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Keywords:

  • activity limitations;
  • Behavioral Risk Factor Surveillance System;
  • cancer survivors;
  • health-related quality of life;
  • Healthy Days Measures;
  • population-based estimates

Abstract

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

BACKGROUND

The authors examined the health-related quality of life (HRQOL) of cancer survivors between ages 20 and 64 years by using a population-based survey of individuals who had activity limitations caused by cancer.

METHODS

A population-based, cross-sectional study was conducted using the 2000 to 2002 Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) to examine HRQOL among respondents who reported activity limitations because of cancer. HRQOL was measured by using the CDC's Healthy Days Measures, including self-rated health status, numbers of unhealthy physical and mental health days, and activity limitation. HRQOL was compared among the following groups: those who reported no activity limitations and those who were limited primarily by cardiovascular conditions, emotional problems, and cancer. Taylor-series linearization methods were used to calculate population-based estimates in this complex sample survey.

RESULTS

Individuals between ages 20 and 64 years who were limited by cancer reported poorer HRQOL measured as higher prevalence of poor or fair self-reported health, more physically unhealthy days, more painful days, and more inadequate sleep days. Compared with the group that had no activity limitations, the individuals who had limitations were more likely to be women and to have annual household incomes <$25,000. They were more likely to be unable to work and to have health insurance. In addition, they were more likely to be former smokers and to be overweight, but they were less likely to participate in leisure-time physical activity.

CONCLUSIONS

Overall, respondents between ages 20 and 64 years who reported being limited primarily by cancer reported lower HRQOL. They also reported unhealthy behaviors that were detrimental to improved HRQOL. The HRQOL and lifestyle modification needs of this population need to be examined prospectively to help decrease their burden of suffering. Cancer 2008. Published 2008 by the American Cancer Society.

Over the past 3 decades, the number of cancer survivors has tripled.1 Approximately 10.1 million individuals were living with a previous diagnosis of cancer as of 2002,1 and >1.2 million individuals received a new diagnosis of cancer.2 Although approximately 66% of cancer survivors are aged ≥65 years, the remaining survivors are young to middle-aged adults who must deal with the sequelae of their cancer and its therapy for years to come. These younger cancer patients, however, are more likely to have been diagnosed recently.1 For example, among colorectal cancer survivors, nearly 33% of incident cases occur in those aged <65 years, whereas only 22.4% of prevalent cases occur in this age group. This age difference by recency of diagnosis has consequences for studying survivors in population-based surveys.3, 4

Traditionally, studies involving health-related quality of life (HRQOL) of cancer burden have focused on monetary costs of cancer care with cost-benefit analyses.5, 6 These studies have tended to focus on patients aged >65 years5 or on those enrolled in managed-care programs,6 neither of which present a population-based assessment of younger cancer survivors. This research focus has shifted toward the nonmonetary costs of cancer, including HRQOL, disability, and health status, as the number of survivors has increased.3, 4 Two recent studies based on the National Health Interview Survey have examined health status, functional limitations, and disability among cancer survivors.3, 4 General health status among these survivors was lower than that among individuals without cancer, and 54.3% of survivors ages 45 to 64 years and 38.6% of survivors ages 18 to 44 years reported 1 or more functional limitations.3 Compared with individuals without cancer, cancer survivors also reported fair or poor health more frequently and reported more limitations in activities of daily living. Among survivors aged <65 years, more reported being unable to work because of a health condition, especially among those with concurrent medical conditions.4 Among respondents to the National Health and Nutrition Examination Survey, 28.6% of those with cancer and 75% of those with multiple medical conditions rated their health as either fair or poor.7

The objective of this study was to compare the HRQOL of cancer survivors ages 20 to 64 years who reported having activity limitations primarily because of their cancer with the HRQOL of respondents who reported no such limitations. These individuals participated in the CDC's 2000 to 2002 surveys of the Behavioral Risk Factor Surveillance System (BRFSS) and responded to several questions regarding their HRQOL.7, 8

MATERIALS AND METHODS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

Data Source and Study Population

The study participants were a population-based sample of respondents to the 2000, 2001, and 2002 BRFSS, an annual, state-based, random-digit-dialed telephone interview survey of adults aged ≥18 years from the 50 states and the District of Columbia.9 For this study, participants were respondents ages 20 to 64 years who had answered a question concerning the presence of activity limitations in their daily life. The wording of this question differed slightly in the year 2000 (“Are you limited in any way in any activities because of any impairment or health problem?”) from that in the years 2001 and 2002 (“Are you limited in any way in any activities because of physical, mental, or emotional problems?”).

Participants who answered “yes” to this question were then asked to identify the major impairment or health problem that limited their activities and the duration of this impairment. The participants whose responses were analyzed for this study had said either that they had no such limitation (“no limitation”; n = 224,606) or that they had such a limitation and that the limitation was either cancer (“cancer”; n = 403); depression, anxiety, or an emotional problem (“emotional problem”; n = 1583); or a heart problem, stroke, or high blood pressure (“cardiovascular disease”; n = 1879). Although these categories were mutually exclusive when main activity limitations were reported, respondents who reported no activity limitations may have had any of these conditions but did not report being limited by them during the survey. In addition, individuals who were limited primarily by cancer also may have had activity limitations because of cardiovascular and emotional problems. Thirty-four states and the District of Columbia provided information in at least 1 of the 3 years of this study.

Selected Demographic and Health Behavior Variables

Study participants also provided information regarding the following demographic characteristics, behavioral risk factors, and access to healthcare: sex, age, race/ethnicity, education, annual household income, employment status, height, weight, cigarette-smoking status, leisure-time physical activity, and health insurance. We grouped participants into 3 age categories: ages 20 to 39 years, ages 40 to 49 years, and ages 50 to 64 years. We calculated each participant's body mass index (BMI) as the weight in kilograms divided by the square of the height in meters and categorized it into 1 of the 6 World Health Organization categories10: underweight (< 18.5 kg/m2), normal weight (18.5–24.9 kg/m2), overweight (25–29.9 kg/m2), obese Class I (30–34.9 kg/m2), obese Class II (35–39.9 kg/m2), and obese Class III (≥40 kg/m2); for analysis, however, we grouped all of the obese classes into 1 category. Finally, we categorized participants as current smokers, former smokers, or never smokers (smoked <100 cigarettes in a lifetime).

HRQOL Measures

Study participants rated their overall health (“excellent,” “very good,” “good,” “fair,” or “poor”) and answered questions concerning several domains of their HRQOL in the 30 days before the interview.11 These questions related to their physical health, mental health, activity limitations, experience with pain, depressive symptoms, anxiety symptoms, sleep difficulties, and vitality. The sum of physically unhealthy days and mentally unhealthy days, with a maximum of 30 days, was defined for this study as “overall unhealthy days.”

Statistical Analyses

To account for the complex survey design of the BRFSS, we used Taylor-linearization methods, assuming sampling with replacement, to estimate percentages and their 95% confidence intervals (95% CIs) and to compare individuals who were limited by cancer with individuals without limitations by age group and by other specific demographic characteristics, behavioral risk factors, and access to healthcare.12, 13 We used these same methods in the 4 study groups by age group to calculate the mean days in each HRQOL domain and the 95% CIs. We conservatively assessed differences between the groups according to whether or not the 95% CIs of these measures overlapped; if these 95% CIs did not overlap, then we considered the differences statistically significant at P = .05.14 All estimates represent population-based estimates for respondents ages 20 to 64 years who responded to the BRFSS in 34 states and in the District of Columbia.

RESULTS

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

In this study, among individuals who reported activity limitations primarily because of cancer, cardiovascular, or emotional problems, those with limitations because of cancer had the highest prevalence of fair or poor self-rated health (Table 1). Seventy-five percent of individuals who were limited by cancer rated their health as either fair or poor (95% CI, 67.6%–82.4%), which was significantly greater than the rate for individuals who were limited by cardiovascular disease (63.7%; 95% CI, 59.9%–67.6%) or by emotional problems (40.5%; 95% CI, 36%–45%). Among those who were limited by cancer, the percentage with fair or poor health increased from 60.6% among respondents ages 20 to 39 years, to 75.9% among respondents ages 40 to 49 years, and to 80.2% among respondents ages 50 to 64 years, although the differences according to age were not statistically significant. Among individuals who were limited by cardiovascular disease, the percentage reporting fair or poor health appeared to increase with age; however, among individuals with emotional problems, the percentages were approximately the same across the 3 age groups. Individuals who were limited by cancer had had these limitations for a shorter time (mean = standard error [SE], 3.6 = 0.5 years) than individuals who had either emotional problems (mean = SE, 8.8 = 0.5 years) or cardiovascular disease (mean = SE, 6.9 = 0.4 years; data not shown).

Table 1. Health-related Quality-of-life Measures of Self-reported Physical Health in the Past 30 Days by Main Source of Activity Limitations and Age: Behavioral Risk Factor Surveillance System, 2000–2002
Main source of activity limitationsNo.Percent with fair or poor self-rated health (95% CI)Mean no. of physically unhealthy days measures (95% CI)
Overall unhealthy daysPhysically unhealthy daysActivity limitation daysPainful days
  1. 95% CI indicates 95% confidence interval.

No limitations      
 All ages224,6068 (7.7–8.3)4.3 (4.2–4.4)1.7 (1.6–1.8)0.8 (0.7–0.9)1.2 (1.1–1.3)
 Ages 20–39 y105,7226.6 (6.3–7)4.6 (4.5–4.6)1.6 (1.5–1.6)0.8 (0.8–0.9)1 (0.9–1)
 Ages 40–49 y59,5758.1 (7.5–8.6)4.2 (4.1–4.4)1.8 (1.7–1.9)0.8 (0.8–0.9)1.3 (1.2–1.4)
 Ages 50–64 y59,30910.9 (10.3–11.4)3.9 (3.7–4)2 (1.9–2.1)0.8 (0.7–0.9)1.5 (1.4–1.6)
Cancer      
 All ages40375 (67.6–82.4)21.2 (19–23.5)18.8 (16.5–21.2)12.7 (10.1–15.3)13.1 (10.8–15.4)
 Ages 20–39 y6360.6 (41.3–79.8)19.3 (14.3–24.2)15.5 (10.4–20.5)11.1 (5.9–16.3)11.7 (7.6–15.9)
 Ages 40–49 y10975.9 (62.9–89)21.6 (18.5–24.6)17.1 (13.6–20.6)11.4 (6.8–16.3)12.2 (8.1–16.3)
 Ages 50–64 y23180.2 (70.9–89.5)22 (18.7–25.3)21 (17.8–24.3)14 (10.4–17.6)14 (10.8–17.2)
Emotional problems      
 All ages158340.5 (36–45)20.2 (19–21.4)8 (7–9)11.9 (10.9–13)8.8 (7.7–10)
 Ages 20–39 y63836.7 (29.4–44)19.7 (18.1–21.4)6.7 (5.4–8)12.1 (10.5–13.8)7 (5.3–8.7)
 Ages 40–49 y50542.4 (34.4–50.5)21.9 (19.8–24)9.2 (7.4–11)13.2 (11.5–14.9)10.4 (8.7–12.1)
 Ages 50–64 y44045.7 (37.7–53.6)19.1 (16.8–21.3)9 (7.1–11)10 (8.1–11.9)10.7 (8.6–12.7)
Cardiovascular disease      
 All ages187963.7 (59.9–67.6)16.3 (15–17.5)12.2 (11–13.4)8.5 (7.6–9.5)9.2 (8.3–10.1)
 Ages 20–39 y22442.9 (32.7–53.2)14.6 (11.3–17.9)8.5 (5.7–11.2)6.9 (4.4–9.4)7.1 (4.8–9.3)
 Ages 40–49 y40466 (57.7–74.3)17.1 (14.9–19.4)11.3 (9.1–13.4)7.9 (6.3–9.5)9 (7.2–10.9)
 Ages 50–64 y125167.4 (62.8–72)16.3 (14.7–17.9)13.4 (11.9–14.9)9.1 (7.9–10.2)9.7 (8.6–10.7)

The physical domains of HRQOL varied according to the source of activity limitations (Table 1). Among respondents who reported activity limitations, on average, individuals with cancer reported having approximately 20 overall unhealthy days (95% CI, 19–21.2 overall unhealthy days) during the preceding 30 days, individuals with emotional problems reported having approximately 23.5 overall unhealthy days (95% CI, 19–21.4 overall unhealthy days) during the preceding 30 days, individuals with cardiovascular disease reported having approximately 16 overall unhealthy days (95% CI, 15–17.5 overall unhealthy days), and individuals without limitations reported having approximately 4 overall unhealthy days (95% CI, 4.2–4.4 overall unhealthy days). Individuals with cancer reported significantly more physically unhealthy days and more days when pain made it hard to do their usual activities than individuals in the other groups. Individuals with cancer and those who reported emotional problems reported similar average recent activity limitation days (approximately 12 days for both groups; 95% CI, 10.1–15.3 days and 10.9–13 days, respectively) that were significantly more than the limitation days among individuals with cardiovascular disease (8.5 days; 95% CI, 7.6–9.5 days) or individuals with no limitations (0.8 days; 95% CI, 0.7–0.9 days).

Similarly, the HRQOL measures for mental health differed according to the source of activity limitations (Table 2). Individuals with emotional problems reported significantly more mentally unhealthy days, days when they were sad or depressed, and days when they felt worried, tense, or anxious (stressful days) than the other groups. All 3 groups with limitations reported significantly more inadequate sleep days (11–15 days) and significantly fewer high-energy days (8–10 days) than those without limitations (8 inadequate sleep days and 20 high-energy days).

Table 2. Health-related Quality-of-life Measures of Self-reported Mental Health in the Past 30 Days by Main Source of Activity Limitations and Age: Behavioral Risk Factor Surveillance System, 2000–2002
Main source of activity limitationsNo.Mean no. of mentally unhealthy days measures (95% CI)
Mentally unhealthy daysSad, blue, depressed daysStressful daysInadequate sleep daysHigh-energy days
  1. 95% CI indicates 95% confidence interval.

No limitations      
 All ages224,6062.8 (2.7–2.9)2.5 (2.4–2.6)4.8 (4.7–4.9)8.4 (8.2–8.5)19.5 (19.3–19.6)
 Ages 20–39 y105,7223.2 (3.1–3.3)2.7 (2.7–2.8)5.4 (5.3–5.5)9.7 (9.6–9.9)18.6 (18.5–18.8)
 Ages 40–49 y59,5752.7 (2.6–2.8)2.5 (2.4–2.6)4.6 (4.5–4.8)7.8 (7.6–7.9)19.9 (19.7–20.1)
 Ages 50–64 y59,3092.2 (2.1–2.3)2.1 (2–2.2)3.7 (3.6–3.9)6.(5.8–6.1)21 (20.8–21.2)
Cancer      
 All ages4039.1 (7–11.1)10.1 (8.1–12.1)12.9 (10.8–15.1)14.5 (12.2–16.8)7.8 (6.1–9.5)
 Ages 20–39 y639.3 (4.6–14.1)7.8 (3.5–12.1)13 (8.6–17.4)16.3 (11.5–21.1)9.6 (5.8–13.5)
 Ages 40–49 y10913.8 (9–18.7)14.8 (11.3–18.3)16.6 (12.8–20.5)13.4 (9.3–17.4)6 (3.4–8.5)
 Ages 50–64 y2316.9 (4.9–8.9)9 (6.7–11.4)11.3 (8.7–14)14.3 (11.2–17.4)7.9 (5.5–10.3)
Emotional problems      
 All ages158317.9 (16.8–19.1)16.9 (15.8–18)19.7 (18.6–20.8)15 (13.9–16)7.7 (6.7–8.7)
 Ages 20–39 y63817.4 (15.8–19.1)16.6 (15–18.3)19.5 (17.8–21.1)15.5 (13.7–17.2)7.9 (6.3–9.5)
 Ages 40–49 y50519.1 (17.2–21)17.8 (16.2–19.4)21.2 (19.4–23.1)15.4 (13.7–17.1)7.5 (6.1–8.9)
 Ages 50–64 y44017.5 (15.2–19.7)16.4 (14.4–18.4)18.3 (16.3–20.4)13.3 (11.5–15)7.6 (5.9–9.3)
Cardiovascular disease      
 All ages18798.2 (7.1–9.4)7.9 (6.9–8.8)10.2 (9.3–11.1)11.2 (10.2–12.3)9.9 (8.9–10.8)
 Ages 20–39 y22411 (8.1–13.9)9.6 (6.8–12.4)13.4 (10.6–16.2)13.8 (11.4–16.2)11.6 (8.8–14.3)
 Ages 40–49 y40410 (7.3–12.6)8.9 (6.9–11)11.8 (9.6–14)11.6 (9.6–13.5)9.2 (7.4–11)
 Ages 50–64 y12517 (5.7–8.3)7.1 (6–8.1)8.9 (8–9.8)10.6 (9.3–11.9)9.7 (8.7–10.8)

Individuals who were limited by cancer differed from those who reported no activity limitations (Tables 3 and 4). Individuals who were limited by cancer were significantly more likely to be women (62.1%; 95% CI, 54.1%–70.1%) than individuals without limitations (49.8%; 95% CI, 49.4%–50.2%) (Table 3). Approximately 40% of individuals who were limited by cancer reported an annual household income <$25,000 (95% CI, 31.3%–53.2%), which was significantly more than the 22.5% among individuals without limitations (95% CI, 22.1%–22.8%). Nonetheless, individuals who were limited by cancer were slightly more likely to have health insurance than individuals without limitations (89.6% [95% CI, 84.6%–94.6%] vs 83.9% [95%CI, 83.6%–84.2%] respectively; age-specific data not shown). Most strikingly, 39.6% of individuals who were limited by cancer were unable to work (95% CI, 31%–48.1%) compared with only 1% of those without limitations (95% CI, 0.9%–1.1%) (Table 3). This significant difference in employment status persisted across all age groups. However, individuals who were limited by cancer resembled the individuals without limitations with respect to race, ethnicity, and having at least some college education.

Table 3. Selected Demographic Characteristics of Individuals Reporting Cancer as the Main Source of Activity Limitations Compared With Individuals Reporting No Limitations: Behavioral Risk Factor Surveillance System, 2000–2002
Main source of activity limitationAges (y)
20–64 years20–39 years40–49 years50–64 years
Demographic characteristics% (95% CI)*No.% (95% CI)*No.% (95% CI)*No.% (95% CI)*No.
  • 95% CI indicates 95% confidence interval; NH, non–Hispanic.

  • *

    Percentages may not add to 100% because of rounding.

  • Estimates are unreliable for sample sizes <50 individuals.

No limitations        
 Sex        
  Men50.2 (49.8–50.6)94,62250.8 (50.3–51.3)44,51550.1 (49.4–50.9)25,46648.9 (48.2–49.6)24,701
  Women49.8 (49.4–50.2)129,94449.2 (48.7–49.7)61,20749.9 (49.1–50.6)34,12951.1 (50.4–51.8)34,608
 Race, Hispanic origin        
  White, NH69 (68.6–69.4)174,09864.3 (63.7–64.8)77,17471.4 (70.6–72.2)47,48376.7 (76–77.5)49,441
  Other31 (30.6–31.4)48,75235.7 (35.2–36.3)27,78228.6 (27.6–29.4)11,63023.3 (22.5–24)9340
 Education        
  ≤High school38.8 (38.4–39.2)82,28938.5 (37.9–39)37,60138.6 (37.8–39.3)21,43939.7 (39–40.5)23,249
  Some college or more61.2 (60.8–61.6)142,05361.5 (61–62.1)69,02761.4 (60.7–62.2)38,06460.3 (59.5–61)35,962
 Annual household income        
  <$25,00022.5 (22.1–22.8)43,55027 (26.5–27.6)24,69216.6 (16–17.3)870418.6 (18–19.3)10,154
  $25,000–$49,99933.2 (32.8–33.6)72,35235.1 (34.6–35.6)36,73630.9 (30.2–31.6)18,18931.4 (30.6–32.1)17,427
  ≥$50,00044.3 (43.9–44.7)83,79437.9 (37.3–38.4)33,87752.4 (51.6–53.2)26,52350 (49.2–50.8)23,394
 Employment status        
  Employed79.1 (78.8–79.4)180,06878.3 (77.9–78.8)84,52586.8 (86.3–87.4)52,30772.6 (71.9–73.3)43,236
  Other19.9 (19.6–20.2)41,79221 (20.6–21.5)20,34212.2 (11.7–12.7)662625.5 (24.9–26.1)14,824
  Unable to work1 (0.9–1.1)23440.7 (0.6–0.7)6911 (0.8–1.2)5361.9 (1.7–2.2)1117
Cancer        
 Sex        
  Men37.9 (29.8–45.9)14434.8 (15.1–54.6)1838.7 (19.9–57.4)2938.7 (28.5–49)97
  Women62.1 (54.1–70.1)25965.2 (46.3–84)4561.3 (43.1–79.5)8061.3 (51.1–71.5)134
 Race, Hispanic origin        
  White, NH77.2 (69–85.4)33068.8 (49.3–88.4)5069.3 (49.6–89.1)8683.7 (74.6–92.7)194
  Other22.8 (14.5–31.1)7031.2 (10–52.3)1330.7 (10–51.3)2216.3 (7–25.6)35
 Education        
  ≤High school44.8 (36.3–53.2)16949 (28.9–69)2152.2 (35.4–69)4740 (28.9–51)101
  Some college or more55.2 (46.8–63.7)23351 (31.6–70.4)4247.8 (31.2–64.5)6260 (49–71)129
 Annual household income        
  <$25,00040.7 (31.6–49.8)15124.9 (8.5–41.3)1856.5 (39–74)3939.6 (27.5–51.8)94
  $25,000–$49,99932.6 (24.9–41.2)9646.4 (24.6–68.2)2024.2 (10.9–37.6)2631.2 (19.4–42.9)50
  ≥$50,00026.7 (18.2–35.2)8828.7 (9.2–48.3)1419.3 (8–30.6)2529.2 (16.3–42)79
 Employment status        
  Employed33.3 (25.3–41.2)14946.8 (27.4–66.2)3124.1 (13.2–35)4431.9 (20.7–43.1)74
  Other27.2 (20.3–34)10223.6 (6.1–41)1418.5 (5.4–31.5)1432.2 (22.6–41.8)74
  Unable to work39.6 (31–48.1)15129.6 (10.8–48.4)1857.5 (41.6–73.3)5035.9 (24.5–47.2)83
Table 4. Selected Behavioral Characteristics of Individuals Reporting Cancer as the Main Source of Activity Limitations Compared With Individuals Reporting No Limitations: Behavioral Risk Factor Surveillance System, 2000
Main source of activity limitationAges (y)
20–64 years20–39 years40–49 years50–64 years
Behavioral characteristics% (95% CI)*No.% (95% CI)*No.% (95% CI)*No.% (95% CI)*No.
  • 95% CI indicates 95% confidence interval; BMI, body mass index (measured by weight in kilograms divided by the square of the height in meters).

  • *

    Percentages may not add to 100% because of rounding.

  • Estimates are unreliable for sample sizes <50 individuals.

No limitations        
 BMI        
  Underweight1.8 (1.7–1.9)39572.6 (2.4–2.8)26061.2 (1–1.3)7860.8 (0.7–0.9)565
  Normal41.4 (41–41.8)91,98346.4 (45.8–46.9)48,32537.8 (37.1–38.5)23,11434.5 (33.8–35.2)20,544
  Overweight37.3 (36.9–37.7)77,12933.9 (33.4–34.4)32,98039 (38.3–39.8)21,06442.7 (42–43.5)23,085
  Obese19.5 (19.2–19.8)41,72417.2 (16.7–17.6)17,40322 (21.3–22.6)11,85822 (21.3–22.6)12,463
 Smoking status        
  Current smoker23.5 (23.2–23.8)54,43225.3 (24.8–25.7)27,36824.4 (23.7–25)15,04718.8 (18.2–19.3)12,017
  Former smoker20.8 (20.5–21.1)48,68413.8 (13.4–14.1)15,17923 (22.4–23.6)13,79233.9 (33.2–34.6)19,713
  Never smoked55.7 (55.3–56)120,98661 (60.5–61.5)62,99652.6 (51.9–53.4)30,57947.3 (46.5–48)27,411
 Leisure time physical activity        
  Yes77.4 (77.1–77.8)176,22778.2 (77.8–78.7)83,98277 (76.3–77.7)46,88276.2 (75.5–76.8)45,363
  No22.6 (22.2–22.9)48,29321.8 (21.3–22.2)21,70023 (22.3–23.7)12,66823.8 (23.3–24.5)13,925
Cancer        
 BMI        
  Underweight7.3 (3.1–11.5)2417.2 (0–35.7)68.1 (0–17.2)83.2 (0–6.6)10
  Normal40.1 (31.9–48.3)15742.8 (22.9–62.6)2540.1 (24–56.2)4439.1 (28–50.2)88
  Overweight25.6 (18.6–32.5)11912.6 (3.3–21.9)1518 (7–28.9)2433.7 (23–44.5)80
  Obese27 (18.4–35.6)9127.4 (7.7–47.1)1533.9 (14.2–53.5)2824 (12.9–35.1)46
 Smoking status        
  Current smoker28.7 (21.2–36.2)11429.3 (11.1–47.4)1727.8 (14.3–41.2)3228.9 (18.4–39.5)65
  Former smoker38.8 (30.3–47.2)15323.3 (6–40.6)1437.3 (18.4–56.1)3745.3 (33.9–56.6)102
  Never smoked32.5 (24.8–40.2)13447.4 (27.9–66.9)3135 (20.1–49.8)3925.8 (16–35.6)64
 Leisure time physical activity        
  Yes52.6 (44.2–61)21277.8 (62.5–93.2)4645.8 (29.3–62.2)5645.8 (34.6–57.1)110
  No47.4 (39–55.9)19122.2 (6–38.3)1754.2 (37.8–70.7)5354.2 (42.9–65.4)121

Individuals who were limited by cancer also differed from individuals who had no activity limitations with respect to health behaviors (Table 4). Compared with individuals who had no activity limitations, individuals who were limited by cancer were significantly less likely to be overweight (25.6% [95% CI, 18.6%–32.5%] vs 37.3% [95% CI, 36.9%–37.7%], respectively) but appeared to be more likely to be obese, although the difference was not statistically significant (27% vs 19.5%, respectively). Individuals who were limited by cancer, especially those ages 40 to 64 years, were less likely to participate in leisure-time physical activity than those without limitations (52.6% [95% CI, 44.2%–61%] vs 77.4% [95% CI, 77.1%–77.8%], respectively). Individuals who were limited by cancer were significantly more likely to have ever smoked than those without limitations (38.8% [95% CI, 30.3%–47.2%] vs 20.8% [95% CI, 20.5%–21.1%], respectively). Current smoking was high among both groups—28.7% for individuals who were limited by cancer and 23.5% for individuals without limitations.

DISCUSSION

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES

In this study, individuals between ages 20 and 64 years who were limited primarily by cancer reported more fair or poor health than individuals who were limited primarily by cardiovascular disease or emotional problems. Those who are limited by a particular condition most likely represent the most severely affected individuals with the condition. Those who were limited by cancer also reported shorter durations of their activity limitation (3.6 years vs 6.9 years for those limited by cardiovascular disease and 8.8 years for those limited by emotional problems). This shorter time of activity limitation implies that cancer patients may be affected by cancer treatment or disease recurrences, because most treatment and recurrences occur in the first 3 to 5 years after diagnosis.3, 4, 15

Individuals who were limited by cancer in this study also reported more physically unhealthy days and more painful days in the past 30 days than those who were limited by cardiovascular disease or by emotional problems. Those who were limited by cancer reported more difficulty sleeping, nearly 50% of the month, than those without any limitations. These findings in a population-based study are consistent with clinical findings that 2 of the most common symptoms experienced by cancer patients are pain and insomnia.16

Individuals who were limited by cancer in this study reported more severe HRQOL abnormalities than those reported by a cohort of adult survivors of childhood cancer in which only 12.5% reported activity limitations.17 Studies examining disability among cancer survivors have reported similar findings, although the magnitude of their findings was not as large.3 In a previous analysis of women of all ages who reported breast cancer on the BRFSS, only 3.7% reported activity limitations.11 This confirms that cancer patients who report activity limitations because of cancer on the BRFSS have high levels of distress and disability.

Several studies of cancer survivors have indicated that cancer survivors are more likely to be women than men.1, 3, 4 Data from population-based cancer registries that participate in the CDC's National Program of Cancer Registries and/or the National Cancer Institute's Surveillance, Epidemiology, and Results Program from 2000 to 2002 confirm this likelihood.18 From ages 20 to 49 years, the cancer incidence rate for all sites combined is significantly higher among women than among men (94.5 per 100,000 women vs 58.7 per 100,000 men among individuals ages 20 to 39 years; 334.4 per 100,000 women vs 210.1 per 100,000 men among individuals ages 40 to 49 years).

Although the BRFSS data did not identify the respondents' cancer site, the leading sites in younger adults differ from those among older adults.18 Breast cancer, which is the leading site among younger women, mainly explains why younger cancer survivors were more likely to be women, with rates of 25.8 per 100,000 among women ages 20 to 39 years and 146.7 per 100,000 among women ages 40 to 49 years (Fig. 1). The incidence rate of the cancer site with the highest rate among men ages 20 to 49 years, lung and bronchus, was only 23.9 per 100,000 men. For men and women ages 50 to 64 years, the leading sites had similar rates (315.2 per 100,000 men for prostate cancer and 296.5 per 100,000 women for breast cancer) (see Fig. 1).

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Figure 1. Age-adjusted cancer incidence rates for the top 10 invasive sites, sex by age, U.S., 2000–2002. Rates are age-adjusted to the 2000 U.S. standard population and cover approximately 90% of the U.S. population. Data are from 43 selected state cancer registries that participate in the National Program of Cancer Registries of the Centers for Disease Control and Prevention and/or the Surveillance, Epidemiology, and End Results Program of the National Cancer Institute; data meet high-quality criteria for all invasive cancer sites combined according to the U.S. Cancer Statistics Working Group2 and Cancer Registry Public Information Data.18 NOS indicates not otherwise specified.

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Consistent with other reports from population-based surveys in these age groups, individuals who were limited by cancer had lower incomes and were unable to work compared with individuals who had no limitations.3, 19 Moreover, those who were limited by cancer in this study were slightly more likely to have health insurance coverage than those without limitations. This may reflect the cancer survivors' higher motivation to maintain coverage to avoid the possibility of becoming uninsurable and the greater likelihood that these cancer survivors have Medicaid coverage because of their lower incomes or Medicare coverage for their disability from cancer.

The individuals who were limited by cancer in the current study more often were underweight and less often were overweight than the individuals without limitations. Those who were limited by cancer also more often were former smokers and less often were nonsmokers than those without limitations. Unlike findings in other studies,4 the percentage of current cigarette smokers among those who were limited by cancer in the current study (29%) resembled that in individuals who reported no limitations (24%). Those who were limited by cancer also were less likely to participate in leisure-time physical activity than those without limitations. In individuals who were limited by cancer, the effects of their cancers, their cancer treatment, or their current and former cigarette smoking habits may have affected their ability to participate in physical activity. Our findings support the need for better efforts from primary care providers and oncologists to intervene in this cohort of patients to deliver wellness messages as well as primary and secondary prevention messages, such as increasing physical activity.1, 20–22 We also may be observing the pessimism that some cancer survivors experience long term.22 These patients may not believe that changing their health behaviors will affect their life expectancy or quality of life.

Our study has several limitations. First, the BRFSS includes only noninstitutionalized adults with telephones. Individuals who are limited by cancer have lower incomes and, thus, may be less likely to own telephones. We also could not identify and, thus, could not classify cancer patients who reported no limitations in their activities or cancer patients who reported limitations because of cardiovascular or emotional problems, because respondents were asked to provide their main limitation and not all limitations. Moreover, and somewhat surprisingly, many cancer survivors do not recall having cancer, a phenomenon that varies by time since diagnosis, type of cancer, and type of treatment received.23 Studies comparing population-based cancer registry data and self reports also have reported similar discrepancies.19 If respondents do not remember that they have cancer, then they are unlikely to report having activity limitations because of cancer. If bias is introduced because of these exclusions or misclassifications, we may expect our results to underestimate the severity of the decreases in HRQOL in cancer patients, because they are not captured in our study population.

Second, the BRFSS is a cross-sectional survey that did not allow us to determine whether the cancer alone caused the activity limitations and the lower HRQOL we observed. Because cancer survivors most likely were included in all 3 comparison groups, the HRQOL results from the current study may underestimate the effect of cancer on HRQOL reported here. Third, despite 3 years of BRFSS data, our sample size was too small to allow us to make consistently definitive statements by age group, particularly in the youngest group of individuals ages 20 to 39 years. Finally, our results were limited by the lack of information regarding the cancer—its type, stage at diagnosis, and phase of care the patient may have been in during the survey. The number and intensity of HRQOL abnormalities varies with the type of cancer.17

Despite these weaknesses, our study has several strengths. To our knowledge, the current study is one of the first studies in a population-based sample to examine the HRQOL-related outcomes for respondents ages 20 to 64 years who reported being limited by cancer in 34 states and the District of Columbia. Although self-report data may be considered a weakness, they also may be considered a strength. HRQOL is an individual-centered outcome that informs us how a patient feels about his or her own illness: It is not an outcome reflected from someone else's values projected onto the individual with cancer. In that sense, the current results will not be purely reproducible even if the same individuals are surveyed, because HRQOL will change over time as an individual's perceptions of health change.

In conclusion, we have examined in detail a subpopulation of BRFSS respondents between ages 20 and 64 years in the states that administered the HRQOL module that reported activity limitations caused by cancer. Survey respondents who reported activity limitations because of cancer had severe HRQOL limitations for all healthy day measures that were examined. These cancer survivors deserve special attention both to develop means to identify them in clinical practice and to develop interventions to improve their quality of life. The BRFSS self-rated health measure and Healthy Days Measures may represent such means to identify adult cancer patients who have HRQOL limitations in the same manner that similar measures are being used in the Childhood Cancer Survivor Study to monitor health status and HRQOL.17

REFERENCES

  1. Top of page
  2. Abstract
  3. MATERIALS AND METHODS
  4. RESULTS
  5. DISCUSSION
  6. REFERENCES
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    Hudson MM,Mertens AC,Yasui Y, et al. Health status of adult long-term survivors of childhood cancer: a report from the Childhood Cancer Survivor Study. JAMA. 2003; 290: 15831592.
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    Cancer Registry Public Information Data. 1999–2002, WONDER online database. United States Department of Health and Human Services, National Program of Cancer Registries, Centers for Disease Control and Prevention. November 2005. Available at: http://wonder.cdc.gov/cancer.html. Accessed on December 2, 2006.
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    Hewitt M,Breen N,Devesa S. Cancer prevalence and survivorship issues: analyses of the 1992 National Health Interview Survey. J Natl Cancer Inst. 1999; 91: 14801486.
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    Demark-Wahnefried W,Aziz NM,Rowland JH,Pinto BM. Riding the crest of the teachable moment: promoting long-term health after the diagnosis of cancer. J Clin Oncol. 2005; 23: 58145830.
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    Ganz PA. A teachable moment for oncologists: cancer survivors, 10 million strong and growing! Clin Oncol. 2005; 23: 54585460.
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    Keating NL,Norredam M,Landrum MB,Huskamp HA,Meara E. Physical and mental health status of older long-term cancer survivors. J Am Geriatr Soc. 2005; 53: 21452152.
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    Desai MM,Bruce ML,Desai RA,Druss BG. Validity of self-reported cancer history: a comparison of Health Interview Data and cancer registry records. Am J Epidemiol. 2001; 153: 299306.