October 2017 VOL 8, NO 10

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Cancer-Related Disabilities

Physical/Psychological Disability Common in Cancer Patients

Two comprehensive reports from the World Health Organization (WHO) show that physical and psychological disabilities are common in people living with cancer, and that they have unmet needs. These findings are part of a wider WHO-led global initiative that focuses on 4 major noncommunicable diseases identified as global challenges, with cancer being one of them.

Cancer-related disability manifests in functional, cognitive, and psychological limitations that can impact on a person’s physical, social, and emotional well-being and quality of life (QOL). Impairment of functioning can be a result of cancer or its treatment, and disability may vary in severity or be temporary or present for the rest of a survivor’s life, explained Edoardo Aromataris, MD, Joanna Briggs Institute, University of Adelaide, Australia.

At the 2017 Annual Meeting of the Multinational Association of Supportive Care in Cancer, Dr Aromataris presented data on cancer-related physical impairment based on a large systematic review of the literature over the past 10 years in multiple languages and databases. The WHO researchers identified 107,000 citations, filtered the studies, and ended up with about 175 quantitative studies.

The main goal was to describe the impact of cancer-related disability on activities of daily living and function according to patient-reported outcomes and QOL measures, and to identify unmet needs for people with impairments due to cancer.

“We looked at all types of patients across the cancer spectrum, and the heterogeneous impact of cancer-related disability is quite clear. Regardless of gender, age, ethnicity, and race, participants reported disability related to cancer,” he told listeners.

Disability included any kind of systemic or structural impairment, activity limitation, and/or restriction in participation in life activities, as defined by the International Classification of Functioning, Disability and Health (ICF) in physical/functional, cognitive, and psychological domains.

“The key message is that disability is remarkably variable and depends on type of cancer and timing,” he said.

Anywhere from 5% to 99% of patients had some form of cancer-related disability. Based on 5 studies, difficulties with activities of daily living affected between 10% and 38% of respondents. About 20% of patients with lung cancer had poor performance status.

Based on 2 studies, 96% of women with a history of breast cancer experienced some type of upper body impairment.

Eighty-two percent of childhood survivors of central nervous system (CNS) cancers experienced mild to severe functional late deficits, and 60% to 65% of survivors of any type of cancer experienced physical late effects.

“All physical function impairments experienced by cancer survivors were associated with decreased QOL,” he said. “Results of 19 epidemiological studies were hard to summarize, but the greater the impairment, the greater the impact on QOL.”

Based on 8 studies, patients had decreased functional status. Five studies showed upper body impairment following breast and head and neck cancer. Five studies showed voice-related disability following head and neck cancer, and 4 studies showed that cancer survivors had pain.

Unmet Needs Related to Physical Disability

Five separate studies from Australia, Taiwan, Sweden, China, and Norway evaluated disabilities (including mood disturbance and fatigue, anxiety and depression, functional impairment, and pain) in patients with breast, colorectal, and lung cancer; CNS cancers in childhood; and any cancer.

“Unmet needs were higher when functional disability was compounded with psychological distress. Unmet needs differed according to type of functional impairment,” Dr Aromataris explained.

Patients with poor performance status had a greater requirement for information, counseling, physical therapy, help with physical needs, and daily living needs. Patients with any type of cancer needed additional information and counseling and had unmet physical/daily living needs.

“This is a revealing picture of 1 section of a very large WHO initiative. A broad question led to a heterogeneous data set, but it is clear that physical disability has a great impact on patients’ lives, and there are many unmet needs in cancer patients,” he said.

Psychological Impairments in People with Cancer

The next talk described the scope of psychological impairments in people with cancer as determined by a large literature review that was part of the WHO initiative.

“Many studies report psychological impairments in patients with cancer, but we needed to find evidence that those impairments were directly related to cancer or its treatment,” said Catalin Tufanaru, MD, PhD, research fellow at the Joanna Briggs Institute, University of Adelaide, Australia.

The umbrella term “psychological impairment” included depression, anxiety, and posttraumatic stress disorder (PTSD) linked directly to cancer, he explained.

“For me, it was a surprise that we found limited studies and limited evidence on the psychological impairments in people with cancer,” Dr Tufanaru said. “This disease had a global prevalence of 28.8 million worldwide in 2008, and it is probably much larger now.”

The literature search included patients with any kind of cancer at any stage of disease, including posttreatment. The same ICF criteria used for Dr Aromataris’ report were used to identify psychological disability.

Participants’ age ranged from 16 to 85 years. There was a huge variability in studies that included all types of cancers, reported at different times (diagnosis during treatment, following treatment, and long-term survival). The studies used a variety of standardized tools to measure psychological disability, including the Hospital Anxiety and Depression Scale (HADS), the Centre for Epidemiologic Studies Depression Scale (CES-D), Beck Depression Inventory (BDI), the PTSD Checklist-Civilian Version (PCL-C), and the PTS Diagnostic Scale (PDS).

The prevalence of depression ranged from 6.25% to 54.9% and was highest during cancer treatment (range, 25%-52%) compared with any other time. At 3 years following diagnosis, the estimated prevalence of depression was 9% to 27%, based on 4 studies.

Results were similar for anxiety. Four studies reported the prevalence of anxiety in cancer patients at various stages of treatment, ranging from 14% to 49.6%. The prevalence of anxiety was 35.3% in lung cancer patients and 38.2% in breast cancer patients. The highest prevalence of anxiety was during treatment, with no significant change over the course of chemotherapy.

Only 2 studies looked at PTSD in cancer patients. The prevalence was 9% to 12%. One study of breast cancer patients in remission showed that 12.1% had PTSD. A second study of survivors of diverse types of childhood cancer found a PTSD prevalence of 9%.

“The clear conclusion is that psychological impairments are frequent in cancer patients. The studies had many limitations. It will be important in the future to promote use of probabilistic samples and studies with larger sample sizes. This has implications for policy and practice and should be included in frameworks and policy documents,” Dr Tufanaru said.

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