You are here

Prevalence of Symptoms in Older Cancer Patients Receiving Palliative Care: A Systematic Review and Meta-Analysis

Journal of Pain and Symptom Management

Abstract

Context

Symptom control is an essential part of palliative care and important to achieve optimal quality of life. Studies showed that patients with all types of advanced cancer suffer from diverse and often severe symptoms. Research focusing on older persons is scarce because this group is often excluded from studies. Consequently, it is unclear which symptoms older palliative care patients with cancer experience and what is the prevalence of these symptoms. To date, no systematic review has been performed on the prevalence of symptoms in older cancer patients receiving palliative care.

Objectives

The objective of this systematic review was to search and synthesize the prevalence figures of symptoms in older palliative care patients with cancer.

Methods

A systematic search through multiple databases and other sources was conducted from 2002 until April 2012. The methodological quality was evaluated. All steps were performed by two independent reviewers. A meta-analysis was performed to pool the prevalence of symptoms.

Results

Seventeen studies were included in this systematic review. Thirty-two symptoms were identified. The prevalence of these symptoms ranged from 3.5% to 77.8%. The most prevalent symptoms were fatigue, excretory symptoms, urinary incontinence, asthenia, pain, constipation, and anxiety and occurred in at least 50% of patients.

Conclusion

There is a high degree of uncertainty about the reported symptom prevalence because of small sample sizes, high heterogeneity among studies, and the extent of instrument validation. Research based on rigorous methods is needed to allow more conclusive results.

Key Words: Elderly, aged, older person, palliative care, signs and symptoms, systematic review, prevalence.

Introduction

In 2008, the estimated incidence of cancer was 12.7 million cases internationally,1 of which 3.2 million cases were in Europe.2 Because aging is a fundamental risk factor for cancer development,3 the number of cancer cases will continue to increase as a result of the growing aging population in the west.4 Cancer remains a leading cause of death, accounting for 13% and 20% of all deaths worldwide1 and in Europe, respectively.2 These prevalences indicate that, for a certain number of patients, the focus of treatment will eventually shift from cure to care. Therefore, many authors have recommended the integration of palliative care with cancer care and that this is done in the early stage of illness.5 and 6

Symptom control is an essential part of palliative care and important to achieve optimal quality of life.3 Studies showed that patients with all types of advanced cancer suffer from diverse and often severe symptoms. Two systematic reviews7 and 8 of patients of all ages with advanced cancer identified between 11 and 56 different symptoms. Teunissen et al.8 reported that the most prevalent symptoms were fatigue, pain, lack of energy, weakness, and appetite loss, occurring in more than 50% of patients with advanced cancer. Moreover, as the number of symptoms and their severity increases, the quality of life for patients decreases.7 Despite the high prevalence of symptoms, many patients remain untreated.9 Research focusing on older persons is scarce because older people are often excluded from studies.10 and 11 Despite the fact that the majority of older people are aging well, the incidence of frail older persons with complex and multiple chronic pathologies and disabilities is increasing.12 Therefore, results from studies in younger persons cannot always be extrapolated to the older person.13 Consequently, it is unclear which symptoms older palliative care patients with cancer experience. To date, no systematic review has been performed on the prevalence of symptoms in older cancer patients receiving palliative care.

Aim

The aim of this systematic review was to search and synthesize the prevalence figures of symptoms in older palliative care patients with cancer. The following questions were addressed: 1) which symptoms do older palliative care patients with cancer experience? and 2) what is the point prevalence of the identified symptoms in this population?

Methods

Review Protocol

The review protocol, which details the predefined criteria for this review, is available from the authors and Joanna Briggs Institute (http://www.joannabriggs.edu.au/).

Search Strategy

Multiple steps were undertaken to identify all relevant literature. First, an initial limited search of PubMed and CINAHL was carried out to define the appropriate index terms and key words. Second, a subsequent search was undertaken across the following electronic databases: PubMed, Embase, CINAHL, Web of Science, and the Cochrane Library. The concepts, using identified index terms and key words, were combined as follows: “palliative” AND “symptoms” AND “prevalence” AND “cancer” AND “older person.” Third, Google Scholar was searched to identify grey literature. Fourth, a hand search through the tables of content of relevant journals (Journal of Pain and Symptom Management, Palliative and Supportive Care, Journal of Palliative Medicine, Supportive Care in Cancer, Critical Review in Oncology, and International Journal of Palliative Nursing), conference proceedings (Congresses of the European Association for Palliative Care and Flemish Congresses on Palliative Care), and reference lists of all the retrieved full-text articles was carried out to identify additional studies.

Articles written in English, French, German, and Dutch and published between 2002 and April 2012 were considered for inclusion. A period of 10 years was adopted because of change over time in treatment options and its influence on symptoms.

Study inclusion criteria were having a quantitative design, reporting on prevalence of symptoms in adults older than 65 years, and reporting on palliative care patients or patients with incurable or advanced cancer. Studies only reporting on the prevalence of symptoms in terminal patients were excluded from this review.

The title and abstract of all identified records were screened by two independent reviewers (A.V.L. and M.V.). Full texts of all potentially relevant records were further checked for inclusion. Differences in assessment were discussed between the two reviewers to reach consensus. In case of disagreement, a third reviewer (A.V.) was consulted. The interrater reliability for study selection was tested using the overall agreement and Cohen's kappa.

Methodological Quality

The methodological quality of the articles selected for retrieval was evaluated independently by two reviewers (A.V.L. and A.V.). Standardized critical appraisal instruments from the Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) were used to explore the presence of potential bias. Three checklists were used depending on the study design: 1) randomized controlled trial/pseudorandomized trial, 2) comparable cohort study/case-control study, and 3) descriptive/case series. The checklist for comparable cohort study/case-control study was used for quasi-experimental studies. The items were rated as + (present) or − (not present). Differences in assessment were discussed between the two reviewers to reach consensus. In case of disagreement, a third reviewer (M.V.) was consulted. No study was excluded based on the evaluation of the methodological quality.

Data Collection and Synthesis

Data from the included studies were extracted by two independent reviewers (A.V.L. and A.V.). A standardized form and detailed instruction guide were used to extract data, which included study design, setting, sample characteristics, symptom description and collection, and results. Subsequently, study characteristics and results were tabulated.

Data Pooling

Prevalence figures were combined using meta-analysis, if the heterogeneity was acceptable. Data were pooled using either the random- or the fixed-effects model depending on the heterogeneity of the included studies. Heterogeneity was determined using Cochran's Q-test at a significance level of 0.10. I² was calculated to quantify the heterogeneity; acceptable heterogeneity was defined as I² <70%.14 In studies with a high heterogeneity (I² >70%), a random-effects model was used.

Logit transformation of the prevalence figures was applied because logits are more likely to have a normal distribution, which is essential for pooling data. The final pooled logit was back transformed, resulting in pooled prevalence and 95% CIs. Following formulas were used: logit event rate = log[event rate/(1 - event rate)], logit event rate stripin: si1.gif, and event rate = (eˆlogit event rate)/(eˆlogit event rate + 1) with e = 2.718. Subgroup analyses were performed based on the type of cancer, but only if there were at least three studies in a subgroup. The comprehensive meta-analysis, version 2 software (BioStat Software, Englewood, NJ), was used to perform the analyses. Microsoft Office Excel 2010 was used to develop the forest plots.

Results

Search Strategy

The electronic database search identified 7881 records: PubMed (n = 2293), Embase (n = 3018), CINAHL (n = 691), Web of Science (n = 1332), and the Cochrane Library (n = 460) (Fig. 1). Google Scholar yielded 136 records. The hand search resulted in 393 records from relevant journals and two records from conference proceedings. No additional record was added after checking the reference lists of the included studies. This resulted in 8325 records, of which 2266 were duplicates. Based on title and/or abstract screening, 293 records potentially met the inclusion criteria. After review of the full texts, 276 records were excluded. Reasons for exclusion are reported in Fig. 1. The systematic review included 17 studies (Table 1).15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, and 31

gr1

Fig. 1 Flow chart of included studies.

Table 1 Characteristics of the Included Studies

Study Study Design and Setting Patient Characteristics Measurement Instrument Symptom Prevalence in the Subgroup of Palliative Elderly
Altundag et al.15 Quasi-experimental study (matched control 2:1)

Cancer center
Sample size a : 138

Number of elderly a : 46

Age: group ≥80 years; median age 82 years

Primary diagnosis: advanced NSCLC (Stages III and IV)

Metastasis: NR

Terminal patients: NR
NR b ≥10% Weight loss (6 months): 4.3%

No data on weight loss for 8.7% of the patients
Biesma et al.16 Randomized controlled trial

Setting: NR
Sample size a : 182

Number of elderly a : 182

Age: all ≥70 years; median age 74 years

Primary diagnosis: inoperable NSCLC (Stages III and IV)

Metastasis: NR

Terminal patients: survival >5.6 months
NR b >10% Weight loss: 8%
Comella et al.17 Randomized controlled trial

Setting: NR
Sample size a : 259

Number of elderly a : 145

Age: group >70 years; median age 74 years

Primary diagnosis: locally advanced NSCLC (Stages III and IV)

Metastasis: more than one metastatic site

Terminal patients: NR
NR b >5% Weight loss: 25%
Feliu et al.18 Quasi-experimental study (no control group)

Ambulatory patients
Sample size a : 50

Number of elderly a : 50

Age: all >70 years; mean age 76 years

Primary diagnosis: advanced colorectal cancer

Metastasis: liver, lung, lymph node, and other sites

Terminal patients: LE >3 months
Memorial Pain

Assessment Card for pain (score ≥20)

VAS (1–100) for asthenia and anorexia (score ≥20)
Asthenia: 56%

Pain: 40%

Anorexia: 28%
Genz et al.19 Case-control study

Special care unit for palliative geriatric patients
Sample size a : 217

Number of elderly a : 101 (116 nononcology)

Age: all >75 years; mean age 76.8 (8.7) years; median age 78 years

Primary diagnosis: palliative patients with different type of cancer

Metastasis: NR

Terminal patients: NR
NR Urinary incontinence: 71%

Fecal incontinence: 44%

Pain: 86%

Constipation: 51%

Agitation: 38%

Dyspnea: 20%

Anorexia: 29%

Diarrhea: 24%

Vomiting: 26%

Nausea: 30%

Confusion: 22%

Dysphagia: 17%

Malnutrition: 46%
Kudoh et al.20 Randomized controlled trial

Setting: NR
Sample size a : 180

Number of elderly a : 180

Age: all ≥70 years; median age 76 years

Primary diagnosis: NSCLC (Stages IIIb and IV)

Metastasis: NR

Terminal patients: LE ≥3 months
NR b >10% Weight loss: 13.4%
Langer et al.21 Randomized controlled trial

Academic and community care centers and practices
Sample size a : 574

Number of elderly a : 86

Age: group ≥70 years; median/mean age: NR

Primary diagnosis: NSCL (Stages III and IV)

Metastasis: lung, pleura, mediastinum, supraclavicular, lymph node, liver, bone, and other

Terminal patients: NR
NR b ≥5% Weight loss: 34.0%

Cough: 37%

Dyspnea: 41%

Hoarseness: 3.5%

Pain: 26%

Respiratory symptoms: 21%

Decreased appetite: 30%
LeCaer et al.22 Randomized controlled trial

Setting: NR
Sample size a : 99

Number of elderly a : 99

Age: mean age 75.9 years

Primary diagnosis: NSCLC (Stages IIIb and IV)

Metastasis: NR

Terminal patients: LE ≥3 months
NR b >5% Weight loss: 37.3%
Li et al.23 Retrospective cohort study

Hospital
Sample size a : 109

Number of elderly a : 109

Age: all >70 years; median age 74 years

Primary diagnosis: unresectable locally advanced NSCLC (Stages IIIb and IV)

Metastasis: present

Terminal patients: NR
NR b >5% Weight loss (3 months): 34.9%
Lloyd-Williams24 Cross-sectional study

Community
Sample size a : 184

Number of elderly a : 44 (>70 years)

Age: median age 64 years

Primary diagnosis: hospice patients with different type of cancer

Metastasis: NR

Terminal patients: survival range from 6 days to 17 months
Edinburgh Postnatal Depression Scale (score ≥13) Depression: 16.28%
Maestu et al.25 Quasi-experimental study (no control group)

Setting: NR
Sample size a : 88

Number of elderly a : 88

Age: all >65 years; median age 74 years

Primary diagnosis: advanced NSCLC (Stages IIIa/b and IV)

Metastasis: NR

Terminal patients: LE >12 weeks
NR b >10% Weight loss: 21.6%

Asthenia: 75.6%

Dyspnea: 73.1%

Pain: 57.7%

Anorexia: 52.6%
Maestu et al.26 Quasi-experimental study (no control group)

Setting: NR
Sample size a : 59

Number of elderly a : 59

Age: all ≥70 years; median age 74 years

Primary diagnosis: advanced NSCLC (Stages IIIb and IV)

Metastasis: NR

Terminal patients: NR
NR b >10% Weight loss: 16.9%
Paillaud et al.27 Cohort study

Palliative care unit
Sample size a : 83

Number of elderly a : 45

Age: group >70 years; median/mean age: NR

Primary diagnosis: incurable cancer

Metastasis: NR

Terminal patients: survival range from 4 to 184 days
Self-report >10% Weight loss: 71%
Su et al.28 Cross-sectional study

Hospital
Sample size a : 200

Number of elderly a : 75

Age: group ≥65 years; mean age 74.01 years

Primary diagnosis: advanced cancer type: NR

Metastasis: NR

Terminal patients: NR
Translated ICD-10 (Chinese) Fatigue: 92%
Teunissen et al.29 Cross-sectional study

Hospital
Sample size a : 203

Number of elderly a : 40

Age: group ≥70 years; median age 77 years

Primary diagnosis: advanced cancer

Metastasis: bone, lymph node, lung, liver, brain, viscera, and other

Terminal patients: survival range from 1 to 759 days
Standardized list Pain: 90%

Excretory problems: 78%

Anorexia: 60%

Constipation: 55%

Fatigue: 53%

Anxiety: 50%

Depressed mood: 48%

Nausea: 43%

Sleeplessness: 30%

Dry mouth: 25%

Confusion: 25%

Dyspnea in rest: 23%

Vomiting: 23%

Diarrhea: 20%

Urinary tract problems: 20%

Drowsiness: 18%

Sore mouth: 18%

>10% Weight loss: 18%

Dysphagia: 15%

Restlessness: 10%

Bed sores: 10%

Delirium: 10%

Coughing: 3%
Trédan et al.31 Quasi-experimental study (no control group)

Setting: NR
Sample size a : 155

Number of elderly a : 155

Age: all ≥70 years; median age 75.5 years

Primary diagnosis: ovarian epithelial carcinoma (Stages III and IV)

Metastasis: NR

Terminal patients: LE ≥3 months
Evaluated as present or absent by investigator Depression: 15.5%
Yoshimura et al.30 Quasi-experimental study (no control group)

Setting: NR
Sample size a : 30

Number of elderly a : 30

Age: all ≥70 years; median age 75 years

Primary diagnosis: NSCLC (Stages IIIb and IV)

Metastasis: NR

Terminal patients: NR
NR b >10% Weight loss: 16.6%

a Reported as number of patients.

b Symptom(s) reported in study as baseline characteristics.

NSCLC = non-small-cell lung cancer; NR = not reported; LE = life expectancy; VAS = visual analogue scale; ICD-10 = International Classification of Diseases.

There was almost perfect agreement between the reviewers: an overall agreement of 99% and a Cohen's kappa of 0.93.

Methodological Quality

In general, the included studies had multiple methodological limitations (Table 2, Table 3, and Table 4). The most common methodological problems were the absence of valid and reliable measurement instruments to identify the prevalence of symptoms and the absence of a representative sample.

Table 2 Quality Assessment of Randomized Controlled Trials

Study Random Assignment Blinding of Patient Blinding of Assessor Allocation Concealment Intention-to-Treat Analysis Comparable Groups at Baseline Identical Treatment Other Than Intervention Outcome Measurement Identical Between Groups Reliable Measurement of Outcome Appropriate Statistical Analysis
Biesma et al.16 + + + + +
Comella et al.17 + + + + +
Kudoh et al.20 + + + + +
Langer et al.21 + +
LeCaer et al.22 + + +

+ = present; − = not present.

Table 3 Quality Assessment of Quasi-Experimental, Comparable Cohort, and Case-Control Studies

Study Representative Sample Patient at Similar Course in Illness Minimized Bias in Selection of Cases/Controls Dealt With Confounding Factors Objective Measurement of Outcome Reliable Measurement of Outcome Sufficient Follow-Up Withdrawals Described and Included in Analysis Appropriate Statistical Analysis
Altundag et al.15 + + + +
Feliu et al.18 + NA + + + + +
Genz et al.19 + + + NA NA +
Li et al.23 + + + + +
Maestu et al.25 + NA + + +
Maestu et al.26 + NA + + + +
Paillaud et al.27 + + + + +
Trédan et al.31 + NA + + +
Yoshimura et al.30 + NA + + +

+ = present; − = not present; NA = not applicable.

Table 4 Quality Assessment of Cross-Sectional Studies

Study (Pseudo) Random Sample Clear Inclusion Criteria Dealt With Confounding Factors Objective Measurement of Outcome Reliable Measurement of Outcome If Comparison, Sufficient Description of Groups Sufficient Follow-Up Withdrawals Described and Included in Analysis Appropriate Statistical Analysis
Lloyed-Williams24 + + NA
Su et al.28 + + NA
Teunissen et al.29 + + + NA +

+ = present; − = not present; NA = not applicable.

Definition of a Palliative Care Patient

Palliative care patients were defined differently across the included studies. Most of the studies (n = 13) did not define the patients as being in a palliative care phase but included patients with advanced cancer.15, 16, 17, 18, 20, 21, 22, 23, 25, 26, 30, and 31 Four studies included cancer patients referred to a palliative/hospice care unit (n = 3)19, 24, and 27 or palliative care team (n = 1).29 None of the studies gave a clear description on when patients were seen as being in a palliative care phase.

Study Characteristics

Participants were older persons based in the community (n = 3),18, 21, and 24 hospital (n = 3),23, 28, and 29 palliative care unit (n = 2),19 and 27 or cancer center (n = 1).15 The setting was not reported in eight studies.16, 17, 20, 22, 25, 26, 30, and 31 In most studies, the primary diagnosis was non-small-cell lung cancer Stage III or IV (n = 10).15, 16, 17, 20, 21, 22, 23, 25, 26, and 30 Other studies included patients with advanced colorectal cancer,18 ovarian epithelial cancer Stages III and IV,31 or various other cancer diagnoses (n = 4).19, 24, 27, and 29 One study did not report on the cancer type.28 Patients in the terminal phase of their illness were included in three studies but did not comprise the total sample.24, 27, and 29 However, the number of terminal phase patients was not reported. In eight studies, it was unclear if terminal phase patients were included.15, 17, 21, 23, 26, 28, and 30 The data collection method was not described in 11 studies,15, 16, 17, 19, 20, 21, 22, 23, 25, 26, and 30 10 of which reported symptom prevalence as a baseline characteristic.15, 16, 17, 20, 21, 22, 23, 25, 26, and 30 The other studies used validated instruments (n = 2),18 and 24 a questionnaire with unknown validity (n = 2),28 and 29 or subjective assessment (n = 2).27 and 31 The prevalence of symptoms was calculated based on samples of 30–182 older patients, with a combined maximum of 652 patients.

Symptom Prevalence

Thirty-two symptoms were identified across 16 studies (Table 5). Sixteen symptoms could be meta-analyzed because they were reported in more than one study. Weight loss, pain, anorexia, and dyspnea were the symptoms reported by at least four studies.

Table 5 Prevalence of Symptoms

Symptom Number of Studies Number of Subjects Pooled Prevalence (%) 95% CI I² (%)
Fatigue 2 109 77.8 a 26.1–92.7 0.0 a
Excretory problems 1 40 77.5 b 62.1–87.9
Urinary incontinence 1 101 71.0 b 61.7–79.3
Asthenia 2 128 66.7 a 45.5–82.7 0.0 a
Pain 5 355 66.3 a 35.8–83.9 16.6 a
Constipation 2 141 52.5 44.2–60.6 0.0
Anxiety 1 40 50.0 b 35.0–65.0
Depressed mood 1 40 48.0 b 32.7–62.7
Malnutrition 1 101 46.0 b 36.1–55.3
Fecal incontinence 1 101 44.0 b 34.2–53.4
Anorexia 4 269 41.5 a 26.8–57.9 3.5 a
Nausea 2 141 33.5 26.2–41.8 52.1
Dyspnea 4 305 33.3 a 13.0–62.5 19.0 a
Weight loss >5% 4 439 32.1 27.9–36.7 42.6
Decreased appetite 1 40 30.0 b 21.5–40.7
Sleeplessness 1 40 30.0 b 17.9–53.4
Dry mouth 1 40 25.0 b 14.0–40.5
Vomiting 2 141 24.9 18.4–32.6 0.0
Confusion 2 141 22.7 16.5–30.4 0.0
Diarrhea 2 141 22.7 16.6–30.4 0.0
Agitation 2 141 21.7 a 5.1–59.2 0.0 a
Respiratory symptoms 1 86 21.0 b 62.1–87.9
Urinary problems 1 40 20.0 b 10.3–35.2
Weight loss >10% 7 652 18.9 a 9.4–34.1 8.3 a
Subgroup: NSCLC 5 567 13.5 10.8–16.7 65.6
Drowsiness 1 40 18.0 b 8.6–32.4
Sore mouth 1 40 18.0 b 8.6–32.4
Dysphagia 2 141 16.3 11.1–23.4 0.0
Depression 2 198 15.7 11.2–21.4 0.0
Cough 2 141 12.6 a 0.7–75.5 0.0 a
Bed sore 1 40 10.0 b 3.8–23.8
Delirium 1 40 10.0 b 3.8–23.8
Hoarseness 1 86 3.5 b 1.1–10.3

a Random-effects model.

b No pooled prevalence (only one study).

NSCLC = non-small-cell lung cancer.

The seven most prevalent symptoms, occurring in at least 50% of the patients, were fatigue, with a pooled prevalence of 77.8% (95% CI, 26.1–92.7; I², 0.0%); excretory symptoms, with an occurrence of 77.5%; urinary incontinence, with an occurrence of 71%; asthenia, with a pooled prevalence of 66.7% (95% CI, 45.5–82.7; I², 0.0%); pain, with a pooled prevalence of 66.3% (95% CI, 35.8–83.9; I², 16.6%); constipation, with a pooled prevalence of 52.5% (95% CI, 44.2–60.6; I², 0.0%); and anxiety, with an occurrence of 50.0%. The pooled prevalences of these symptoms are displayed in forest plots (Fig. 2). Wide confidence intervals were found for the pooled prevalence of eight symptoms (fatigue, asthenia, pain, anorexia, dyspnea, agitation, weight loss >10%, and cough). For one symptom (weight loss >10%), subgroup analyses could be done based on the cancer type.

gr2

Fig. 2 Forest plots of symptoms occurring in at least 50% of the patients. Logit transformation of the prevalence figures was applied. The final pooled logit was back transformed, resulting in pooled prevalence and 95% CIs.

Discussion

The purpose of this systematic review and meta-analysis was to identify the prevalence of symptoms in older cancer patients receiving palliative care. A rigorous method was applied to maximally reduce the risk of bias. In addition, the interrater reliability for screening of records was high between reviewers.

Thirty-two symptoms were identified. The most prevalent symptoms were fatigue, excretory symptoms, urinary incontinence, asthenia, pain, constipation, and anxiety and occurred in at least 50% of patients. None of the studies assessed nor reported prevalences on social and spiritual symptoms.

The results of the meta-analysis should be considered with caution. First, only two studies reported the use of valid and reliable instruments to collect symptom data. An unknown risk of instrument bias is likely to have occurred, and therefore, prevalence could have been estimated incorrectly. Many validated instruments exist to assess single symptoms in the older or cancer population. However, an instrument to assess multiple symptoms in older palliative care cancer patients is lacking. Therefore, the development and validation of an instrument that assesses symptoms on physical, psychological, social, and spiritual levels in older cancer patients receiving palliative care is recommended.32

Second, it should be noted that the 95% CIs of the prevalence rates are wide. The wide CIs in the individual studies could be explained by the small sample size (between 30 and 182 patients) and the inclusion of different cancer types in one sample.33 A pooled prevalence with a wide CI is related to the number of studies included in the meta-analysis and the heterogeneity among the included studies.33 In this review, few studies were included in the meta-analysis, and heterogeneity among studies was obvious. Moreover, even the size of combined samples remained rather small, ranging between 109 and 652 patients. Therefore, it is recommended to conduct more research on the prevalence of symptoms in an older palliative care cancer population with an appropriate sample size. The required sample size to estimate a prevalence of 50%, seen as the worst-case scenario, with a precision of 5% and a confidence limit of 95% is, on average, 400 participants.

Third, there is no clear and internationally accepted definition regarding the palliative care patient.34 In this review, no study provided a definition of palliative care, and therefore, it is unclear when patients were seen as being in the palliative phase. Most of the studies (n = 12) included patients with advanced cancer. These studies reported a median overall survival between 29 weeks26 and 25.9 months.31 In research, patients with advanced cancer are often referred to as palliative patients.35 and 36 This is in line with the recommendation to offer palliative care in the early course of illness.6 and 37 The remaining studies included incurable cancer patients (n = 1) and cancer patients in the palliative phase (n = 4). Consequently, the heterogeneity among patients in the studies included in the meta-analysis is likely.

Fourth, the majority of the symptoms were identified in the studies by Genz et al.19 and Teunissen et al.29 These two studies focused on older patients referred to a specialized geriatric palliative care unit and a palliative care team, respectively. No study included patients not referred to a specialized palliative care unit or palliative care team. Therefore, results could be less representative of daily practice as the literature has revealed that older patients are significantly less often referred to a palliative care unit or team.38 More research is needed on the prevalence of symptoms in older palliative cancer patients hospitalized on a general ward, in long-term care facilities, and not referred to a palliative care team.

Teunissen et al.8 conducted a systematic review on symptom prevalence in advanced cancer patients of all ages. Comparison between this systematic review and that by Teunissen et al.8 is difficult because the prevalences in the review by Teunissen at al. are based on at least five studies compared with few studies in this review. Moreover, Teunissen et al. regrouped different symptoms, which complicate the comparison. Therefore, comparison should be interpreted with caution. Twenty of the 32 symptoms identified in this review also were reported in the review by Teunissen et al. Five symptoms had a higher prevalence (>5% difference) in older patients compared with a younger population: constipation, anxiety, depressed mood, confusion, and diarrhea. Six symptoms had a lower prevalence (>5% difference) in older patients compared with a younger population: weight loss, decreased appetite, sleeplessness (compared with insomnia), dry mouth, cough, and hoarseness. The nine remaining symptoms were equally prevalent (<5% difference) in older and younger patients: fatigue, pain, nausea, dyspnea, vomiting, urinary problems, drowsiness, sore mouth, and dysphagia. In both reviews, fatigue, pain, and depressed mood were among the most prevalent symptoms, and a sore mouth, hoarseness, and confusion were among the least prevalent.

The current systematic review also indicates that older palliative cancer patients suffer from a variety of symptoms as the prevalence of most symptoms was high. To optimize care for palliative care patients, international and national organizations have already published different guidelines on the control of multiple symptoms.39, 40, and 41 However, these guidelines are often developed for a large population and are not focused on the older person. The care for older patients is complex as these patients are often confronted with multiple chronic pathologies, comorbidities, polypharmacy, disability, frailty, and psychosocial problems.12 Therefore, when implementing these guidelines, health care facilities and professionals should take the complexity of care for older patients into account.

Conclusion

Thirty-two symptoms were identified in this systematic review. The most prevalent symptoms were fatigue, excretory symptoms, urinary incontinence, asthenia, pain, constipation, and anxiety and occurred in at least 50% of the patients. There is a high degree of uncertainty about the identified prevalences because of small sample sizes, high heterogeneity among the studies, and the extent of instrument validation. Further rigorous research is needed to be able to make more precise conclusions. First, valid and reliable instruments should be developed and used to assess symptom prevalence. Second, results should be based on larger sample sizes.

Disclosures and Acknowledgments

No funding was received for this systematic review, and there are no financial conflicts of interest associated with this article.

References

  • 1 J. Ferlay, H.R. Shin, F. Bray, et al. Estimates of worldwide burden of cancer in 2008: GLOBOCAN 2008. Int J Cancer. 2010;127:2893-2917
  • 2 J. Ferlay, D.M. Parkin, E. Steliarova-Foucher. Estimates of cancer incidence and mortality in Europe in 2008. Eur J Cancer. 2010;46:765-781
  • 3 V.N. Anisimov, E. Sikora, G. Pawelec. Relationships between cancer and aging: a multilevel approach. Biogerontology. 2009;10:323-338
  • 4 E. Davies, I.J. Higginson (Eds.) Better palliative care for older people (World Health Organization Regional Office for Europe, Copenhagen, 2004) http://www.euro.who.int/__data/assets/pdf_file/0009/98235/E82933.pdf Available from:Accessed April 18, 2012
  • 5 J.H. Von Roenn, J. Temel. The integration of palliative care and oncology: the evidence. Oncology (Williston Park). 2011;25:1258-1260
  • 6 E. Bruera, D. Hui. Integrating supportive and palliative care in the trajectory of cancer: establishing goals and models of care. J Clin Oncol. 2010;28:4013-4017
  • 7 S. Gilbertson-White, B.E. Aouizerat, T. Jahan, C. Miaskowski. A review of the literature on multiple symptoms, their predictors, and associated outcomes in patients with advanced cancer. Palliat Support Care. 2011;9:81-102
  • 8 S.C. Teunissen, W. Wesker, C. Kruitwagen, et al. Symptom prevalence in patients with incurable cancer: a systematic review. J Pain Symptom Manage. 2007;34:94-104
  • 9 E.A. Laugsand, S. Kaasa, F. de Conno, G. Hanks, P. Klepstad, Research Steering Committee of the EAPC. Intensity and treatment of symptoms in 3,030 palliative care patients: a cross-sectional survey of the EAPC Research Network. J Opioid Manag. 2009;5:11-21
  • 10 G. Bugeja, A. Kumar, A.K. Banerjee. Exclusion of elderly people from clinical research: a descriptive study of published reports. BMJ. 1997;315:1059
  • 11 M.E. McMurdo, M.D. Witham, N.D. Gillespie. Including older people in clinical research. BMJ. 2005;331:1036-1037
  • 12 C.A. Depp, D.V. Jeste. Definitions and predictors of successful aging: a comprehensive review of larger quantitative studies. Am J Geriatr Psychiatry. 2006;14:6-20
  • 13 J.A. Bell, F.E. May, R.B. Stewart. Clinical research in the elderly: ethical and methodological considerations. Drug Intell Clin Pharm. 1987;21:1002-1007
  • 14 J.P. Higgins, S.G. Thompson, J.J. Deeks, D.G. Altman. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557-560
  • 15 O. Altundag, D.J. Stewart, F.V. Fossella, et al. Many patients 80 years and older with advanced non-small cell lung cancer (NSCLC) can tolerate chemotherapy. J Thorac Oncol. 2007;2:141-146
  • 16 B. Biesma, A.N. Wymenga, A. Vincent, et al. Quality of life, geriatric assessment and survival in elderly patients with non-small-cell lung cancer treated with carboplatin-gemcitabine or carboplatin-paclitaxel: NVALT-3 a phase III study. Ann Oncol. 2011;22:1520-1527
  • 17 P. Comella, A. Gambardella, G. Frasci, A. Avallone, R. Costanzo, SICOG investigators. Comparison of the safety and efficacy of paclitaxel plus gemcitabine combination in young and elderly patients with locally advanced or metastatic non-small cell lung cancer. A retrospective analysis of the Southern Italy Cooperative Oncology Group trials. Crit Rev Oncol Hematol. 2008;65:164-171
  • 18 J. Feliu, A. Salud, P. Escudero, et al. XELOX (capecitabine plus oxaliplatin) as first-line treatment for elderly patients over 70 years of age with advanced colorectal cancer. Br J Cancer. 2006;94:969-975
  • 19 H. Genz, E. Jenetzky, K. Hauer, P. Oster, M.H. Pfisterer. Palliative geriatrics. What are the differences between oncologic and non-oncologic palliative geriatric inpatients?. Z Gerontol Geriatr. 2010;43:369-375 [in German]
  • 20 S. Kudoh, K. Takeda, K. Nakagawa, et al. Phase III study of docetaxel compared with vinorelbine in elderly patients with advanced non-small-cell lung cancer: results of the West Japan Thoracic Oncology Group Trial (WJTOG 9904). J Clin Oncol. 2006;24:3657-3663
  • 21 C.J. Langer, J. Manola, P. Bernardo, et al. Cisplatin-based therapy for elderly patients with advanced non-small-cell lung cancer: implications of Eastern Cooperative Oncology Group 5592, a randomized trial. J Natl Cancer Inst. 2002;94:173-181
  • 22 H. LeCaer, F. Barlesi, R. Corre, et al. A multicentre phase II randomised trial of weekly docetaxel/gemcitabine followed by erlotinib on progression, vs the reverse sequence, in elderly patients with advanced non small-cell lung cancer selected with a comprehensive geriatric assessment (the GFPC 0504 study). Br J Cancer. 2011;105:1123-1130
  • 23 J. Li, P. Chen, C.-H. Dai, X.-Q. Li, Q.-L. Bao. Prognostic factors in elderly patients with advanced non-small cell lung cancer treated with chemotherapy. Oncology. 2009;76:355-362
  • 24 M. Lloyd-Williams. Is it appropriate to screen palliative care patients for depression?. Am J Hosp Palliat Care. 2002;19:112-114
  • 25 I. Maestu, L. Gómez-Aldaravi, M.D. Torregrosa, et al. Gemcitabine and low dose carboplatin in the treatment of elderly patients with advanced non-small cell lung cancer. Lung Cancer. 2003;42:345-354
  • 26 I. Maestu, J. Muñoz, L. Gómez-Aldaravi, et al. Assessment of functional status, symptoms and comorbidity in elderly patients with advanced non-small-cell lung cancer (NSCLC) treated with gemcitabine and vinorelbine. Clin Transl Oncol. 2007;9:99-105
  • 27 E. Paillaud, P. Caillet, B. Campillo, P.N. Bories. Increased risk of alteration of nutritional status in hospitalized elderly patients with advanced cancer. J Nutr Health Aging. 2006;10:91-95
  • 28 W.-H. Su, E.-T. Yeh, H.-W. Chen, M.-H. Wu, Y.-L. Lai. Fatigue among older advanced cancer patients. Int J Gerontol. 2011;5:84-88
  • 29 S.C. Teunissen, H.C. de Haes, E.E. Voest, A. de Graeff. Does age matter in palliative care?. Crit Rev Oncol Hematol. 2006;60:152-158
  • 30 N. Yoshimura, S. Kudoh, T. Kimura, et al. Phase II study of docetaxel and carboplatin in elderly patients with advanced non-small cell lung cancer. J Thorac Oncol. 2009;4:371-375
  • 31 O. Trédan, J.F. Geay, S. Touzet, et al. Carboplatin/cyclophosphamide or carboplatin/paclitaxel in elderly patients with advanced ovarian cancer? Analysis of two consecutive trials from the Groupe d'Investigateurs Nationaux pour l'Etude des Cancers Ovariens. Ann Oncol. 2007;18:256-262
  • 32 D.F. Polit, C.T. Beck. Nursing research. Generating and assessing evidence for nursing practice. 8th ed. (Lippincott Williams & Wilkins, Philadelphia, 2008)
  • 33 J.P. Higgins, S. Green. Cochrane handbook for systematic reviews of interventions (v. 5.1.0 [updated March 2011]). (The Cochrane Collaboration, 2011) http://www.cochrane-handbook.org Available from:Accessed April 18, 2013
  • 34 W. Van Mechelen, B. Aertgeerts, K. De Ceulaer, et al. Defining the palliative care patient: a systematic review. Palliat Med. 2013;27:197-208
  • 35 I.J. Higginson, M. Costantini. Dying with cancer, living well with advanced cancer. Eur J Cancer. 2008;44:1414-1424
  • 36 O. Minton, F. Strasser, L. Radbruch, P. Stone. Identification of factors associated with fatigue in advanced cancer: a subset analysis of the European palliative care research collaborative computerized symptom assessment data set. J Pain Symptom Manage. 2012;43:226-235
  • 37 T.J. Smith, S. Temin, E.R. Alesi, et al. American Society of Clinical Oncology provisional clinical opinion: the integration of palliative care into standard oncology care. J Clin Oncol. 2012;30:880-887
  • 38 J. Burt, R. Raine. The effect of age on referral to and use of specialist palliative care services in adult cancer patients: a systematic review. Age Ageing. 2006;35:469-476
  • 39 A. Caraceni. The EPCRC project to revise the European Association for Palliative Care (EAPC) guidelines on the use of opioids for cancer pain. Palliat Med. 2011;25:389-390
  • 40 L. Rayner, A. Price, M. Hotopf, I.J. Higginson. The development of evidence-based European guidelines on the management of depression in palliative cancer care. Eur J Cancer. 2011;47:702-712
  • 41 Vanden Eynde J, Delaruelle A. Nausea and vomiting in palliative care [in Dutch]. 2010. Available from: http://www.pallialine.be. Accessed December 20, 2012.

Footnotes

a Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium

b Department of Geriatric Medicine, University Hospital Ghent, Ghent, Belgium

c Nursing Science, University Hospital Ghent, Ghent, Belgium

d Belgian Interuniversity Collaboration of Evidence-Based Medicine (BICEP), Belgian Center for Evidence-Based Medicine, Catholic University of Leuven, Leuven, Belgium

Address correspondence to: Aurélie Van Lancker, MSc, RN, Nursing Science, Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, UZ 2 Blok A, De Pintelaan 185, 9000 Ghent, Belgium.


Search this site

Stay up-to-date with our monthly e-alert

If you want to regularly receive information on what is happening in Quality of Life in Oncology research sign up to our e-alert.

Subscribe »

QOL (Quality of Life) newsletter e-alert

NEW! Free access to the digital version of a new publication in Cancer Supportive Care


Cancer cachexia: mechanisms and progress in treatment

Authors: Egidio Del Fabbro, Kenneth Fearon, Florian Strasser

This book was supported by an educational grant from Helsinn Healthcare SA.

Featured videos

Quality of Life promotional video

Made possible by an educational grant from Helsinn

Helsinn does not have any influence on the content and all items are subject to independent peer and editorial review

Society Partners

European Cancer Organisation Logo

Share