1. F UNCTIONAL L IMITATIONS IN C ANCER S URVIVORS A MONG E LDERLY M EDICARE B ENEFICIARIES Prachi P. Chavan, MD, MPH Epidemiology PhD Student Xinhua Yu MD PhD, Satish Kedia PhD University of Memphis, School of Public Health

2. Background An estimated 11.1 million cancer patients present in the United States survive for one or more years after cancer diagnosis/treatment (cancer survivors). Comorbidities and psycho-social impairments add complexity in caring for long term cancer survivors. About 52% of elderly adults ≥ 65 years have at least one disability. A large proportion of cancer survivors has functional limitations which affects their quality of life. Functional limitations also increases their dependence on caregivers.

3. Purpose Aim: To examine the differences in and determinants of functional limitations between cancer survivors and non cancer elderly people. Hypothesis: Functional limitations are significantly higher among cancer survivors compared to non cancer patients. Primary outcome: Severity of physical, social, and personal functional limitations among the cancer survivors.

4. Study Cohort The Medicare Current Beneficiary Survey (MCBS) data from 2006 to 2009 with patients >=65 years of age MCBS is a nationally representative longitudinal survey. The survey is conducted 3 times a year over 3 years to track changes in health and healthcare use. One third of participants are rotated out of the study each Fall. The individual’s functional status is evaluated once a year during the Fall survey. The total sample consists of 15,601 beneficiaries.

5. Methods Physical, social, and personal functional status was measured with standard questionnaires in the MCBS survey. Each functional limitation domain included five items, and each item was measured on a five point scale. Answers with “a lot of difficulty” or “not able to do it” were considered as having “functional limitation”. Functional limitation for the domain is defined as having two or more (out of five) functional limitation items. Descriptive statistics and logistic regressions were weighted by cross-sectional survey weights.

6. Demographic Characteristics Characteristics Cancer Survivors n= 2,759 (%) Non-cancer patients n=12,842 (%) P-value Age >=65 to < 75 years1,054 (38)6,215 (48) <0.0001 >=75 to < 85 years1,172 (42)4,663 (36) >=85 years533 (19)1,964 (15) Gender Male1,246 (45)5,581 (43)0.102 Female1,513 (54)7,261 (56) Ethnicity Caucasian2,495 (90)11,020 (85) <0.0001 African American177 (6)1,138 (8) Other87 (3)684 (5) Income (per year) <15,000663 (24)3,496 (27) 0.002 >=15,000 to <=30,000965 (34)4,342 (33) >=30,0001,131 (40)5,004 (38)

7. Physical Limitations at Baseline Functional Limitations Cancer Survivors n=2,759 (%) Non-cancer patients n=12,842 (%) χ 2, P-value Physical limitations Yes791 (28)3,154 (24) <0.0001 No1,968 (71)9,688 (75) Difficulty stooping Yes979 (35)3,877 (30)<0.0001 No1,780 (64)8,965 (69) Difficulty walking Yes 848 (30)3,369 (26)<0.0001 No 1,911 (69)9,473 (73) Difficulty reaching Yes 289 (10)1,049 (8) <0.0001 No 2,470 (89)11,793 (91) Difficulty lifting Yes 517 (18)2,061 (16)0.0008 No 2,242 (81)10,773 (83) Difficulty writing Yes 165 (6)758 (5)0.87 No2,594 (94)12,084 (94)

8. Social Limitations at Baseline Functional LimitationsCancer Survivors n= 2,759 (%) Non-cancer patients n=12,842 (%) χ 2, P-value Social limitations Yes400 (14)1,522 (11)0.0001 No2,359 (85)11,320 (88) Problem using telephone Yes200 (7)808 (6) 0.06 No2,559 (93)12,034 (94) Problem doing housework Yes250 (9)984 (7)0.01 No2,509 (91)11,858 (92) Problem preparing meals Yes200 (7)783 (6)0.02 No2,559 (93)12,059 (94) Problem shopping Yes309 (11)1,199 (9)0.002 No2,450 (89)11,643 (90) Problem paying bills Yes142 (5)561 (4)0.07 No2,617 (95)12,281 (95)

9. Personal Limitations at Baseline Functional LimitationsCancer Survivors n= 2,759 (%) Non-cancer patients n= 12,842 (%) χ 2, P-value Personal Limitations Yes474 (17)1,838 (14)0.0001 No2,285 (83)11,004 (85) Help with bathing Yes328 (12)1,258 (10)0.001 No2,431 (88)11,584 (90) Help with dressing Yes188 (6)835 (6)0.548 No2,571 (93)12,007 (93) Help with eating Yes70 (2)277 (2)0.21 No2,689 (97)12,565 (98) Help with walking Yes746 (27)2,959 (23)<0.0001 No2,013 (73)9,883 (77) Help with using toilet Yes154 (5)613 (5)0.07 No2,605 (94)12,229 (95)

10. Determinants of Functional Limitations at Baseline Adjusted Odds Ratio (Confidence Interval) Determinants Physical limitation Social limitation Personal limitation Cancer Survivors vs. Non-cancer 1.31 (1.15 – 1.48)1.36 (1.18 – 1.58)1.30 (1.41 – 1.50) Age (ref: >=65 to < 75 years) -- >=75 to < 85 years 1.68 (1.53 – 1.84)1.66 (1.46 – 1.89)1.86 (1.65 – 2.10) >=85 years 3.53 (3.10 – 4.03)2.99 (2.61 – 3.43)3.75 (3.30 – 4.26) Female vs. male 0.65 (0.58 – 0.72)0.68 (0.59 – 0.78)0.72 (0.63 – 0.81) African Americans vs. Caucasians 0.99 (0.83 – 1.19)1.17 (0.95 – 1.45)1.09 (0.93 – 1.27) Income (ref: <15,000 per year) -- >=15,000 to <=30,000 0.65 (0.58 – 0.73)0.67 (0.57 – 0.80)0.69 (0.60 – 0.79) >=30,000 0.34 (0.30 – 0.39)0.35 (0.30 – 0.42)0.45 (0.39 – 0.53) Model included all the variables.

11. Physical Functional Limitations over Follow-up years Adjusted by age, race, sex, and income

12. Personal and Social Functional Limitations over Follow up years Adjusted by age, race, sex, and income

13. Conclusions Cancer survivors had more physical, social, and personal limitations at baseline and over the follow-up years compared to non cancer patients. Physical limitations affected social and personal limitations, significantly more among cancer survivors than people without cancer at baseline (interaction p = 0.01). Physical limitations at baseline were found to aggravate social and personal limitations in the follow-up years. Cancer survivors developed functional limitations earlier than people without cancer, with larger differences in limitations at baseline compared to follow-up years.

14. Discussion Cancer survivors contribute to a very large percentage of the elderly population. Cancer survivors experience various physical, emotional, and social difficulties which make their daily life challenging. Cancer and associated treatments may increase the risk of functional limitations among cancer survivors. Cancer survivors suffer disproportionately more functional limitations compared to non cancer patients.

15. Public Health Implications The burden of complicated treatments among cancer survivors may hinder their care for other comorbidities and functional limitations. A well coordinated and comprehensive care plan should be developed for elderly cancer survivors. Healthcare providers should pay particular attention to the additional health needs of the cancer survivors. With growing number of cancer survivors, targeted interventions should be developed and implemented to address functional limitations.

16. Thank You Acknowledgement: Dr. Xinhua Yu, Division of Epidemiology, Biostatistics, and Environmental Health Dr. Satish Kedia, Division of Social & Behavioral Sciences School of Public Health, University of Memphis