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See related editorial on sthis Gresham from a free adult skin. Use the link below to share a full-text version of this article with your friends and colleagues. Learn more. Fatigue is prevalent and distressing among cancer survivors, but its subjective nature makes it difficult to identify. Fatigability, defined Gresham from a free adult skin task-specific fatigue, and endurance performance may be useful supplemental measures of functional status in cancer survivors.
Fatigability, endurance performance, and cancer history were assessed every 2 years in Baltimore Longitudinal Study of Aging participants between and Fatigability was defined according to the Borg rating of perceived exertion scale after a 5-minute, slow treadmill walk; and endurance performance was calculated according to the ability and time to complete a fast-paced, meter walk.
The association between cancer history, fatigability, and endurance performance was evaluated using longitudinal analyses adjusted for age, sex, body mass index, and comorbidities. The current findings suggest that a history of cancer is associated with fatigability and poor endurance and that this effect is ificantly greater in older adults. Evaluating the effects of cancer and age on fatigability may illuminate potential pathways and targets for future interventions.
Cancer ; Fatigue is a prevalent and distressing symptom among cancer survivors that often persists years after treatment completion. Improved approaches to identify, quantify, and monitor issues related to fatigue in patients with cancer and survivors may increase our understanding of the nature and impact of fatigue and how best to manage it.
The construct of fatigability, a relatively new and emerging concept, assesses fatigue in relation to specified activities or situations and thus may provide an important and discriminating supplement to typical health and functional status evaluations in patients with cancer and survivors.
Routine assessment of fatigability in patients with cancer and cancer survivors may lead to a more complete and accurate picture of the psychological and physical effects of fatigue in this population and its threats to future function and quality of life. Given the increasing age and survivorship of the cancer population, a better understanding of the assessment, management, and treatment of cancer-related fatigue is imperative for improving quality of life and extending functional longevity among cancer survivors. The current study examines baseline and longitudinal differences in perceived fatigability the Borg rating of perceived exertion [RPE] after a 5-minute slow treadmill walk and endurance walk performance in which failure to complete or slow performance can be interpreted as indicative of performance fatigability ability and time to complete a fast meter walk 11 by cancer history in participants from the Baltimore Longitudinal Study of Aging BLSAa well functioning cohort of middle-aged and older adults.
We hypothesized that, after adjusting for meaningful confounders, those with a history of cancer would have higher perceived and performance fatigability at baseline and would experience a steeper increase in fatigability over subsequent follow-up.
A general description of the sample and enrollment criteria has been ly reported. All participants are community-dwelling volunteers who pass a comprehensive health and functional screening evaluation and are free of all major chronic conditions and cognitive and functional impairments at the time of enrollment. Adults with a history of cancer may enroll provided they have been cancer-free for at least 10 years.
However, once enrolled, participants are followed for life, regardless of disease development, and undergo extensive testing every 1 to 4 years, depending on age.
Among BLSA participants who underwent a comprehensive physical examination, health history assessment, and fatigability testing during their clinic visits between August and Decemberindividuals reported a history of cancer and were cancer-free Fig. There were 80 patients who had unknown cancer status at baseline and were excluded from the analysis.
The participants' first clinic visit at which fatigability was assessed was termed the index visit for the purpose of this analysis. Participants with a history of cancer diagnosis either 1 enrolled 10 years after completion of treatment or 2 developed cancer during their time under study.
Trained and certified technicians administered all assessments according to standardized protocols. The Internal Review Board of the National Institute for Environmental Health Sciences approved the study protocol, and participants provided written informed consent at each visit. Perceived fatigability was assessed immediately after a slow-paced, 5-minute Gresham from a free adult skin walk 1. Endurance walk performance was evaluated as the ability and time to complete a fast meter walk, over a meter course in an uncarpeted corridor. Analyses examined endurance walk performance assessed as the time in seconds to walk meters, with poor endurance walk performance as a binary outcome defined as either: 1 inability to complete the meter walk or 2 taking more than 5 minutes to complete meters.
work in the Health, Aging and Body Composition Study has determined that walk times longer than 5 minutes are indicative of substandard execution and thus can be considered evidence of performance deterioration. Covariates included age, sex, race, body mass index BMIsmoking status, education, and comorbidities. Height and weight were assessed in light clothing using a stadiometer and calibrated scale, respectively, and BMI was calculated as mass in kilograms divided by height in meters squared.
Age, education, and history of chronic conditions were derived from a health history interview conducted by a nurse practitioner. Age was dichotomized at 65 years to increase clinical interpretability. BMI was treated as a continuous variable, and sex, race, and smoking status were treated as categorical variables. Comorbidities included the presence of cardiovascular disease, pulmonary disease, liver disease, kidney disease, hypertension, diabetes, and depression.
The total of comorbidities was calculated for each individual and analyzed as a continuous variable. Descriptive statistics were calculated as of the participant's first clinic visit at which fatigability was assessed the index visit. Differences in demographic characteristics and comorbidities were evaluated using Fisher exact and chi-square tests for categorical variables and the Student t test for continuous variables.
Group differences in comorbidities were assessed using similar methods. Gresham from a free adult skin association between fatigability and history of cancer was evaluated using longitudinal and time-to-event analyses. For the longitudinal analyses, the effect of cancer history on perceived fatigability and poor endurance walk performance was evaluated using generalized estimating equations with exchangeable correlations structures adjusted for age, BMI, sex, comorbidities, and race. The time origin the index visit and the time since that visit in years was the time variable. Model fit statistics were compared to select the best model.
Tests for interactions between age and cancer diagnoses were assessed. Cox-regression analyses adjusted for sex, BMI, and the of comorbidities were fit to calculate the hazard ratios associated with high perceived fatigability and poor endurance. Subgroup analyses were conducted among participants who had been diagnosed with colorectal, breast, prostate, or lung cancers, because these represent the 4 most prevalent cancers among North Americans and are more homogeneous in treatments and long-term effects than less common cancers, such as leukemia.
A sensitivity analysis was done using the same models as described above, but excluding participants diagnosed with cancer after the index visit. If the exclusion of incident cases did not alter the overall findings, it was decided to keep these cases in the analysis sample. In total, participants were included in the analysis; of these, had a reported history of cancer, including who had had a history of cancer at the time of their first fatigability visit, and an additional 86 developed cancer after the index visit Fig.
The mean follow-up was 4. The distribution of cancer types in this population is outlined in Figure 1. Demographic and medical characteristics of individuals with and without a history of cancer are presented in Table 1. The most common comorbidities included Gresham from a free adult skin and cardiovascular disease. In individuals who had a history of cancer, the median age at cancer diagnosis was 66 years interquartile range, yearsand the median time since diagnosis was 8 years. In the overall study population, fatigability increased over time. After adjusting for sex, BMI, and comorbidities in the longitudinal model, a history of cancer diagnosis was associated with a 1.
In addition, older adults with a history of cancer had 8.
To provide clinical perspective, we examined the association between cancer history and time to high perceived fatigability and poor endurance walk performance. Specifically, when stratified by cancer history and age, older adults with a history of cancer showed the shortest time to high perceived fatigability Fig. No statistically ificant interactions were observed between age and cancer history in Cox regression models.
Furthermore, no ificant differences were observed across patient characteristics between incident and prevalent cases, and the change in perceived and performance fatigability were similar. Thus, patients with both incident and prevalent cancer were included in the analyses. Analyses were repeated in a subgroup of participants who had a history of lung, prostate, breast, or colorectal cancer diagnosis to verify findings among more prevalent types of cancer.
A history of 1 of these types of cancer was associated with 1. Fatigue is a serious challenge for patients with cancer and for cancer survivors, and it poses a considerable threat to quality of life with aging. We observed that, even in this well functioning population, a history of cancer was associated with higher perceived fatigability and poorer endurance walk performance. Furthermore, the combination of older age and history of cancer appears to accelerate the onset and progression of fatigability.
These findings support the hypothesis that a history of cancer is associated with higher fatigability and that this effect worsens with advancing age. Both aging and cancer have been independently associated with declines in objective measures of physical function, including gait speed and loss of mobility. Combined with our work defining an increased risk of poor functional outcomes among those with higher fatigability 611 independent of reported tiredness and energy level, the current analysis underscores the increased risk of functional decline in older adults with a history of cancer and links this risk to fatigability status and poor endurance.
A typical individual aged 65 years is living with 2 or more comorbid conditions. This is consistent with findings in the gerontology literature, in which multiple chronic conditions have been associated with energy dysregulation, which subsequently may contribute to worsening fatigue and reduced daily physical activity. There are limitations associated with this analysis.
First, the BLSA is a longitudinal cohort study that was deed to investigate the process of aging and is not specific to cancer. Therefore, additional information regarding cancer stage, treatment details, and pathology was not available. Some cancers may result in higher levels of fatigue than others, 37 but the differential effects of cancer type could not be determined given the relatively small sample size.
Although treatment details were not provided in the BLSA questionnaires, the majority of cancer survivors would have received some form of treatment for their respective cancers. Thus, the ability to detect a difference regardless of disease stage and treatment effects strengthens our confidence in these findings. In the majority of patients, the index visit time of the first fatigability assessment occurred after a cancer diagnosis; therefore, the time since diagnosis of cancer varied across participants and could introduce survivor bias in our findings, especially in the survival analysis.
Finally, the BLSA study participants are generally healthier than the general population because of enrollment criteria. Therefore, lower rates of cancer were observed than expected, Gresham from a free adult skin survivors with a history of more aggressive cancers were less likely to return for their visits or to perform in the meter walk test, resulting in potential underestimation of the true effects.
It would also be of interest to study the impact of different cancer regimens in patients with advanced cancer and advanced cancer survivors. In conclusion, our findings suggest that Gresham from a free adult skin risk of both perceived fatigability and poor endurance is high among older adults with a history of cancer.
More research on fatigability and the interactions with cancer treatments, as well as its impact on quality of life, will help elucidate how best to incorporate this construct into cancer symptom and survivorship research. Currently, there are no screening interventions or tools for fatigability in cancer survivors. Given that the additional burden of cancer on an inevitable aging process is complex, more research is needed to disentangle their combined effects on fatigability.
The use of this methodology among those with a history of cancer may help illuminate potential causal and treatment pathways for managing fatigue in this population. Gillian Gresham: Conceptualization, methodology, validation, formal analysis, data curation, writing—original draft, Gresham from a free adult skin and editing, and visualization.
Sydney M. Dy: Methodology, investigation, writing—review and editing, and supervision. Vadim Zipunnikov: Methodology and validation, writing—review and editing.
Ilene S. Browner: Writing—review and editing. Stephanie A. Studenski: Investigation and writing—review and editing. Eleanor M. Simonsick: Conceptualization, methodology, investigation, data curation, and writing—review and editing. Luigi Ferrucci: Methodology, investigation, resources, writing—review and editing, supervision, and funding acquisition National Institute on Aging, Intramural.
Jennifer A. Schrack: Conceptualization principal investigatormethodology, validation, investigation, data curation, resources, writing—review and editing, supervision, project administration, and funding acquisition.Gresham from a free adult skin
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