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


As the population ages, greater numbers of older adults may be candidates for cancer surgery, yet this population remains understudied because of lack of accrual to clinical trials.[4,5] We conducted a secondary data analysis of study participants 65 years or older who underwent thoracic, abdominal, and pelvic cancer surgery to better understand factors influencing the symptom distress experienced by older adults. Our analysis suggests that, on average, our study population experienced a typical postoperative pattern of decreasing symptom distress over the 6-month period after surgery even though more than half of the study population received adjuvant treatment.

Furthermore, our analysis found several factors that were associated with increased symptom distress. Patients with heightened symptom distress also experienced worse mental health and decreased function. Patients with a diagnosis of thoracic, digestive, and gynecologic cancers experienced greater symptom distress than those with a diagnosis of genitourinary cancers. Our findings also demonstrated that patients reporting 3 or more comorbidities experienced greater symptom distress than those with no comorbidities. In addition, study participants 75 years or older experienced, on average, greater symptom distress over the 6-month period of the study than study participants aged 65 to 69 years.

Previous studies support several of our findings. Earlier research has demonstrated that site of cancer, particularly thoracic cancer, and increased comorbidity burden are significantly associated with increased symptom distress.[45,46] Other researchers have reported that mental health is significantly and negatively correlated with symptom distress among older women with and without breast cancer.[47]

Some of our findings, though, contradict previous studies. In our study, participants 75 years or older reported greater symptom distress at 6 months than their younger counterparts. This finding differs from previous studies that show younger patients with cancer report greater symptom distress than do older patients.[13,14] We also found that type of treatment (surgery, surgery plus radiation therapy, surgery plus chemotherapy, surgery plus chemotherapy and radiation therapy) was unassociated with symptom distress. In contrast, previous researchers have reported that patients receiving adjuvant therapy following surgery experience greater symptom distress than those not receiving adjuvant therapy.[48] The explanations for the difference in our findings from previous studies may include that we limited the patient population to those 65 years or older and to those who were primarily treated with thoracic, abdominal, or pelvic cancer surgery.

Clinical Implications

Our findings suggest that older adults, on average, experience a typical postoperative course with decreasing symptom distress over time. Although older adults are a heterogeneous population, there are some who appear to beat risk for increased symptom distress beginning in the postoperative period and extending through adjuvant cancer therapy. These patients include those with a diagnosis of thoracic or digestive cancers. Patients 75 years or older may also be at risk for greater symptom distress at 6 months after surgery than their younger counterparts. The adoption of increasing appointments at more frequent intervals after surgery for patients 75 years or older may limit symptom distress and prevent potential complications requiring subsequent hospitalizations. Furthermore, frequent appointments provide time for clinicians to educate patients and caregivers about the importance of prompt reporting of escalating symptom distress that may signal changes in the patient's status. Other clinical interventions that could help ameliorate older adults' symptom distress include monitoring for changes in mental health and function.

Research Implications

As the population ages, surgery for older adults is becoming an accepted practice.[49] Greater numbers of older adults will become candidates for cancer surgery. Hence, more research is needed to clarify the relationship between age and risk for increased symptom distress following surgery. For example, clinical studies are needed to examine the interactions of age, type of comorbidity, and site of cancer surgery that may increase older adults' risk for adverse outcomes. In addition, more studies are needed to test novel interventions to alleviate symptom distress among older adults following surgery. For example, nurse-directed clinics associated with oncology practices could test the use of newly developed telehealth interventions to facilitate older adults' and caregivers' reporting of escalating symptom distress.[50]

Strengths and Limitations

The strength of our study comes from combining subsets of patients 65 years or older from 5 nurse-directed clinical trials of community-residing patients with cancer. The combining of data subsets increased the number of patients available for analysis, resulting in greater power of the study to detect significant findings. This also increased the generalizability of our findings. We also avoided the challenge of recruiting older adults to clinical trials. Despite the increased number of study patients, only 12 patients were 85 years or older. Thus, the relationship of age and symptom distress in the oldest adults with cancer remains understudied.

Our study has several limitations. Combining 5 oncology nurse–directed clinical trials conducted over a 25-year period may have introduced heterogeneity. Changes in symptom management, such as better medications for nausea and increased imaging, over the past 25 years have been introduced over this period. We instituted methods, though, to decrease the heterogeneity of combined studies. We used studies similar in design and methods, updated cancer stage data, and included the nurse intervention as a covariate in the multivariable model.

The use of secondary data and combining data sets influenced the choice of measures for the covariates mental health and functional status. For mental health, the 5 parent studies used differing mental health scales across studies. We found 1 consistent mental health indicator—feeling "blue/downhearted." In the psychometric studies of the Mental Health Inventory 5-item version, researchers found this item to be a powerful, nonspecific detector of mental health disorders.[27] For function, the measures differed among studies; all studies used the ESDS except study 4, which measured functional status with the SF-36. This necessitated standardization of the 2 measures in order to combine the studies. Despite the potential heterogeneity that these adjustments may have introduced into the study, both covariates demonstrated strong association with symptom distress.