Symptom Distress in Older Adults Following Cancer Surgery

Janet H. Van Cleave, PhD, RN; Brian L. Egleston, PhD; Elizabeth Ercolano, DNSc, RN; Ruth McCorkle, PhD, RN


Cancer Nurs. 2013;36(4):292-300. 

In This Article

Abstract and Introduction


Background: Symptom distress remains a significant health problem among older adults with cancer following surgery. Understanding factors influencing older adults' symptom distress may lead to early identification and interventions, decreasing morbidity and improving outcomes.

Objective: We conducted this study to identify factors associated with symptom distress following surgery among 326 community-residing patients 65 years or older with a diagnosis of thoracic, digestive, gynecologic, and genitourinary cancers.

Methods: This secondary analysis used combined subsets of data from 5 nurse-directed intervention clinical trials targeting patients after surgery at academic cancer centers in northwest and northeastern United States. Symptom distress was assessed by the Symptom Distress Scale at baseline and at 3 and 6 months.

Results: A multivariable analysis, using generalized estimating equations, showed that symptom distress was significantly less at 3 and 6 months (3 months: P < .001, 6 months: P = .002) than at baseline while controlling for demographic, biologic, psychological, treatment, and function covariates. Thoracic cancer, comorbidities, worse mental health, and decreased function were, on average, associated with increased symptom distress (all P < .05). Participants 75 years or older reported increased symptom distress over time compared with those aged 65 to 69 years (P < .05).

Conclusions: Age, type of cancer, comorbidities, mental health, and function may influence older adults' symptom distress following cancer surgery.

Implications for Practice: Older adults generally experience decreasing symptom distress after thoracic, abdominal, or pelvic cancer surgery. Symptom management over time for those with thoracic cancer, comorbidities, those with worse mental health, those with decreased function, and those 75 years or older may prevent morbidity and improve outcomes of older adults following surgery.


Older adults, 65 years or older, comprise 60% of the 10.8 million persons living with cancer and 80% of all cancer deaths.[1,2] Symptoms from both cancer and its treatment represent a major health problem among older adults, leading to delays in treatment and heath resource use.[3] New management strategies, such as targeted pharmacotherapeutics and improved surgical techniques, have been introduced into the clinical setting to help alleviate symptoms. These strategies, though, are mainly tested among persons younger than 65 years and have the potential to cause unexpected reactions when prescribed or used among older adults.[4,5] Hence, older adults' symptoms from cancer and its treatment continue to challenge clinicians and researchers.

Symptoms are characterized as multidimensional, arising from a physiological process from the cancer site and stage, and influenced by psychosocial factors including patients' perception of vulnerability, anxiety, and depressive symptoms.[6,7] Experts describe symptoms in terms of frequency, intensity, and distress.[8–10] Of these terms, symptom distress, defined as the degree of discomfort from the particular symptom, imparts the greatest information about the patients' experience and the meaning that the symptom holds for each individual.[10–12]

Cancer treatment consists of surgery, chemotherapy, and radiation therapy, and each type or combination of treatments may impact patients' symptom distress. Despite a large body of literature addressing cancer treatment, the factors influencing symptom distress among older adults undergoing surgery remain unclear. Some study findings suggest that younger patients with cancer experience greater symptom distress than older adults.[13,14] Other study findings show either no association[15] or a positive association between age and symptom distress.[16] However, these studies consisted of heterogeneous populations in terms of age and cancer treatment.

One study was conducted to examine the factors influencing older adults' symptom distress following breast cancer surgery. In this study, the researchers limited the study population to those 60 years or older. The study findings demonstrated that symptom distress at hospital discharge is negatively correlated with age and positively correlated with education. At 6 months, married study participants report greater symptom distress.[17] These findings support that limiting study populations to older adults may enable researchers to explicate factors influencing older adults' symptom distress following cancer surgery. The challenge of limiting study populations to older adults undergoing surgery is the lack of participation by patients 65 years or older in clinical trials.[4,5]

The purpose of this article was to report findings from a secondary analysis conducted to determine the influence of age categories 65 to 69 years, 70 to 74 years, and 75 years or older on symptom distress among older adults undergoing thoracic, abdominal, and pelvic surgery. To do this, we combined data from 5 oncology nurse–directed clinical trials to increase the size of the study population and the power of the study to detect significant findings. The specific aims for this study were to describe (1) older adults undergoing thoracic, abdominal, and genitourinary cancer; (2) the mean symptom distress by age category and type of cancer; and (3) the association of age categories with symptom distress after cancer surgery at the postoperative period (baseline), then at 3 and 6 months while controlling for demographic, biologic, psychological, treatment, and function covariates.