Cross-Sectional Analysis of the Associations Between Four Common Cancers and Disability

Exclusion of people from oncology clinical trials based on functional status

BACKGROUND/AIMS

People with disability have higher rates of cancer, excluding skin cancer, compared with people without disability. Food and Drug Administration draft guidelines from 2024 address use of performance status criteria to determine eligibility for clinical trials, advocating for less restrictive thresholds. We examined the exclusion of people with disability from clinical trials based on performance status and other criteria.

METHODS

We reviewed eligibility criteria in approved interventional Phase III and Phase IV oncology clinical trials listed on ClinicalTrails.gov between 1 January 2019 and 31 December 2023. Functional status thresholds were assessed using the Eastern Cooperative Oncology Group Performance Status Scale and Karnofsky Performance Scale in clinical trial eligibility criteria. Qualitative analysis was used to review eligibility criteria relating to functional impairments or disability.

RESULTS

Among 96 oncology clinical trials, approximately 40% had restrictive Eastern Cooperative Oncology Group and Karnofsky Performance Scale thresholds, explicitly including only patients with Eastern Cooperative Oncology Group 0 or 1, or equivalent Karnofsky Performance Scale 70 or greater. Only 20% of studies included patients with Eastern Cooperative Oncology Group 2 and Karnofsky Performance Scale 60. Multiple studies contained miscellaneous eligibility criteria that could potentially exclude people with disability. No studies described making accommodations for people with disability to participate in the clinical trial.

CONCLUSION

Draft Food and Drug Administration guidelines recommend including patients with Eastern Cooperative Oncology Group scores of 2 and Karnofsky Performance Scale scores of 60 in oncology clinical trials. We found that oncology clinical trials often exclude people with more restrictive performance status scores than the draft Food and Drug Administration guidelines, as well as other criteria that relate to disability. These estimates provide baseline information for assessing how the 2024 Food and Drug Administration guidance, if finalized, might affect the inclusion of people with disability in future trials.

Population-based cancer screening access needs of disabled people: A qualitative evidence synthesis

BACKGROUND

Cancer is one of the most common causes of mortality among disabled people, and population-based screening is an effective method to identify some cancers early; however, its uptake is lower among the disabled population. There is a lack of evidence regarding why they access less, and their need to access population-based screening programmes.

AIM

To synthesise evidence of the experience of accessing population-based screening programmes for disabled people.

METHOD

A qualitative evidence synthesis (QES) was carried out by searching electronic databases including Medline, CINAHL, Web of Science Core Collection, and Scopus. Grey literature was also searched for. The search yielded 32 relevant publications.

RESULTS

The findings are based on Levesque's conceptual framework. Several factors affect the accessibility of screening services, including people's perceptions, family support, affordability, literacy, and accessibility.

CONCLUSION

Screening services need to acknowledge the needs of disabled people and integrate reasonable accommodations to facilitate their needs.

Activity limitations, use of assistive devices, and mortality and clinical events in 25 high-income, middle-income, and low-income countries: an analysis of the PURE study

BACKGROUND

The focus of most epidemiological studies has been mortality or clinical events, with less information on activity limitations related to basic daily functions and their consequences. Standardised data from multiple countries at different economic levels in different regions of the world on activity limitations and their associations with clinical outcomes are sparse. We aimed to quantify the prevalence of activity limitations and use of assistive devices and the association of limitations with adverse outcomes in 25 countries grouped by different economic levels.

METHODS

In this analysis, we obtained data from individuals in 25 high-income, middle-income, and low-income countries from the Prospective Urban Rural Epidemiological (PURE) study (175 660 participants). In the PURE study, individuals aged 35-70 years who intended to continue living in their current home for a further 4 years were invited to complete a questionnaire on activity limitations. Participant follow-up was planned once every 3 years either by telephone or in person. The activity limitation screen consisted of questions on self-reported difficulty with walking, grasping, bending, seeing close, seeing far, speaking, hearing, and use of assistive devices (gait, vision, and hearing aids). We estimated crude prevalence of self-reported activity limitations and use of assistive devices, and prevalence standardised by age and sex. We used logistic regression to additionally adjust prevalence for education and socioeconomic factors and to estimate the probability of activity limitations and assistive devices by age, sex, and country income. We used Cox frailty models to evaluate the association between each activity limitation with mortality and clinical events (cardiovascular disease, heart failure, pneumonia, falls, and cancer). The PURE study is registered with ClinicalTrials.gov, NCT03225586.

FINDINGS

Between Jan 12, 2001, and May 6, 2019, 175 584 individuals completed at least one question on the activity limitation questionnaire (mean age 50·6 years [SD 9·8]; 103 625 [59%] women). Of the individuals who completed all questions, mean follow-up was 10·7 years (SD 4·4). The most common self-reported activity limitations were difficulty with bending (23 921 [13·6%] of 175 515 participants), seeing close (22 532 [13·4%] of 167 801 participants), and walking (22 805 [13·0%] of 175 554 participants); prevalence of limitations was higher with older age and among women. The prevalence of all limitations standardised by age and sex, with the exception of hearing, was highest in low-income countries and middle-income countries, and this remained consistent after adjustment for socioeconomic factors. The use of gait, visual, and hearing aids was lowest in low-income countries and middle-income countries, particularly among women. The prevalence of seeing close limitation was four times higher (6257 [16·5%] of 37 926 participants vs 717 [4·0%] of 18 039 participants) and the prevalence of seeing far limitation was five times higher (4003 [10·6%] of 37 923 participants vs 391 [2·2%] of 18 038 participants) in low-income countries than in high-income countries, but the prevalence of glasses use in low-income countries was half that in high-income countries. Walking limitation was most strongly associated with mortality (adjusted hazard ratio 1·32 [95% CI 1·25-1·39]) and most consistently associated with other clinical events, with other notable associations observed between seeing far limitation and mortality, grasping limitation and cardiovascular disease, bending limitation and falls, and between speaking limitation and stroke.

INTERPRETATION

The global prevalence of activity limitations is substantially higher in women than men and in low-income countries and middle-income countries compared with high-income countries, coupled with a much lower use of gait, visual, and hearing aids. Strategies are needed to prevent and mitigate activity limitations globally, with particular emphasis on low-income countries and women.

FUNDING

Funding sources are listed at the end of the Article.

Tendencies in disability of the population as a result of malignant neoplasms in Ukraine (on the example of the Poltavia region)

OBJECTIVE

Aim: To study the dynamics of the prevalence and structure of primary disability, including due to cancer, among the population of the Poltava region.

PATIENTS AND METHODS

Materials and Methods: The study used a retrospective analysis - the depth of the research search was six years (2019-2023); a comparative analysis - to establish the differences in disability indicators. Determining the trends of disability: analyzing the dynamic series.

RESULTS

Results: The rate of initial disability due to neoplasms (including malignant) for 2019-2023 in Ukraine population is generally stable with a slight downward trend, in the Poltava region, there is a slight downward trend during the years 2019-2021, starting from 2022, begins to increase sharply, while throughout Ukraine the indicator remains stable. Among the able-bodied population of the Poltava region: if until 2021 the picture is identical to the indicators among the adult population, then starting from 2022 the disability of this contingent in the Poltava region begins to increase, while in Ukraine - to decrease. In 2023 among the population of the Poltava region, diseases of the musculoskeletal system became the cause of disability in 20.5 per 10,000 working-age population (І rank place) ; from circulatory system diseases was 12.3 (ІІ rank place); the rate of disability from a neoplasm is 16.1(ІІІ rank place).

CONCLUSION

Conclusions: Analysis of the dynamics and structure of disabling pathology is important and necessary, as it allows to identify diseases that lead to permanent disability, as well as to develop medical and social measures to prevent disability.

Association of difficulties in daily physical activities and handgrip strength with cancer diagnoses in 65,980 European older adults

BACKGROUND

People with cancer usually report physical deconditioning, which can limit daily activities.

AIMS

Our aim was to analyze associations between daily physical activities and handgrip strength with cancer diagnoses among European older adults.

METHODS

We used data from SHARE (a representative survey of individuals aged 50 years or older) wave 7, residing in 27 European countries and Israel. Participants self-reported difficulties in daily physical activities and cancer diagnoses, and handgrip strength was objectively assessed using a handheld dynamometer. Data were analyzed using binary logistic regression.

RESULTS

Overall, 65,980 participants (average age 67.6 years (SD = 9.4)) were analyzed. Having difficulties in any daily physical activity was significantly associated with higher odds of cancer diagnoses. Lower handgrip strength was significantly associated with cancer diagnoses among participants included in the first (adjusted odds ratio (AOR) = 1.27 [95%CI = 1.11-1.45]) and the second third (AOR = 1.15 [95%CI = 1.03-1.28]) when compared with participants from the last third in the final adjusted model.

DISCUSSION

Having difficulties in daily physical activities as well as lower levels of handgrip strength is positively associated with cancer diagnoses.

CONCLUSION

Adults with difficulties lifting or carrying weights over 5 kilos or having difficulties in two or more activities showed critical associations with cancer diagnosis.

Cancer Disparities Experienced by People with Disabilities

People with disabilities, who represent a rapidly growing and seriously disadvantaged segment of the U.S. population, face unremitting barriers to equal and accessible healthcare and a high prevalence of chronic health conditions. A slowly growing body of research suggests multiple cancer-related disparities between people with and without disabilities. This commentary identifies multiple aspects of the cancer experience and highlights ways cancer is impacted by disability. This includes vulnerabilities to risk factors, barriers to accessing healthcare, and disparities in screening, diagnosis, and treatment. The authors offer six essential pathways for reducing cancer disparities faced by people with disabilities. It is clear that reducing cancer health disparities experienced by people with disabilities will require the commitment and cooperation of a wide range of stakeholders.

Allostatic Load, Mobility Disability, and Viral Effects in Cancer: A Structural Equation Model

A growing number of cancers have been linked to specific oncogenic viruses and physiological stress. Recently, two separate studies linked mobility limitations to allostatic load and four major cancer types. The objective of this study was to determine if cancer occurrence regresses on three latent domains of Allostatic Load, Level of Physical Functioning (i.e., Mobility Disability), and Viral Exposure. We compared several structural equation models using adult participant (n = 17,969) data from three National Health and Nutrition Examination Survey (NHANES) periods. The primary two-level model with three exogenous latent factors and a single Cancer endogenous latent factor demonstrated a strong fit (GFI = 0.948, RMSEA = 0.024), and the model had a non-significant Chi-Square indicative of a strong model.What is already known on this subjectAllostatic load represents how the body responds to physiological stress and is associated with increased morbidity/mortality, including cancers.Viruses are the causative agents of 15-20% of cancers and can be stress activated.People with mobility limitations experience significantly higher allostatic loads and secondary health conditions, and one recent study indicates a heightened risk for certain cancers.What this study addsThis study is original in its testing of a conceptual model that links together cancer outcomes with latent factors/variables including disability/mobility limitations, allostatic load, and viral exposure.The study indicates that there might be important associations between allostatic load, disability burden, and viral exposure/activation on the occurrence of cancer.The research suggests the need for stress reduction, preventative health interventions, and additional supports for people with disabilities and their caregivers.

Use of Accessible Weight Scales and Examination Tables/Chairs for Patients with Significant Mobility Limitations by Physicians Nationwide

BACKGROUND

Mobility limitations are the most common disability type among the 61 million Americans with disability. Studies of patients with mobility limitations suggest that inaccessible medical diagnostic equipment poses significant barriers to care.

METHODS

The study team surveyed randomly selected US physicians nationwide representing seven specialties about their reported use of accessible weight scales and exam tables/chairs when caring for patients with mobility limitations. A descriptive analysis of responses was performed, and multivariable logistic regression was used to examine associations between accessible equipment and participants' characteristics.

RESULTS

The 714 participants (survey response rate = 61.0%) were primarily male, White, and urban, and had practiced for 20 or more years. Among those reporting routinely recording patients' weights (n = 399), only 22.6% (standard error [SE] = 2.2) reported always or usually using accessible weight scales for patients with significant mobility limitations. To determine weights of patients with mobility limitations, 8.1% always, 24.3% usually, and 40.0% sometimes asked patients. Physicians practicing ≥ 20 years were much less likely than other physicians to use accessible weight scales: odds ratio (OR) = 0.51 (95% confidence interval [CI] = 0.26-0.99). Among participants seeing patients with significant mobility limitations (n = 584), only 40.3% (SE = 2.2) always or usually used accessible exam tables or chairs. Specialists were much more likely than primary care physicians to use accessible exam tables/chairs: OR = 1.96 (95% CI = 1.29-2.99).

CONCLUSION

More than 30 years after enactment of the Americans with Disabilities Act, most physicians surveyed do not use accessible equipment for routine care of patients with chronic significant mobility limitations.

Perspectives of Patients with Pre-existing Mobility Disability on the Process of Diagnosing Their Cancer

BACKGROUND

Mobility disability is the most common disability among adult Americans, estimated at 13.7% of the US population. Cancer prevalence is higher among people with mobility disability compared with the general population, yet people with disability experience disparities in cancer screening and treatment.

OBJECTIVE

We explored experiences of patients with mobility disability with the process of cancer diagnosis.

DESIGN

Open-ended individual interviews, which reached data saturation. Interviews were transcribed verbatim for conventional content analysis.

PARTICIPANTS

We interviewed 20 participants with pre-existing mobility disability that required the use of an assistive device or assistance with performance of activities of daily living and who were subsequently diagnosed with cancer (excluding melanoma).

KEY RESULTS

Concerns coalesced around five broad categories: inaccessibility of medical diagnostic equipment affecting the process of cancer diagnosis, attitudes of clinical staff about accommodating disability, dismissal of cancer signs/symptoms as emotional responses to chronic health conditions, misattributing cancer signs/symptoms to underlying disability, and attitudes about pursuing legal action for substandard care. Participants provided examples of how erroneous assumptions and potentially biased attitudes among clinicians interfered with the process of their cancer diagnosis, sometimes contributing to an insufficient workup and diagnostic delays.

CONCLUSIONS

Physical and attitudinal barriers affect the process of cancer diagnosis in people with mobility disability. Though people with mobility disability may be clinically complex, clinicians should be aware of the risks of diagnostic overshadowing (i.e., the misattribution of cancer signs/symptoms to underlying disability) and other erroneous assumptions that may affect timeliness of cancer diagnosis and quality of care. Further efforts, including educating clinicians about challenges in caring for persons with disability, should be considered to improve the process of cancer diagnosis for this population.

TRIAL REGISTRATION

N/A.

Multi-institutional survey of cancer disparities in disabled patients in the region of northwestern Japan

BACKGROUND

Potential disparities between cancer patients with and without disabilities remained to be validate in Japan.

METHODS

We surveyed retrospective data on hospital cancer registration as well as information on disability certificates obtained through the Hokushin Ganpro database. In total, 93,545 cancer patients in 10 principal hospitals covering the region of northwestern Japan were registered with the Hokushin Ganpro database between 2010 and 2015. The database included the following data: diagnosis date, cancer type, staging, treatment, cancer detection process, and possession of a disability certificate.

RESULTS

We found that 2983 patients, which accounted for 3.2% of the total patients, had disabilities. No significant differences in gender, age at diagnosis, cancer stage distribution, and cancer incidence rates were observed between the disabled and non-disabled patients. Even though the proportion of early-stage cancer among disabled patients differed only slightly from that in non-disabled patients, early-stage cancer was more frequently diagnosed in patients with disabilities during their regular hospital visits than in those without disabilities, who had more opportunity for early cancer detection during cancer screening. According to in-house data reflecting treatment period and process from a single hospital, all 16 disabled patients treated with chemotherapy completed the treatment until disease progression or end of predetermined cycles.

CONCLUSION

These results indicate that deep disparities between cancer patients with and without disabilities are not apparent and that the disabled patients in the region of northwestern Japan receive appropriate hospital follow-up.

Associations Between Disability and Breast or Cervical Cancers, Accounting for Screening Disparities

INTRODUCTION

Studies suggest that women with disability experience disparities in routine, high-value screening services, including mammograms and Papanicolaou (Pap) tests. However, few studies have explored whether women with disability have higher risks than other women of developing breast or cervical cancers.

METHODS

The authors analyzed 2010, 2013, 2015, and 2018 National Health Interview Surveys, which involved civilian, noninstitutionalized US residents, and included supplemental surveys on cancer screening. The authors used self-reported functional status limitations to identify women without disability and women with movement difficulties (MDs) or complex activity limitations (CAL) predating breast or cervical cancer diagnoses. Multivariable models evaluated associations of disability status to cancer diagnosis, adjusting for other variables. Analyses used sampling weights, producing national estimates.

RESULTS

The sample included 66,641 women; 24.4% reported MD and 14.5% reported CAL. Compared with women without disability, women with pre-existing MD or CAL had significantly higher rates of breast cancer (2.2% vs. 3.5% and 3.6%, respectively) and cervical cancer (0.6% vs. 0.8% and 1.0%, respectively). Women with disability had significantly lower recent mammography and Pap test rates than women without disability. After adjusting for all covariates, the values for odds ratio (95% confidence interval) of pre-existing CAL for cancer diagnoses were 1.21 (1.01-1.46; P=0.04) for breast cancer and 1.43 (1.04-1.99; P=0.03) for cervical cancer.

CONCLUSIONS

Pre-existing disability is associated with a higher likelihood of breast and cervical cancer diagnoses, raising the urgency of eliminating disability disparities in mammography and Pap testing. Further research will need to explore the causes of these higher cancer rates.

Exploring Cancer Treatment Experiences for Patients With Preexisting Mobility Disability

OBJECTIVE

We explored the process of cancer care for patients with preexisting mobility disability, focusing on treatment decisions and experiences.

DESIGN

We recruited 20 participants with preexisting mobility disability, requiring use of an assistive device or assistance with activities of daily living, subsequently diagnosed with cancer (excluding skin cancers). We conducted open-ended individual interviews, which reached data saturation and were transcribed verbatim for conventional content analysis.

RESULTS

Concerns coalesced around 4 themes: disability-related healthcare experiences affect cancer treatment decisions; concerns about cancer treatment worsening functional impairments; access barriers; and limited provider awareness and biases about treating people with disability. Residual fear from previous medical interventions and concerns about exacerbating functional impairments influenced cancer treatment preferences. Participants also raised concerns that their underlying disability may be used to justify less aggressive treatment. Nevertheless, cancer treatment did exacerbate mobility difficulties for some participants. Inaccessible hospital rooms, lack of accessible medical equipment, and attitudinal barriers complicated treatments.

CONCLUSIONS

People with preexisting mobility disability experience barriers to cancer treatment, compromising quality of care and potentially outcomes. Further training and proactive planning for accommodating disability during cancer treatment and rehabilitation are warranted.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of the article, the reader should be able to: (1) Recognize inadequate accommodations that compromise the diagnosis and treatment of a new cancer in patients with preexisting disability; (2) Recommend involving rehabilitation specialists in the process of care and clinical decision making from the time of cancer diagnosis for patients with preexisting disability newly diagnosed with malignancy; and (3) In the setting of accessibility barriers, facilitate efforts to accommodate patients with preexisting disability to improve quality of care in diagnosing and treating cancer.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Exploring the Process of Cancer Care for Patients With Pre-Existing Mobility Disability

PURPOSE

Approximately 13% of the US population report mobility disability. People with mobility disability experience healthcare disparities, including lower rates of cancer screening and substandard cancer care compared with nondisabled people. We explored clinicians' reports of aspects of diagnosing and treating three common cancer types among persons with pre-existing mobility disability.

METHODS

We used standard diagnosis codes and natural language processing to screen electronic health records (EHR) in the Research Patient Data Repository for patients with pre-existing chronic mobility impairment who were newly diagnosed with one of three common cancers (colorectal, prostate, and non-Hodgkin lymphoma) between 2005 and 2017. We eliminated numerous cases whose EHRs lacked essential information. We reviewed EHRs of 27 cases, using conventional content analysis to identify themes concerning their cancer diagnoses and treatments.

RESULTS

Clinicians' notations coalesced around four major themes: (1) patients' health risks raise concerns about diagnostic processes; (2) cancer signs or symptoms can be erroneously attributed to the patient's underlying disabling condition, delaying diagnosis; (3) disability complicates cancer treatment decisions; and (4) problems with equipment accessibility and disability accommodations impede cancer diagnoses.

DISCUSSION

Clinicians view patients with pre-existing mobility disability as often clinically complex, presenting challenges for diagnosing and treating their cancer. Nonetheless, these patients may experience substandard care because of disability-related problems. Given the growing population of people with mobility disability, further efforts to improve care quality and timeliness of diagnosis are warranted.

Exploring attitudes about developing cancer among patients with pre-existing mobility disability

OBJECTIVE

Mobility disability affects approximately 13.7% of the United States population, representing the most common disability type. People with mobility disability experience disparities in cancer screening and higher prevalence of some cancers compared to the general population. We sought to explore the attitudes of people with pre-existing mobility disability about their cancer diagnosis.

METHODS

We conducted open-ended individual interviews with 20 participants who had pre-existing mobility disability requiring use of an assistive device or assistance with performance of activities of daily living (ADLs), subsequently diagnosed with cancer (excluding skin cancers). Interviews reached data saturation and were transcribed verbatim for conventional content analysis.

RESULTS

Concerns coalesced around three major themes: sense of control over health conditions, seeking support, and recommendations for other people with disability seeking cancer care. Some participants described feeling a loss of control over their cancer diagnosis that they did not have regarding disability, while others suggested that disability presented greater challenges than their cancer diagnosis. Participants described seeking various forms of support, including emotional support (e.g., from friends and family), informational support (e.g., recommendations for seeking care), instrumental support (e.g., ADLs), and appraisal (e.g., self-reflection of personal qualities for fighting cancer). They provided recommendations, highlighting importance of self-advocacy and being attuned to changes in health status.

CONCLUSIONS

We found that people with pre-existing mobility disability and cancer express complex attitudes towards their cancer diagnosis. Findings may inform efforts to improve quality of relevant supports to meet the psychosocial needs of this population.