. Older adults with more advanced cancer stage at diagnosis (b = −2.67) and poorer performance status (b = −4.96) had significantly lower social function. Being optimistic (b = 6.84) was significantly related to higher social function. While receiving more support from family (b = 5.93) was significantly related to higher social function, having more financial burden on medical costs (b = −4.91) was significantly related to lower social function. Factors significantly influencing global quality of life of older adults with cancer were age (b = 0.65), education (b = 0.56), performance status (b = −8.84), optimism (b = 7.87), other life stressors (b = −7.66) and financial burden on medical costs (b = −2.59). Being older, having higher education and being more optimistic were significantly related to a higher level of global quality of life. Older adults with poorer performance 988 |
status, more daily hassles and more financial burden on medical costs were found to have a lower level of global quality of life. The model explained 32% of the variance in global quality of life of older adults with cancer. Eastern Cooperative Oncology Group performance status and optimism were significant predictors of all four function scales (physical, role, emotional and social function) and global quality of life of older adults with cancer.
Practical problems experienced by older persons with cancer Table 5 shows practical problems experienced by older adults with cancer. In regard to work situation, nearly 55% experienced changes in work situation; stopped working permanently (25.1%), working hours (20.4%) and stopped working temporarily (9.7%). Although 85.8% were cared for by their family members (47.0% by spouse, 37.6% by adult children, 1.2% by relatives), 4.1% were cared for by paid caregivers and 8.9% did not receive any care from either family members or paid caregivers. In July 2008, Korea introduced a Long-Term Care Insurance system. With increasing awareness of Long-Term Care Insurance, the proportion of older adults who have applied for benefits reached 12.3% in 2010, with 45.9% deemed to be © 2014 Japan Geriatrics Society
Quality of life of older adults with cancer
Table 5 Practical problems n (%) Changes in work status Nothing changes Stopped working permanence Stopped working temporarily Working less hours Occupational resettlement Availability of Caregivers Spouse Children & Spouse Relatives or friends, brothers and sisters External caregivers None Financial burden on medical costs Not at all A little Some Much Very much Private cancer insurance Yes No
145 (42.9) 85 (25.1) 33 (9.7) 69 (20.4) 1 (0.3) 159 (47.0) 127 (37.6) 4 (1.2) 14 (4.1) 30 (8.9) 27 (8.0) 41 (12.2) 64 (19.0) 110 (32.6) 95 (28.2) 59 (17.6) 277 (82.4)
ECOG, Eastern Cooperative Oncology Group.
eligible. Because of limited coverage and immaturity of Long-Term Care Insurance, the proportion of older adults receiving benefits was 4.4% in 2010, and the findings reflect this lack of usage of the governmental program.30 With regard to financial difficulties as a result of medical costs, 79.8% had financial burden on medical costs, and just 17.5% had private healthcare insurance.
Discussion Eastern Cooperative Oncology Group performance status measuring physical functioning was a significant factor influencing all four function scales (physical, role, emotional and social function) and global quality of life. Consistent with prior research findings, this finding supports the view that physical functioning produces a broad negative impact on various dimensions of quality of life, and suggests the importance of giving more attention to physical function and physical rehabilitation of older adults with cancer.31–34 Optimism, a dispositional or trait-like characteristic, was also a consistent predictor of all the four functions and global quality of life. Optimists’ advantage in wellbeing seems to be due in part to their characteristic approach to managing both stressful problems and stress-induced emotions; that is, their coping style.35 Although optimism has been considered as a personal© 2014 Japan Geriatrics Society
ity trait that is relatively stable over time and through different experiences, it was also modifiable through the use of cognitive and behavioral therapy, a psychotherapeutic approach that aimed to reduce negative thinking, and the associated behavioral and emotional responses. Cognitive and behavioral therapy techniques including self-monitoring, the modification of internal dialogues, positive self-talk, visualization and cognitive restructuring, have been adapted to increase levels of optimism.36 It is suggested that healthcare providers assist older adults with cancer by using cognitive and behavioral therapy techniques to modify dysfunctional beliefs that restrain optimism. Nearly 60% of older adults with cancer had financial difficulties owing to medical costs. Although Korea adopted the National Health Insurance system since 1989, the out-of-pocket payment system by patients is a key private-sector funding source for healthcare, which accounts for 39% of total health expenditures. While out-of-pocket payments might discourage frivolous demands and limit costs, they can hardly care for catastrophic or chronic illness, and for those unable to afford even modest copayments. In addition to penalizing low-income households, out-of-pocket payments create a substantial burden on those with chronic health problems, such as older adults with cancer.30 There are a number of important limitations and caveats that need to be considered in interpreting this research. First, although the sample was concentrated on five major cancer diseases in Korea (colorectal, stomach, lung, liver and kidney cancer), a large proportion of those who were selected were patients with colorectal and stomach cancer. Among colorectal and stomach cancers, cancer stage at diagnosis, treatments received and recurrence was heterogeneous. Because of this limitation, we could not examine the effect of different stages, different types of treatments received and recurrence of cancer separately, and generalize the results to all the older adults with cancer in Korea. Second, the analysis presented in the present study was cross-sectional in nature. Cross-sectional data precluded definitive causal inference. A prospective, longitudinal study is necessary to definitely establish causal associations. As we complete data collection on later waves of this study, we expect to present a more complete understanding of the quality of life of older adults with cancer in a longitudinal context.
Acknowledgment This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2011-371-B00015). This research was supported by the Hallym University Specialization Fund (HRF-S-21). | 989
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Disclosure statement No potential conflicts of interest were disclosed.
References 1 Statistics Korea. Population projection for provinces: 2010–2040, 2012. 2 National Cancer Center. National cancer registration and statistics in Korea 2010. 3 Taylor SE. How psychosocial resources enhance health and well-being. In: Donaldson SI, Csikszentmihalyi M, Nakamura J, eds. Applied Positive Psychology: Improving Everyday Life, Health, Schools, Work, and Society. New York: McGraw-Hill, 2011; 65–77. 4 Cohen F, Lazarus R. Coping with the stress of illness. In: Stone GC, Cohen F, Adler NE, eds. Health Psychology: A Handbook. San Francisco, CA: Jossey-Bass, 1979; 217–254. 5 Taylor SE. Health Psychology, 8th edn. New York: McGrawHill, 2012. 6 Scheier MF, Carver CS. Effects of optimism on psychological and physical well-being: theoretical overview and empirical update. Cognit Ther Res 1992; 16: 201–228. 7 de Moor JS, de Moor CA, Basen-Enguist K, Kudelka A, Bevers MW, Cohen L. Optimism, distress, health-related quality of life, and change in cancer antigen 125 among patients with ovarian cancer undergoing chemotherapy. Psychosom Med 2006; 68: 555–562. 8 Friedman LC, Kalidas M, Elledge R et al. Optimism, social support and psychosocial functioning among women with breast cancer. Psychooncology 2006; 15: 595–603. 9 Deimling GT, Bowman K, Sterns S, Wagner LJ, Kahana B. Cancer-related health worries and psychological distress among older adult, long-term cancer survivors. Psychooncology 2006; 15: 306–320. 10 Schou I, Ekeberg O, Ruland CM, Sandvik L, Karesen R. Pessimism as a predictor of emotional morbidity one year following breast cancer surgery. Psychooncology 2004; 13: 309–320. 11 Allison PJ, Guichard C, Gilain L. A prospective investigation of dispositional optimism as a predictor of healthrelated quality of life in head and neck cancer patients. Qual. Life Res 2001; 9: 951–960. 12 Carver CS, Smith RG, Antoni MH, Petronis VM, Weiss S, Derhagopian RP. Optimistic personality and psychosocial well-being during treatment predict psychosocial wellbeing among long-term survivors of breast cancer. Health Psychol 2005; 24: 508–516. 13 Zenger M, Brix C, Borowski J, Stolzenburg J-U HA. The impact of optimism on anxiety, depression and quality of life in urogenital cancer patients. Psychooncology 2010; 19: 879–886. 14 Bloom J. Surviving and thriving? Psychooncology 2002; 1: 89–92. 15 Mullens AB, McCaul KD, Erickson SC, Sandgren AK. Coping after cancer: risk perceptions worry and health behaviors among colorectal cancer survivors. Psychooncology 2004; 13: 367–376. 16 Cohen S, Wills TA. Stress, social support, and the buffering hypothesis. Psychol Bull 1985; 98: 310–357. 17 Jang Y, Haley WE, Small BJ, Mortimer JA. The role of mastery and social resources in the associations between disability and depression in later life. Gerontologist 2002; 42: 807–813.
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18 Hays JC, Steffens DC, Flint EP, Bosworth HB, George LK. Does social support buffer functional decline in elderly patients with unipolar depression? Am J Psychiatry 2001; 158: 1850–1855. 19 Helgeson VS, Snyder P, Seltman H. Psychological and physical adjustment to breast cancer over 4 years: identifying distinct trajectories of change. Health Psychol 2004; 23: 3–15. 20 Fayers PM, Aaronson NK, Bjordal K et al. The EORTC QLQ-C30 Scoring Manual 3rd Ed. Brussels: European Organization for Research and Treatment of Cancer, 2001. 21 Aaronson NK, Ahmedzai S, Bergman B et al. The European Organisation for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology. J Natl Cancer Inst 1993; 85: 365–376. 22 Yun YH, Park YS, Lee ES et al. Validation of the Korean version of the EORTC QLQ-C30. Qual Life Res 2004; 13: 863–868. 23 Cull A, Sprangers M, Bjordal K et al. EORTC Quality of Life Study Group Translation Procedure. Brussels: EORTC, 2002. 24 Oken MM, Creech RH, Tormey DC et al. Toxicity and response criteria of the Eastern Cooperative Oncology Group. Am J Clin Oncol 1982; 5: 649–655. 25 Scheier MF, Carver CS, Brides MW. Distinguishing optimism from neuroticism (and trait anxiety, self-mastery, and self-esteem): a reevaluation of the Life Orientation Test. J Pers Soc Psychol 1994; 67: 1063–1078. 26 Scheier MF, Carver CS. Optimism, coping, and health: assessment and implications of generalized outcome expectancies. Health Psychol 1985; 4: 219–247. 27 Gotay CC, Muroaka MY. Quality of life in long-term survivors of adult-onset survivors. J Natl Cancer Inst 1998; 90: 656–667. 28 Bowman KF, Smerglia VL, Deimling GT. A stress model of cancer survivorship in older long-term survivors. J Ment Health Aging 2004; 10: 163–182. 29 Zimet GD, Dahlem NW, Zimet SG, Farley GK. The Multidimensional Scale of Perceived Social Support. J Pers Assess 1988; 52: 30–41. 30 Yoon H. Korea: balancing economic growth and social protection for older adults. Gerontologist 2013; 53: 361– 368. 31 Hurria A, Hurria A, Zuckerman E et al. A prospective, longitudinal study of the functional status and quality of life of older patients with breast cancer receiving adjuvant chemotherapy. J Am Geriatr Soc 2006; 54: 1119–1124. 32 Pinquart M, Koch A, Eberhardt B, Brix C, Wedding U, Rohrig B. Associations of functional status and depressive symptoms with health-related quality of life in cancer patients. Qual Life Res 2006; 15: 1565–1570. 33 Wedding U, Rohrig B, Klippstein A, Brix C, Pientra L, Hoffken K. Co-morbidity and functional deficits independently contribute to quality of life before chemotherapy in elderly cancer patients. Support Care Cancer 2007; 15: 1097– 1104. 34 Wedding U, Koch A, Rohrig B et al. Depression and functional impairment independently contribute to decreased quality of life in cancer patients prior to chemotherapy. Acta Oncol 2008; 47: 56–62. 35 Solberg Nes L, Segerstrom SC. Dispositional optimism and coping: a meta-analytic review. Pers Soc Psychol Rev 2006; 10: 235–251. 36 Riskind JH, Sarampote CS, Mercier MA. For every malady a sovereign cure: optimism training. J Cogn Psychother 1996; 10: 105–117.
© 2014 Japan Geriatrics Society
Geriatr Gerontol Int 2015; 15: 983–990
ORIGINAL ARTICLE: EPIDEMIOLOGY, CLINICAL PRACTICE AND HEALTH
Factors affecting quality of life of older adults with cancer in Korea Hyunsook Yoon,1 Yojin Kim,1 Yeon Ok Lim,2 Hyun Joo Lee3 and Kyoungwon Choi1 1 Department of Social Welfare, 2Institute of Aging, Hallym University, and 3Department of Social Welfare, Hallym Polytechnic University, Chuncheon-si, Korea
Aim: The main objective of the present study was to examine the quality of life of older adults with cancer and investigate factors associated with it. Some practical problems experienced by older adults with cancer are introduced, such as changes in work situation, availability of caregivers and financial difficulties relative to medical expenditures. Methods: A total of 339 patients aged 65 years or older who were treated for five major cancer diseases – colorectal, stomach, lung, liver or kidney cancer – participated in the present study. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire was used to measure the quality of life. Performance status (physical functioning) was assigned according to the Eastern Cooperative Oncology Group classification. The Life Orientation Test-Revised was used to assess future expectations. The multiple linear regression analysis was used to identify predictors of the quality of life of older persons with cancer. Results: The results showed that physical functioning and optimism were significant predictors of all four functions (physical, role, emotional and social function) and global quality of life of older adults with cancer. Nearly 60% experienced changes in work situation and had financial burden on medical costs. Conclusions: The findings suggest that efforts to assess physical functioning with more attention and enhance optimism should be emphasized in interventions for older adults with cancer. Geriatr Gerontol Int 2015; 15: 983–990. Keywords: cancer, older adults, optimism, performance status, quality of life.
Introduction Cancer has special significance for the health of older adults because of the greater likelihood of its occurrence in old age, and because of the expected increase of cancer survivors among older adult cohorts in current aging societies. Over half of all cancers occur in individuals aged over 65 years, and the incidence of stomach, lung, liver and colorectal cancers increases gradually with age.1 The 5-year survival rate of Korean older people diagnosed with cancer between 2006 and 2010 reached 64.1%, 10.4% points higher than that of people diagnosed with the disease between 2000 and 2005. The 10-year survival rate also increased from
Accepted for publication 27 July 2014. Correspondence: Dr Yojin Kim PhD, Department of Social Welfare, Hallym University, 39 Hallymdaehak-gil, Chuncheon-si, Gangwon-do, 200-702, Korea. Email: [email protected]
© 2014 Japan Geriatrics Society
40.6% to 49.4% over the same period in Korea.2 Considering the current rate of growth in the number of people aged 65 years and older, the proportion of cancer survivors in older adult cohorts is sure to continue to expand. As a result of the symptoms caused by the disease, the toxicity of treatment and the treatment approach, quality of life has become a major concern for older adults with cancer, their caregivers and healthcare providers. A model by Taylor,3 which is derived from Cohen and Lazarus’s4 coping process paradigm, might help us understand the experiences and the quality of life of older adults with cancer. In this model, Taylor presented the paths of how people cope with stressful events, which involve internal and external resources/ impediments that influence how people manage stress.3 Psychosocial resources help people to appraise and cope with stressors, and foster resilience in the face of stressful events.5 Characteristics of cancer and its treatment (cancer stage at diagnosis, number of treatments received and recurrence) as well as performance status doi: 10.1111/ggi.12378
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represent stressors or stressful events. Optimism and cancer-related health worries are the internal resources/ impediments that modify the effect the stressor has on quality of life. The external resources/impediments include social support, other life stressors and financial burden on medical costs. Optimism is a relatively stable personality trait characterized by the expectancy that in general, future events in one’s life will be of a positive nature.6 During diagnostic and initial treatment periods, optimism was associated with lower distress and better health-related quality of life in cancer patients undergoing chemotherapy.7 Cross-sectional and longitudinal studies of cancer survivors or cancer patients have found that optimism is a significant predictor of emotional wellbeing, social functioning, better health-related quality of life or depression.8–13 Cancer-related health worries can persist into the chronic stage of survivorship.14 After diagnosis, cancer patients’ concerns are most likely to focus on the treatability of the disease and prognosis for survival. However, once treatment begins, patients’ concerns might shift to the potential risks of invasive procedures and the often adverse effects of treatment. After treatment, concerns about recurrence are likely to be predominant. With the passage of time, worries about recurrence might be reduced to some degree, whereas other cancer-related health worries, such as concerns about another cancer resulting from radiation or chemotherapy, could occur.15 Deimling et al. reported that approximately one-third of the older, long-term cancer survivors (≥5 years) continued to report worries about recurrence, worries about a second cancer and worries that symptoms that they experience might be from cancer.9 As suggested by the stress-buffering hypothesis,16 social support has been shown to modify adverse physical and mental consequences associated with stress.17,18 It can also assist individuals in effectively coping with cancer by offering a better understanding of the problem and by increasing motivation to take more adaptive action. Sound social support has also been found to partially explain trajectories of psychological adjustment in cancer patients.19 Diverse sources of social support from family, friends and health professionals might be helpful in obtaining benefits of supportive care services, reducing psychological distress and enhancing quality of life. The main objective of the present study was to examine the quality of life of older adults with cancer, and investigate factors associated with it. In addition, to help improve understanding of the problem, some of the practical problems experienced by older adults with cancer are introduced, such as changes in work situation, availability of caregivers and financial difficulties relative to medical expenditures. 984 |
Methods Participants The present study was a baseline survey of a 5-year longitudinal study about the quality of life of older adults with cancer. The sample was selected from 600 persons with cancer aged 55 years or older who were treated at three sites of Hallym University Medical Center, Samsung Medical Center and Ajou University Hospital. A total of 339 participants were selected by the following criteria: (i) patients who were aged 65 years or older; (ii) patients who had been treated for five major cancer diseases in Korea – colorectal, stomach, lung, liver or kidney cancer; (iii) patients with prostate cancer and breast cancer were excluded to balance sex effects; and (iv) patients with any cognitive debilitating comorbidity were screened and excluded. Clinical personnel introduced participants who met the selection criteria to research staff during admission or scheduled hospital visits. Research staff provided information about the study and acquired informed consent. Patients completed a questionnaire by oneself or with assistance from the research staff. The present study was approved by the institutional review board of Hallym University (HIRB-2011-0089), Samsung Medical Center (SMCIRB-2012-2005-006) and Ajou University Hospital (AJIRB-MED-SUR-11– 404).
Measures of study variables Some of the instruments only in English had to be first translated into Korean and then back-translated into English. They were reviewed and revised by three experts who were proficient in both Korean and English. The questionnaire was first tested with seven cancer survivors. The revised questionnaire was shown to be valid by face and content validity tests. Internal consistency of each translated scale was assessed by the reliability coefficient Cronbach’s alpha, and results of internal consistency analysis showed that no major differences were found to exist as a result of the language of administration.
Quality of life The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (QLQC30), a questionnaire developed to assess the quality of life of cancer patients, was used to measure the quality of life of the participants.20,21 The quality of life in the present study was measured with four function subscales of QLQ-C30 including physical function, role function, emotional function and social function, and one global quality of life scale. The Korean version has © 2014 Japan Geriatrics Society
Quality of life of older adults with cancer
been validated.22,23 Alpha internal consistency coefficients for each Korean subscale were 0.83 (physical function), 0.85 (role function), 0.87 (emotional function), 0.81 (social function) and 0.86 (global quality of life).
Cancer/treatment characteristics All the information on cancer and treatment characteristics (type of cancer, stage at diagnosis, types of treatment received and recurrence of cancer) was extracted from the medical records at hospitals. The types of treatment included surgery, chemotherapy, radiation and/or other. Each type was coded as a dichotomous variable (0 = did not receive, 1 = received).
scored on a five-point continuum from “1 = strongly agree” to “5 = strongly disagree”.9 The alpha reliability coefficient was 0.89.
Social support The Multidimensional Scale of Perceived Social Support (MSPSS) by Zimet, Dahlem, Zimet and Farley was modified to measure social support from three types of providers including family, friends and medical professionals. Each type was composed of two items to measure a participant’s perception of the level of support.29 Each item was rated on a five-point scale (from 1 = strongly disagree to 5 = strongly agree). Reliability analysis reached satisfactory levels of alpha above 0.70 for all types of providers.
Performance status Performance status as an indicator of physical functioning was assigned according to the Eastern Cooperative Oncology Group performance status classification as follows: grade 0 for patients fully active, able to carry on all predisease activities without restriction; grade 1 for patients restricted in physically strenuous activity, but ambulatory and able to carry out work of a light or sedentary nature; for example, light house work or office work; grade 2 for patients ambulatory and capable of all self-care, but unable to carry out any work activities, up and about more than 50% of waking hours; grade 3 for patients capable of only limited self-care, confined to bed or chair more than 50% of waking hours; and grade 4 for patients completely disabled, who cannot carry out any self-care and are totally confined to bed or chair.24
Optimism The Life Orientation Test-Revised (LOT-R)25 is a 10-item revision of the original LOT,26 in which Likert responses (from 1 = strongly disagree to 5 = strongly agree) are used to assess future expectations (e.g. “In certain times, I usually expect the best”). The internal consistency of the LOT-R was 0.65.
Analysis Descriptive statistics was used to describe the sociodemographic and cancer/treatment characteristics of the participants, and practical problems. Pearson’s correlation analysis was used to examine the association between the study variables and the quality of life. We used multiple linear regressions to identify predictors of the quality of life of the respondents. Predictor variables used in the regression analyses included sociodemographic factors (sex, age, education and living with spouse), cancer/treatment factors (stage of cancer, number of treatments received, recurrence and performance status), internal resources (optimism and cancerrelated health worries) and external resources (social support, other life stressors and financial burden on medical cost). These variables were entered into the regression model simultaneously, thereby allowing the effect of each independent variable to be examined while taking into account the rest of the variables in the model. Both the unstandardized and standardized coefficients are reported. All P-values are two tailed, and P < 0.05 was considered to be significant.
Results
Cancer-related health worries
Characteristics of participants and descriptions of study variables
Cancer-related health worries were conceptualized and measured based on the work of Gotay and Muraoka,27 which had been previously used by Deimling et al.9 and Bowman et al.28 to study appraisal of the cancer experience by older adults. Four items that tap this domain were included in this research: “I worry about my cancer coming back,” “I am sometimes concerned that symptoms I experience may indicate the recurrence of cancer,” “I worry about future diagnostic tests” and “I worry about another type of cancer.” Responses were
The sociodemographic and cancer/treatment characteristics of the participants are provided in Tables 1 and 2. The level of association between sociodemographic characteristics, cancer/treatment characteristics, internal resources (optimism and health related worries), external resources (social support, other stressors and financial burden on medical cost) and quality of life are shown in Table 3. Optimism was inversely associated with cancer-related health worries. Social supports from family, friends and medical professionals were positively
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Table 1 Sociodemographic characteristics of the participants
Table 2 Cancer/treatment characteristics of the participants n (%)†
n (%) Sex Men Women Age (years) Mean (SD) 65–69 70–74 75–79 ≥80 Education Mean (SD) Less than primary school Primary school Junior school High school College or more Living with spouse With spouse Without Spouse
217 (64.0) 122 (36.0) 71.8 (4.5) 116 (34.2) 132 (38.9) 71 (20.9) 20 (5.9) 8.0 (4.9) 42 (12.4) 104 (30.7) 59 (17.4) 75 (22.1) 59 (17.4) 241 (71.1) 98 (28.9)
associated with optimism, but inversely associated with cancer-related health worries. Four functions (physical function, role function, emotional function and social function) and global quality of life were positively interrelated. All four functions and global quality of life were positively associated with optimism, but negatively associated with cancer-related health worries and financial burden on medical costs. Emotional function, social function and global quality of life were inversely associated with other stressors, but positively associated with support from friends. Physical function, role function, emotional function and global quality of life were positively associated with support from medical professionals.
Factors affecting the quality of life of older adults with cancer Although the correlation coefficients provide a preliminary picture of the factors that explain the quality of life of older adults with cancer, the multivariate approach that regression provides makes it possible to identify the net effects (controlling for other predictors/ covariates) of each predictor. Table 4 provides the standardized regression coefficient (beta), along with the unstandardized coefficients (b), and the related P-values for each of the four functions and global quality of life. With regard to physical function, being a man (b = 8.88), higher education (b = 0.61) and being opti986 |
Cancer diagnosis Lung Stomach Colorectal Liver/pancreas Kidney/bladder Stage of the cancer at diagnosis Stage I Stage II Stage III Stage IV Cancer therapy received Surgery Radiation therapy Chemotherapy Surgery + radiation Surgery + chemotherapy Surgery + radiation + chemotherapy Radiation + chemotherapy Recurrence of cancer Recurrence No recurrence ECOG performance status Fully active Restricted in physically strenuous activity Ambulatory and capable of all self-care Capable of only limited self-care Completely disabled
36 (10.6) 106 (31.3) 160 (47.2) 20 (5.9) 17 (5.0) 85 (25.8) 88 (26.7) 91 (27.7) 64 (19.5) 76 (22.4) 5 (1.5) 42 (12.4) 4 (1.2) 174 (51.3) 30 (8.8) 8 (2.4) 38 (11.2) 301 (88.8) 13 (3.8) 17 (50.1) 138 (40.7) 12 (3.5) 6 (1.8)
†
Missing responses are not presented. ECOG, Eastern Cooperative Oncology Group.
mistic (b = 6.76) were significantly related to higher physical function. Older adults with more advanced cancer stage at diagnosis (b = −3.23) and poorer performance status (b = −9.00) had significantly lower physical function. The model explained 34% of the variance in physical function of older adults with cancer. Factors with significant influences on role function were education (b = 1.18), optimism (b = 8.57), cancer stage at diagnosis (b = −3.79) and performance status (b = −13.05). Although having more education and being optimistic were significantly related to higher role function, having more advanced cancer stage at diagnosis and having poorer performance status were significantly related to lower role function. The model explained 27% of the variance in role function. Education (b = 0.82), optimism (b = 7.56), performance status (b = −5.08) and other life stressors (b = −11.08) were significant factors influencing © 2014 Japan Geriatrics Society
© 2014 Japan Geriatrics Society
Sex Age Education Living with spouse Stage of the cancer at diagnosis No. treatments Recurrence of cancer ECOG performance status Optimism Health worries Support from family Support from friends Support from medical staff Other life stressors Financial burden on medical costs QoL-Physical function Qol-Role function QoL-Emotional function QoL-Social function QoL-Global Quality of life
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 1 0.162** 0.038 −0.126* 0.086 0.093 0.139* 0.227** 0.151**
12
11
1 −0.033 0.027 0.201** 0.210** −0.061 −0.049 −0.292** −0.238** −0.245**
1 −0.155** −0.180** 0.034 −0.130* 0.033 0.153** −0.092 −0.129* 0.027 −0.142** 0.049 0.094 0.000 −0.159** −0.096 0.036 −0.007 0.063
1 −0.046 0.487** 0.404** −0.085 0.112* 0.013 −0.089 −0.080 −0.058 −0.022 0.009 −0.018 −0.049 −0.040 0.263** 0.156** 0.127* 0.038 0.106*
2
.1 −0.027 −0.040 0.192** 0.152** 0.149** 0.083 0.233**
13
1 0.307** −0.037 0.080 0.012 −0.123* 0.111* −0.090 0.106 0.126* −0.022 0.034 −0.111* 0.289** 0.248** 0.237** 0.154** 0.211**
3
1 .092 .026 .037 .026 −0.008 .104
14
1 −0.084 0.081 −0.019 −0.116* 0.015 −0.091 0.118* 0.059 0.004 −0.089 −0.003 0.167** 0.060 0.146** 0.037 0.079
4
*P < 0.05, **P < 0.01, ***P < 0.001. ECOG, Eastern Cooperative Oncology Group; QoL, quality of life.
Sex Age Education Living with spouse Stage of the cancer at diagnosis No. treatments Recurrence of cancer ECOG performance status Optimism Health worries Support from family Support from friends Support from medical staff Other life stressors Financial burden on medical costs QoL-Physical function Qol-Role function QoL-Emotional function QoL-Social function QoL-Global Quality of life
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20.
1
Table 3 Correlations among study variables
1 −0.142** −0.127* −0.209** −0.367** −0.258**
15
1 −0.030 −0.020 0.112* −0.038 0.151** 0.015 −0.031 0.009 0.087 0.071 −0.238** −0.209** −0.118* −0.170** −0.096
5
1 0.669** 0.467** 0.497** 0.452**
16
1 0.211** −0.005 −0.066 0.042 0.060 0.052 −0.026 0.027 −0.019 −0.008 −0.018 0.055 −0.029 −0.017
6
1 0.491** 0.464** 0.464**
17
1 −0.080 0.082 −0.021 0.019 0.074 0.068 0.057 −0.120* 0.126* 0.059 0.120* 0.081 0.091
7
1 0.518** 0.532**
18
1 −0.120* 0.183** −0.055 −0.251** −0.048 −0.009 0.075 −0.406** −0.377** −0.252** −0.238** −0.352**
8
1 0.452**
19
1 −0.166** 0.240** 0.240** 0.205** 0.139* −0.126* 0.256** 0.272** 0.311** 0.282** 0.360**
9
1
20
1 −0.116* −0.112* −0.155** −0.127* 0.222** −0.181** −0.149** −0.257** −0.227** −0.234**
10
Quality of life of older adults with cancer
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Table 4 Regression analyses of quality of life of older adults with cancer Physical function B (beta) Sex Age Education Living with spouse Stage of the cancer at diagnosis No. treatments Recurrence of cancer ECOG performance status Optimism Health worries Support from family Support from friends Support from medical staff Other life stressors Financial burden on medical costs F R2
Role function B (beta)
Emotional function B (beta)
Social function B (beta)
Global Quality of life B (beta)
8.88 (0.19)** −0.49 (−0.10) 0.61 (0.13)* −1.14 (−0.02) −3.23 (−0.16)**
5.40 (0.09) −0.13 (−0.02) 1.18 (0.19)** −5.24 (−0.08) −3.79 (−0.14)**
0.18 (0.00) 0.45 (0.09) 0.82 (0.17)** 3.96 (0.08) −1.93 (−0.09)
0.72 (0.01) −0.25 (−0.04) 0.56 (0.10) −2.87 (−0.05) −2.67 (−0.11)*
1.22 (0.03) 0.65 (0.14)* 0.56 (0.12)* 1.96 (0.04) −0.87 (−0.04)
3.14 (0.09) −0.24 (−0.00) −9.00 (−0.28)***
1.62 (0.03) −0.09 (−0.00) −13.05 (−0.31)***
3.80 (0.10) 1.66 (0.02) −5.08 (−0.15)**
1.94 (0.05) −2.30 (−0.03) −4.96 (−0.13)*
0.54 (0.02) −3.22 (−0.05) −8.84 (−0.28)***
6.76 (0.19)*** −1.11 (−0.05) 0.83 (0.02) 0.53 (0.02) −2.25 (−0.05)
8.57 (0.18)** 0.10 (0.00) 0.43 (0.01) 0.304 (0.007) −1.67 (−0.03)
7.56 (0.20)*** −2.07 (−0.09) −1.64 (−0.04) 0.79 (0.02) −1.60 (−0.03)
6.84 (0.16)** −2.24 (−0.09) 5.93 (0.12)* −3.28 (−0.09) −3.62 (−0.06)
7.87 (0.22)*** −1.36 (−0.07) −1.98 (−0.05) 3.37 (0.10) 0.73 (0.02)
0.67 (0.01) −0.39 (−0.02)
−0.53 (−0.01) −1.07 (−0.04)
−11.08 (−0.22)*** −1.58 (−0.08)
−6.09 (−0.11)* −4.91 (−0.23)***
−7.66 (−0.16)** −2.59 (−0.14)**
9.81*** 0.34
6.90*** 0.27
7.11*** 0.27
6.47*** 0.26
8.86*** 0.32
*P < 0.05, **P < 0.01, ***P < 0.001. ECOG, Eastern Cooperative Oncology Group.
emotional function. Higher emotional function was significantly related to higher education and being optimistic. Older adults with poorer performance status and more daily hassles showed significantly lower emotional function. The model explained 27% of the variance in emotional function. In the multiple linear regression model to predict social function, 26% of the variance was predicted by cancer stage at diagnosis, performance status, optimism, support from family and financial burden on medical costs. Older adults with more advanced cancer stage at diagnosis (b = −2.67) and poorer performance status (b = −4.96) had significantly lower social function. Being optimistic (b = 6.84) was significantly related to higher social function. While receiving more support from family (b = 5.93) was significantly related to higher social function, having more financial burden on medical costs (b = −4.91) was significantly related to lower social function. Factors significantly influencing global quality of life of older adults with cancer were age (b = 0.65), education (b = 0.56), performance status (b = −8.84), optimism (b = 7.87), other life stressors (b = −7.66) and financial burden on medical costs (b = −2.59). Being older, having higher education and being more optimistic were significantly related to a higher level of global quality of life. Older adults with poorer performance 988 |
status, more daily hassles and more financial burden on medical costs were found to have a lower level of global quality of life. The model explained 32% of the variance in global quality of life of older adults with cancer. Eastern Cooperative Oncology Group performance status and optimism were significant predictors of all four function scales (physical, role, emotional and social function) and global quality of life of older adults with cancer.
Practical problems experienced by older persons with cancer Table 5 shows practical problems experienced by older adults with cancer. In regard to work situation, nearly 55% experienced changes in work situation; stopped working permanently (25.1%), working hours (20.4%) and stopped working temporarily (9.7%). Although 85.8% were cared for by their family members (47.0% by spouse, 37.6% by adult children, 1.2% by relatives), 4.1% were cared for by paid caregivers and 8.9% did not receive any care from either family members or paid caregivers. In July 2008, Korea introduced a Long-Term Care Insurance system. With increasing awareness of Long-Term Care Insurance, the proportion of older adults who have applied for benefits reached 12.3% in 2010, with 45.9% deemed to be © 2014 Japan Geriatrics Society
Quality of life of older adults with cancer
Table 5 Practical problems n (%) Changes in work status Nothing changes Stopped working permanence Stopped working temporarily Working less hours Occupational resettlement Availability of Caregivers Spouse Children & Spouse Relatives or friends, brothers and sisters External caregivers None Financial burden on medical costs Not at all A little Some Much Very much Private cancer insurance Yes No
145 (42.9) 85 (25.1) 33 (9.7) 69 (20.4) 1 (0.3) 159 (47.0) 127 (37.6) 4 (1.2) 14 (4.1) 30 (8.9) 27 (8.0) 41 (12.2) 64 (19.0) 110 (32.6) 95 (28.2) 59 (17.6) 277 (82.4)
ECOG, Eastern Cooperative Oncology Group.
eligible. Because of limited coverage and immaturity of Long-Term Care Insurance, the proportion of older adults receiving benefits was 4.4% in 2010, and the findings reflect this lack of usage of the governmental program.30 With regard to financial difficulties as a result of medical costs, 79.8% had financial burden on medical costs, and just 17.5% had private healthcare insurance.
Discussion Eastern Cooperative Oncology Group performance status measuring physical functioning was a significant factor influencing all four function scales (physical, role, emotional and social function) and global quality of life. Consistent with prior research findings, this finding supports the view that physical functioning produces a broad negative impact on various dimensions of quality of life, and suggests the importance of giving more attention to physical function and physical rehabilitation of older adults with cancer.31–34 Optimism, a dispositional or trait-like characteristic, was also a consistent predictor of all the four functions and global quality of life. Optimists’ advantage in wellbeing seems to be due in part to their characteristic approach to managing both stressful problems and stress-induced emotions; that is, their coping style.35 Although optimism has been considered as a personal© 2014 Japan Geriatrics Society
ity trait that is relatively stable over time and through different experiences, it was also modifiable through the use of cognitive and behavioral therapy, a psychotherapeutic approach that aimed to reduce negative thinking, and the associated behavioral and emotional responses. Cognitive and behavioral therapy techniques including self-monitoring, the modification of internal dialogues, positive self-talk, visualization and cognitive restructuring, have been adapted to increase levels of optimism.36 It is suggested that healthcare providers assist older adults with cancer by using cognitive and behavioral therapy techniques to modify dysfunctional beliefs that restrain optimism. Nearly 60% of older adults with cancer had financial difficulties owing to medical costs. Although Korea adopted the National Health Insurance system since 1989, the out-of-pocket payment system by patients is a key private-sector funding source for healthcare, which accounts for 39% of total health expenditures. While out-of-pocket payments might discourage frivolous demands and limit costs, they can hardly care for catastrophic or chronic illness, and for those unable to afford even modest copayments. In addition to penalizing low-income households, out-of-pocket payments create a substantial burden on those with chronic health problems, such as older adults with cancer.30 There are a number of important limitations and caveats that need to be considered in interpreting this research. First, although the sample was concentrated on five major cancer diseases in Korea (colorectal, stomach, lung, liver and kidney cancer), a large proportion of those who were selected were patients with colorectal and stomach cancer. Among colorectal and stomach cancers, cancer stage at diagnosis, treatments received and recurrence was heterogeneous. Because of this limitation, we could not examine the effect of different stages, different types of treatments received and recurrence of cancer separately, and generalize the results to all the older adults with cancer in Korea. Second, the analysis presented in the present study was cross-sectional in nature. Cross-sectional data precluded definitive causal inference. A prospective, longitudinal study is necessary to definitely establish causal associations. As we complete data collection on later waves of this study, we expect to present a more complete understanding of the quality of life of older adults with cancer in a longitudinal context.
Acknowledgment This work was supported by the National Research Foundation of Korea Grant funded by the Korean Government (NRF-2011-371-B00015). This research was supported by the Hallym University Specialization Fund (HRF-S-21). | 989
H Yoon et al.
Disclosure statement No potential conflicts of interest were disclosed.
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