In a nationally representative sample, older adults with a previous cancer diagnosis had a higher prevalence of geriatric syndromes than those without a previous cancer diagnosis. After adjustment for known potential clinical and demographic confounders, a cancer diagnosis remained statistically significantly associated with depression, falls, osteoporosis, hearing trouble, and incontinence. In our analyses, relative risk estimates show that a cancer diagnosis independently increased the probability of experiencing these outcomes compared with no cancer diagnosis by 13% to 36%, depending on the outcome. To our knowledge, this research is the first to establish that a history of cancer is independently associated with specific geriatric syndromes.
Geriatric syndromes represent common yet serious conditions for older persons and are associated with adverse outcomes and quality of life. The etiology of geriatric syndromes is typically multifactorial, and shared risk factors include older age, cognitive impairment, functional impairment, and impaired mobility.5
As a group, geriatric syndromes are known to increase risk for hospitalization and mortality, and each individual geriatric syndrome has been shown to increase risk for functional decline and death in older adults.5,10,15
This study reveals that older adults with a history of cancer have an even higher likelihood of having specific geriatric syndromes than those without a history of cancer, which may put them at a higher risk for further morbidity and mortality.
Geriatric syndromes often coexist with other diseases. Our study demonstrated that comorbidities and geriatric syndromes are more prevalent in patients with cancer than in those without cancer. An analysis from the Health and Retirement Study showed that two geriatric syndromes (falls and urinary incontinence) often co-occur with chronic conditions, such as heart disease and diabetes mellitus.16
Our study results showing that geriatric syndromes coexist with cancer are consistent with previous research.6,7,17,18
Koroukian et al6
found that a clinically significant geriatric syndrome was found in 35% of patients with newly diagnosed breast cancer, 45% of patients with colon cancer, and 51% of patients with prostate cancer within the Ohio Cancer Incidence Surveillance System. Flood et al7
showed that geriatric syndromes were highly prevalent in acutely ill hospitalized patients with cancer. In these studies, it is unclear whether a history of cancer or other comorbidities were associated with the increased prevalence of geriatric syndromes in older persons.
In our study, the prevalence of specific geriatric syndromes in older patients with cancer ranged from 7% for poor vision to more than 26% for depression and falls. Fifty percent of community-dwelling older adults in the Health and Retirement Study had one or more geriatric syndrome, which is comparable to the prevalence found in our noncancer group.19
Studies of screening for specific geriatric syndromes in elderly cancer cohorts have demonstrated a similarly high prevalence of these conditions. For example, the prevalence of depression in elderly patients with cancer ranges from 17% to 25%.20
The higher prevalence of geriatric syndromes in older patients with cancer could be a result of the interactions between symptoms of cancer, adverse effects of treatment, and underlying vulnerability. For example, older patients with prostate cancer receiving hormonal therapy have a high prevalence of physical performance problems, falls, and osteoporosis.18,21,22
More research is required to evaluate the impact of cancer symptoms and treatment complications on age-related conditions.
Because of the smaller sample size, associations between cancer subtypes and specific geriatric syndromes can be considered hypothesis generating and should be confirmed in further prospective research. These associations may be related to specific symptoms from cancer, stage of disease, or complications from treatment. Stage of cancer influences nutrition in older patients with cancer. Incontinence is a known adverse effect of prostate cancer treatment. Hearing difficulties in patients with lung cancer could be a result of cisplatin chemotherapy. Other relationships found may be related to interaction of aging and cancer, sex, or other underlying demographic factors. Older women with gynecologic cancers and patients with lung cancer had the highest numbers of geriatric syndromes, which may be related to length of survivorship or adverse health behaviors linked to the cancer diagnosis (eg, smoking, low physical activity). A diagnosis of prostate cancer seemed protective against osteoporosis, despite knowledge that hormonal therapy leads to osteoporosis. It may be that osteoporosis is under-recognized in this population, or patients with prostate cancer were not told or do not remember being told of this underlying condition.
There is little information at this time regarding the impact of geriatric syndromes on cancer decision making and outcomes. A study by Koroukian et al23
showed that presence of geriatric syndromes was associated with a lower likelihood of undergoing surgery and adjuvant chemotherapy. Individuals with two or more geriatric syndromes had an estimated disease-specific mortality and overall mortality more than double those of individuals with no geriatric syndromes. Currently, the presence or absence of geriatric syndromes is not currently captured within cancer clinical trials and not routinely captured within administrative datasets. Future research should incorporate assessment of geriatric syndromes prospectively to evaluate the relationships between these common but serious conditions and efficacy and toxicity of cancer treatment.
The presence of geriatric syndromes can be a clinical manifestation of vulnerability and frailty, which are now being recognized as important to assess in geriatric oncology patients.24–27
Our previous research found that a cancer history was independently associated with frailty, for the most part resulting from high prevalence of geriatric syndromes.8
A multidimensional comprehensive geriatric assessment includes a compilation of reliable and valid tools that can assess geriatric syndromes.15
According to National Cancer Comprehensive Network guidelines, a comprehensive geriatric assessment should be a key part of the treatment approach for vulnerable and frail older patients with cancer.24,25,28
There are limitations that should be considered when interpreting these findings. Our cancer sample was heterogeneous and included any persons with a reported diagnosis of cancer. We did not have information on date of diagnosis of cancer, cancer stage, or treatment. The sample thus likely included patients at all stages of disease, from long-term survivors to those receiving active treatment for metastatic disease. Because this is a cross-sectional study, we cannot determine causality in the associations of a cancer history with geriatric syndromes. Therefore, this study cannot determine whether the associations of cancer with specific geriatric outcomes are a function of survivorship (ie, previous cancer predisposes to geriatric syndromes later in life) or active ongoing treatment. Although the prevalence of geriatric syndromes was high, some syndromes like delirium, failure to thrive, and self neglect were not captured within the MCBS. Although we adjusted for comorbidity, there is still the possibility that an unmeasured effect of comorbid conditions has confounded our association between a cancer history and geriatric syndromes. Because we were restricted to the questions asked on the MCBS and self-reporting, our comorbidity and geriatric syndrome lists have not been previously validated. Self-reporting, however, has been shown to reliably identify comorbidity in other settings.29,30
Despite the above limitations, this study establishes the increased baseline prevalence of geriatric syndromes in elders with a history of cancer that have been associated with adverse health outcomes, such as mortality, in the more general geriatric population. These conditions are most prevalent in the older population and thus pose distinct challenges for clinicians caring for this population. Interventions that target geriatric syndromes in patients with cancer may help to improve quality of life and therapeutic outcomes. Care guidelines, rather than considering one condition at a time, should be developed to address comprehensive and coordinated management of co-occurring conditions such as cancer and geriatric syndromes.