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. 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