Factors Affecting Older Adults’ Symptom Distress Following Cancer Surgery

Janet H. Van Cleave PhD, RN1

Brian Egleston PhD2

Elizabeth Ercolano DNSc3

Ruth McCorkle PhD, RN, FAAN3

1New York University College of Nursing2Fox Chase Cancer Center3Yale School of Nursing

BackgroundOlder adults 65 and over comprise majority

of persons living with and dying from cancerSymptom distress remains a significant

health problem of older adults after cancer surgery

Little is known about older adults’ symptom distress following cancer surgery

Understanding the relationship between age and symptom distress may help identify interventions to improve older adults’ outcomes

Specific Aims1. Describe older adults undergoing

thoracic, abdominal, and genitourinary cancer surgery,

2. Elucidate the relationship of age categories with symptom distress following cancer surgery at baseline, three, and six months controlling for demographic, biologic, psychological, and treatment covariates.

Vulnerability Factors

Human Responses

Risk/Support Factors

Vulnerability/Risk/Human Response/Care Model

Adapted from J. Shaver, Nursing Outlook, 33, pp. 186-191 and B. Steele & J. Shaver, Advances in Nursing Science, 15, p. 72

Vulnerability Risk

Human Response Framework

VulnerabilityFactors

Risk/SupportFactors

HumanResponses

Definition of Concepts

Present Within

Individual

PresentOutside

Individual

Change inHuman

Dimensions

StudyVariables Demographic Biologic Psychological Treatment Symptom Distress

Empirical Indicators

Age CategoriesGender

RaceMarital Status

EducationIncome

ComorbiditiesType of CancerCancer Stage

Mental Health

Cancer TreatmentAdvanced Practice Nurse Intervention Symptom Distress

MethodsSecondary analysis Combined subsets of data of 326

adults ages 65 or greaterFive clinical trials of nurse-

directed interventions targeting patients post-surgery

Data collection at baseline (post-surgery period), and 3 and 6 months

Outcome VariableSymptom distress

Measure: Symptom Distress Scale (McCorkle & Young, 1978; McCorkle et al., 1998)

Demonstrated reliability and validity with reported Cronbach alphas 0.70 to 0.89

Symptom Distress Scale (SDS) (McCorkle et al, 1998)

Frequency and severity of nauseaAppetiteInsomniaFrequency and severity of painFatigueBowel patternConcentrationAppearanceBreathingOutlookCough

Statistical AnalysisDescriptive Statistics

Multiple linear regression analysis by Generalized Estimating Equations controlling for demographic, biologic, psychological, and treatment covariates

Aim 1: Patient CharacteristicsCharacteristic N %Age65 to 69 147 4570 to 74 108 3375 and over 71 22

GenderFemale 162 50Male 161 50

RaceWhite 247 76Black/Other 57 18

Aim 1: Study Population Balanced Across All Types of Cancer

22%

28%23%

27%

Type of Cancer

Digestive Thoracic Gyn GU

Aim 1: Majority of Patients Received Surgery With or Without Chemotherapy

47%

32%

9%

13%

Type of Treatment

Surgery Surg+ChemotxSurg+RadtxSurg+Chemotx+Radtx

Aim 1: Majority of Patients With Three or Greater Number of Symptoms

11%

14%

12%64%

Number of Symptoms

NoneOneTwoThree or more

Aim 2: Symptom Distress Significantly Decreased Over Time

Variable Estimate P ValueAge65 to 69 Reference70 to 74 -0.60 0.48975 and over -2.17 0.062

TimeBaseline Reference3 months -2.64 <0.0016 months -2.57 0.002

Aim 2: Symptom Distress Significantly Increased In Ages75 and Over at 6 Months Variable Estimate P ValueAge x TimeAge 65 to 69 x 3 months

Reference

Age 70 to 74 x 3 months

1.405 0.199

Age 75 and over x 3 months

1.45 0.199

Age 65 to 69 x 6 months

Reference

Age 70 to 74 x 6 months

0.803 0.476

Age 75 and over x 6 months

2.491 0.049

Aim 2: Symptom Distress Significantly Associated with Type of Cancer and ComorbiditiesVariable Estimate P ValueType of CancerDigestive 2.83 <0.001Thoracic 4.45 <0.001Gynecologic 2.22 0.023Genitourinary Reference

ComorbiditiesNone ReferenceOne -0.07 0.939Two 1.06 0.273Three or more 1.77 0.044

Aim 2: Symptoms Distress Significantly Increased with Worse Mental Health and Function

Variable Estimate P ValuePsychologicalMental health -1.34 <0.001

FunctionFunction score -0.33 <0.001

Symptom Distress by Age Category Over Time

Baseline 3 months 6 months2021222324252627282930

Ages 65 to 69

Ages 75 and older

Ages 70 to 74M

ean

Sym

ptom

Dis

tres

s

Symptom Distress By Type of Cancer Over Time

Baseline 3 Months 6 Months15

17

19

21

23

25

27

29

Digestive

GU

Thoracic

Gynecologic

Mea

n Sy

mpt

om D

istr

ess

LimitationsSecondary data analysis

Studies occurred over 20 year span

ConclusionMore older candidates for cancer surgery as

population agesOlder adults experience typical post–operative

pattern Decreasing symptom distress over 6 months

despite type of cancer treatmentThoracic cancer patients may experience greater

symptom distressFunction, mental health, and number of

comorbidities associated with symptom distressStudy participants age 75 and older experienced

greater symptoms distress over time than those aged 65 to 69

Study ImplicationsAdoptions of more frequent

appointments for older patients and those with thoracic cancer

Monitor for changes in mental health

Need to investigate novel symptom assessment interventions including nurse-directed clinics and telehealth interventions

AcknowledgementsNew York University College of Nursing,

Hartford Institute of Geriatric NursingUniversity of Pennsylvania Post-Doctoral

Fellowship T32NR009356: Individualized Care for At-Risk Older Adults, 2008 – present

John A. Hartford Foundation Building Academic Geriatric Nursing Capacity Program 2006 – 2008 Pre-Doctoral Scholar

Yale School of Nursing Pre-Doctoral Fellowship T32NR008346 : Self and Family Management, 2004-2006