Monthly Archives: March 2019

The impact of a cancer diagnosis on health and wellbeing

People with cancer are living longer than ever before. Developments in the detection and treatment of cancer mean that half of people diagnosed with cancer in the UK survive for at least 10 years after the point of diagnosis. As such, there is now a growing emphasis not only on prolonging life, but enhancing quality of life for these patients.

Emerging evidence suggests that cancer survivors may suffer impairments in health and wellbeing that pre-date their cancer diagnosis by several years. In one of the first studies to include pre-diagnostic data in analyses of changes in health and wellbeing around the time of a cancer diagnosis, we observed differences in self-rated health, physical function, quality of life, and psychological wellbeing between cancer cases and controls at all examined time points – including up to 2 years before the cancer was diagnosed. This finding begs the question: How far in advance of a cancer diagnosis do impairments in health and wellbeing become evident?

Using prospective data from a large, population-based cohort, we examined changes in a range of health and wellbeing outcomes at two-year intervals from 4-6 years pre-cancer diagnosis to 0-2 years post-diagnosis. We included data from a cancer-free comparison group to distinguish changes in cancer survivors from those occurring in the general population.

Our results indicate that there may be early signs of deterioration in perceptions of health that precede the development of symptoms leading to diagnosis by many years; potential targets for new thinking about cancer awareness and early diagnosis. Some deficits (e.g. relating to mobility and disability) may be of long standing, evident up to six years prior to diagnosis. Other changes (e.g. in depression and quality of life) appear to be more acute in nature and may require targeted support around the point of diagnosis.

Focusing in on quality of life (Figure 1), operationalised as total CASP-19 score, it is clear to see that while scores were almost identical in both groups at 2-4 and 0-2 years pre-diagnosis, from 0-2 years pre-diagnosis to 0-2 years post-diagnosis, mean quality of life decline in the cancer survivor group and increased slightly in the comparison group.

Figure 1_Quality of life by group and time

Figure 1. Quality of life by group and time. The mean quality life score (with 95% confidence intervals) for each group at each time point (adjusted for age, sex, wealth, and diagnosis wave) is shown. ** P < 0.01 for the difference between the cancer survivor group and comparison group.

 These findings have important implications for clinical practice. Health problems that predate the cancer diagnosis by a number of years may contribute to the onset of cancer or share a common aetiology. With potentially modifiable risk factors such as obesity, physical activity, diet, smoking, and alcohol intake among the leading causes of cancer death, health promotion and behaviour change interventions at the general-population level continue to be of critical importance.

More acute changes in depression and quality of life that take place around the time of diagnosis are likely a reaction to the stressful nature of cancer diagnosis and treatment. This highlights a need to ensure cancer patients are screened for these risk factors at diagnosis and have access to psychological support. With evidence relating psychosocial stress to adverse changes in the cellular immune response at the tumor level, which may lead to faster disease progression, initiatives aimed at reducing stress and enhancing quality of life may even offer significant benefits in terms of disease course.

The next steps for advancing this research are to establish whether similar trends are observed in patient subgroups, such as men and women, those from higher versus lower SES levels, those affected by cancer at various sites/organs, and those diagnosed at different stages.

Guest blog post by Dr Sarah E. Jackson, Department of Behavioural Science and Health, University College London.

This article is based on:

Jackson SE, Williams K, Beeken RJ, Steptoe A. Changes in health and wellbeing in the years leading up to a cancer diagnosis: a prospective cohort study. Cancer Prevention Research. 2019; 12(2): 79-87. DOI: 10.1158/1940-6207.CAPR-18-0277


Long-term trajectories of depressive symptoms in old age: relationships with sociodemographic and health-related factors

Depression is more than feeling blue and transitorily losing the capacity to experience pleasure. Depression syndromes are highly prevalent in later life, and last longer than in other periods of life. Almost one in three older people may show clinical levels of depressive symptoms in the UK. Clinically relevant depression symptom episodes in old age are related to devastating consequences (e.g., increased risk of mortality, higher disability, reduced quality of life), even from earliest stages (e.g., subclinical conditions). Little is known about the relationship between symptom course and health-related outcomes. The search for person-specific symptom trajectories may help identify at-risk profiles, thus uncovering potential targets for treatment.

Many factors deserve consideration when depression course being studied. Sex constitutes a biological condition highly connected with depression symptom manifestation. Why do women fall into depression more frequently than men? Probably this is due to sexually-mediated biological processes (e.g., estradiol releasing patterns) and social influence that may put women at higher risk for developing depression problems. Moreover, women often show more heightened courses of depression symptoms over time. Unfortunately, little is known about the sex-specific trajectories of depression symptoms and their related impact on daily living, health and quality of life.

This study aimed at depicting the longitudinal trajectories of depression symptoms in older men and women, with a special interest in identifying heterogeneous trajectories of symptoms. Moreover, we intended to uncover the sociodemographic and health-related profile that featured each symptom trajectory. Finally, we were interested in examining how symptom trajectories may predict health-related outcomes two years later (i.e., quality of life, satisfaction with life and daily living functioning).

To do so, we used data from the English Longitudinal Study of Ageing (ELSA). The ELSA constitutes an excellent cohort study on ageing, relied on surveying British older adults every two years since 2002. The study aims at collecting information across multiple domains (socioeconomic, environmental, health-related, etc.). More concretely, data from 8317 older adults (46.02% men), aged between 65-90 years, were used in our study. None of these participants showed dementia diagnosis and responded by themselves the ELSA survey across waves.

Depressive symptoms were assessed over an 8-year follow-up (from 2002-2010, across five waves), by means of the Center for Epidemiologic Studies Depression Scale, 8-item version (CES-D 8). Moreover, information on time-varying (self-reported health across waves, amount of morbid conditions, feelings of loneliness, sensory function course) and time invariant depression concomitants (education level, household income, history of psychiatric problems in adulthood and age of retirement) were collected.

The identification of sex-specific symptom trajectories relied on robust structural equation modelling. Also, the relationships between symptom trajectory membership and concomitants were examined. Finally, generalised linear regression was used to examine how symptom trajectory membership may predict health-related outcomes at wave 6 (2012). The CASP-19 (the composite score) was used to measure quality of life. The instrument works quite well in old population and shows adequate psychometric properties. More concretely, we found satisfactory reliability levels within our sample (Cronbach’s α = .89).

As a result, we uncovered three heterogeneous trajectories of depression symptoms in men and women. For both sexes, we identified a low-symptom trajectory class (covering more than 77% of men and 68% of women, respectively), with minimal symptom levels over time; a subclinical-symptom trajectory (over 17% of men and 21% of women, respectively), featured by increasing levels of symptoms, that surpassed the cut-off point of clinical meaningfulness over time; and a chronic-symptom trajectory (6% of men and 11% of women), featured by heightened levels of symptoms over time. Sex-related differences were revealed in terms of higher proportion of women showing subclinical and chronic-symptom trajectories in comparison to men. For both sexes, the chronic-symptom trajectory was associated with increasing course of hearing difficulties and the history of psychiatric problems. The subclinical-symptom trajectory was featured by a higher increase in visual difficulties over time. Also, some sex-specific relationships were found: higher amount of morbid conditions in women with subclinical-symptom trajectory; and higher multimorbidity and loneliness feelings in men with chronic-symptom trajectory.

Finally, trajectory class predicted the health-related outcomes in the follow-up. More concretely, individuals with a chronic-symptom trajectory showed the lowest levels of quality of life and satisfaction with life, and the highest levels of disability. Surprisingly, individuals showing a subclinical-symptom trajectory also manifested poorer health-related outcomes than individuals in the normative trajectory class.

Our study constitutes a flexible, but robust approach to study depression symptom dynamics over time and its concomitants. We aimed at providing some evidence to raise awareness of personalised medicine (by means of identifying person-specific trajectories) and its usefulness in geriatric sciences. Moreover, we would like to highlight that depression should be tackled even from its earliest states (subclinical symptom trajectories also showed decreased quality of life) in order to tackle its devastating impact.

Manuscript published in: De la Torre-luque A, De la Fuente J, Prina M, Sanchez-Niubo A, Haro JM, Ayuso-Mateos JL. Long-term trajectories of depressive symptoms in old age: Relationships with sociodemographic and health-related factors. J Affect Disord. 2019;246(November 2018):329-337. doi:10.1016/j.jad.2018.12.122

Guest blog by Alejandro de la Torre Luque, Centre for Biomedical Research in Mental Health (CIBERSAM), Department of Psychiatry. Universidad Autonoma de Madrid, Spain:

Providing care to ageing parents: Is it damaging for quality of life?

Next to spouses and partners, adult children are the most important source of support for older persons in need of care. When adult children take on the caregiver role, this may not be without negative consequences, however. In a recent study published in Ageing and Society, Emily Grundy and I used the short version of the CASP-scale to examine how adult children’s quality of life changes when they start providing informal care to ageing parents.

The team that designed the CASP-scale defined quality of life as “the degree to which human needs are satisfied”. They argued that to achieve quality of life there were four key domains of need to be satisfied: control, autonomy, self-realization and pleasure. It is important to note that caregiving can bring positive things for the person providing it, such as learning new skills or a heightened sense of purpose. Nevertheless, we expected the overall impact of caregiving on quality of life to be negative, because the caregiver-stress model developed by Leonard Pearlin and colleagues suggests that caregiving can be detrimental for all of the four domains of quality of life.

Particularly when the needs of person care for are high, caregiving may diminish one’s sense of mastery, that is, the perceived control over forces that influence one’s life.

Moreover, caregivers may experience role captivity, that is, the feeling of being in the caregiving role involuntarily. This experience is at odds with a sense of autonomy.

Furthermore, caregiving may be a barrier for self-realization, given that Pearlin and colleagues explain that the identity and the life of a caregiver often becomes closely bound to those of the person cared for. For the caregiver, this may result in loss of self. The stress that results both directly and indirectly from caregiving can impede the pleasure experienced by persons providing care.

The caregiver stress model also stresses the importance of the context in which care is provided. When governments make care services more easily accessible, adult children of older people in need of care are less strongly pushed in caregiving role and they may escape the vicissitudes associated with caregiving. In our study we focused on two countries where coverage of long-term care services was traditionally extensive: Denmark and Sweden. However, cutbacks were implemented at the end of the 20th century in Sweden and more recently in Denmark.

We analyzed data from the Survey of Health, Ageing and Retirement in Europe collected between 2004 and 2015. Given that the coverage of long-term care services was more generous in Denmark and in Sweden for most of the period studied, we expected caregiving to be more detrimental for quality of life in the latter than in the former country. In line with these expectations, we noted a quality of life decline in Swedish, but not Danish, adult children when they became caregivers. Also as expected, the country difference in the detrimental effect of caregiving became smaller when further long-term care cutbacks took place in Denmark, but not in Sweden. These results strongly suggest that the extent to which providing informal care is harmful for quality of life depends on the way long-term care is organized in the country where the informal caregiver lives.

Guest blog post by Dr. Thijs van den Broek, Erasmus School of Health Policy & Management, Erasmus University Rotterdam, The Netherlands

Van den Broek, T. & Grundy, E. (2018). Does long-term care coverage shape the impact of informal care-giving on quality of life? A difference-in-difference approach. Ageing & Society.

The research leading to these results has received funding from the European Research Council under the European Union’s Seventh Framework Programme (FP7/2007–2013)/ ERC grant agreement n° 324055.


Quality of life associated with handgrip strength and sarcopenia in Brazil

Geriatric syndromes, such as sarcopenia (the joint reduction of strength and muscle mass), although frequent in the population, can be prevented or delayed onset which can promote active and healthy aging. The study aims to verify the association between handgrip strength (HGS), sarcopenia, sarcopenic obesity and quality of life (QoL) in older adults from a major city of southern Brazil.

This study is part of a longitudinal, population-based and home-based epidemiological survey, EpiFloripa Aging, conducted with individuals aged 60 years or older from Florianópolis, Santa Catarina State, Brazil, in 2013/14. Multiple linear regression was performed to estimate the associations of handgrip strength (HGS – verified by mechanical dynamometer), sarcopenia (appendicular skeletal muscle mass by DXA /body weight <2 standard deviations below gender-specific means of young adults), sarcopenic obesity (obesity by percentage of body fat + sarcopenia), and the outcome of quality of life (CASP-16 Brazil), adjusted by age, family income, leisure and transportation physical activity, functional dependence, cognitive deficit and depressive symptoms.

Of the 1,197 of EpiFloripa follow-up, 604 older adults attended the laboratory, image and functional physical examination, and 584 underwent evaluation of body composition and HGS.  Considering the range of QoL score, from 0 to 48, the mean score was 38.2 (±7.2) and 39.3 (±6.5), respectively, for females and males.

Woman had a mean HGS of 17.9 kgf (±5.5), a prevalence of 6.6% (95%CI:3.9;10.8) of sarcopenia and 1.8% (95%CI: 0.9;3.3) of sarcopenic obesity. Among man HGS mean was 29.5 kgf (±8.5), 9.8% (95%CI:  5.6;16.6) presented sarcopenia and 14.2% (95%CI: 8.8;22.1) sarcopenic obesity.

Despite no statistical difference between the mean of QoL and the prevalence of sarcopenia or sarcopenic obesity, there was difference in the linear regression. In the adjusted analysis, at each increase of one kgf in HGS there was a 0.24 and 0.18 increase in the QoL score, for females and males, respectively. The sarcopenia was negatively associated with QoL, only in males, with a decrease of 3.06 points, but sarcopenic obesity wasn’t associated with QoL.

Considering the impact muscle and mass strength have on QoL, interventions that minimize the phenotypes related these conditions are fundamental. The adoption of exercises that improve the efficiency of muscular development and strength, as well as nutritional counseling, based on individual needs and socioeconomic level with a multi-professional team is emphasized. Since the HGS evaluation is a quick, simple, noninvasive and low-cost measure, it can be adopted by health professionals in the geriatric evaluation, and especially to become an important tool for monitoring and evaluate health groups results.

Guest blog by Larissa Pruner Marques – Researcher at EpiFloripa Aging Study, Department of Public Health, Federal University of Santa Catarina

Marques, L. P., Confortin, S. C., Ono, L. M., Barbosa, A. R., & d’Orsi, E. (2019). Quality of life associated with handgrip strength and sarcopenia: EpiFloripa Aging Study. Archives of gerontology and geriatrics81, 234- doi: 10.1016/j.archger.2018.12.015