Cancer Epidemiology 51 (2017) 30–34

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Cancer Epidemiology
journal homepage: www.elsevier.com/locate/canep

Original Research Article

Self-rated health and associated factors in elderly patients with non-Hodgkin MARK
lymphoma
⁎
Lívia Maria Santiagoa,b, , Daniel Richard Mercanteb, Inês Echenique Mattosb
a
Federal University of Rio de Janeiro, Rua Rodolpho Paulo Rocco, 255/room 9E11, Cidade Universitária, Zip Code 21941- 913, Rio de Janeiro, RJ, Brazil
b
National School of Public Health/Oswaldo Cruz Foundation, Rua Leopoldo Bulhões, 1480/room 817b, Manguinhos, Zip Code 21041-210 Rio de Janeiro, RJ, Brazil

A R T I C L E I N F O A B S T R A C T

Keywords: Background: Self-rated health is a useful indicator for understanding health issues in elderly populations and
Self-rated health considered to be a predictor of adverse health outcomes in this group. This study aims to identify factors as-
Non-Hodgkin’s lymphoma sociated with self-rated health in elderly people with non-Hodgkin’s lymphoma.
Elderly patients Methods: Cross-sectional study performed at a cancer referral hospital in Rio de Janeiro, Brazil, included 162
patients, aged 60 or more years. All patients received a Multidimensional Geriatric Assessment, including seven
health dimensions, and socio-demographic, epidemiological and it were collected clinical data. Descriptive
analyses were performed and prevalence ratios were calculated to assess associations between self-rated health
and the independent variables. Multivariate analysis was performed using Poisson’s regression, to a ≤0.05 level
of statistical significance.
Results: The study population mean age was 68.8 (SD = 7.1) years; most were women, lived with a partner and
had little education. Prevalence of fair/poor self-rated health was 33.6%. Being female, not living with a partner,
functional dependence, depressive symptoms and nutritional risk/malnutrion showed associations with fair/
poor self-rated health. In the multiple model, dependence in instrumental activities of daily living (PR 2.96;
95%CI 1.66-5.30) and presence of depressive symptoms (PR 1.78; 95%CI 1.15-2.75) remained associated with
fair/poor health.
Conclusion: Variation in perceived health status supports the hypothesis that self-rated health is related to
multiple issues, regardless of disease status. The risk profile for poor self-rated health identified may be a useful
tool in care for older cancer patients, as it points to those at higher risk of adverse health outcomes.

1. Introduction an important predictor of treatment tolerance and mortality in elderly

Self-rated (SRH) is a useful indicator for understanding health issues
in elderly populations and is considered an independent predictor of
adverse health outcomes in this group [1–4]. This measure represents a
perception by subjects themselves, based on their interpretations of
physical and mental status and their expectations and benchmarks for
comparison [5].
Studies have shown many factors associated with SRH among the
elderly, including socio-demographic variables, social support, lifestyle,
health and access to health services [6–9]. Self-reported health is also
believed to associate with populations’ cultural values [10].
Although most studies in the literature on self-rated health consider
overall health in community-dwelling elderly people, some studies do
report on specific chronic diseases, including cancer [4,11–13]. Poor
self-rated health was identified, over a seven-year follow-up period, as
women with breast cancer [14]. It was also associated with an in-
creasing number of comorbidities during treatment period among el-
derly patients with solid tumours or haematological cancer [4,13].
Non-Hodgkin’s lymphoma is a frequent haematological neoplasm in
the elderly. In 2012, mean age at diagnosis for non-Hodgkin’s lym-
phoma in the United States was 67 years [15]. In the United Kingdom,
individuals 60 or more years old constituted two thirds of cases diag-
nosed [16]. With advancing age, incidence of non-Hodgkin’s lymphoma
has been observed to increase constantly, independently of sex and race
[17–19]. Although the literature demonstrates that world rates of in-
cidence and mortality for various types of cancer have declined in re-
cent decades, non-Hodgkin’s lymphoma rates continues to show growth
[17], for as yet unknown reasons [16].
This study aimed to identify factors associated with self-rated health
in elderly people with non-Hodgkin’s lymphoma in the city of Rio de

⁎
Corresponding author at: National School of Public Health/Oswaldo Cruz Foundation, Rua Leopoldo Bulhões, 1480/room 817b, Manguinhos, Zip Code 21041-210 Rio de Janeiro, RJ,
Brazil.
E-mail addresses: liviamsantiago@gmail.com (L.M. Santiago), danielmercante@grupocoi.com.br (D.R. Mercante), imattos@ensp.fiocruz.br (I.E. Mattos).

http://dx.doi.org/10.1016/j.canep.2017.10.002
Received 23 June 2017; Received in revised form 26 September 2017; Accepted 1 October 2017
1877-7821/ © 2017 Elsevier Ltd. All rights reserved.
L.M. Santiago et al. Cancer Epidemiology 51 (2017) 30–34

Janeiro, Brazil. Table 1

Characterisation of elderly patients with non-Hodgkin lymphoma, Rio de Janeiro, Brazil,
2013 (N = 162).
2. Material and methods
Variables N %
This cross-sectional study was conducted at a cancer referral hos-
pital in Rio de Janeiro, Brazil. From February to July 2013, 176 con- Self-rated health Excellent 29 19.1
Very good 18 11.8
secutive patients with non-Hodgkin’s lymphoma, 60 or more years old
Good 54 35.6
and treated in the outpatient hematologic clinic were contacted, if able Fair 44 28.9
to answer a structured questionnaire. Of those, the 162 who agreed to Poor 7 4.6
participate in the study underwent a Multidimensional Geriatric Gender Male 75 46.3
Assessment (MGA), including functional capacity, comorbidity, nutri- Female 87 53.7
tion, emotional condition, social support and use of medication. Data
Marital Status Married 91 56.2
was also collected on socio-demographic and clinical variables. Living with partner 7 4.3
The study was approved by the Research Ethics Committees of the Divorced/separated 18 11.1
National School of Public Health/Oswaldo Cruz Foundation and Widowed 31 19.1
Single 15 9.3
National Cancer Institute and was conducted in accordance to the
principles of the declaration of Helsinki. Education level Upper Secondary/Higher 52 32.5
Lower Secondary 91 56.9
Did not attend school 17 10.6
2.1. Measuring instruments
Functional Capacity in ADL Independent 136 84.5
Dependent 25 15.5
The MGA used comprised a set of selected instruments commonly
used for health assessment in elderly populations. Functional capacity Functional Capacity in IADL Independent 85 52.5
Dependent 77 47.5
in Basic Activities of Daily Living (ADL), and in Instrumental Activities
of Daily Living (IADL), were assessed on the Katz [20] and Lawton [21] Severe Comorbidity No 125 77,2
Yes 37 22,8
scales, respectively. For both scales, individuals were “dependent” if
they needed help or were unable to perform any activity. The Cumu- Polypharmacy (4 or more regular No 108 66.7
lative Illness Scale-Geriatric (CIRS-G) was used to investigate co- medications) Yes 54 33.3

morbidity [22], and individuals were classified using an adapted ver- Depressive Symptoms No depressive symptoms 113 74.8
sion of the classification proposed by Rodriguez et al. [23]: no Mild depressive symptoms 29 19.2
Severe depressive 9 6.0
comorbidity (0 points), mild comorbidity (1–2 points), moderate co-
symptoms
morbidity (3–8 points) and severe comorbidity (> 8 points). Nutri-
Nutritional Risk No nutritional risk 83 53.9
tional status was evaluated by the short version of the Mini Nutritional
At nutritional risk 53 34.4
Assessment (MNA) [24] and patients were classified into no nutritional Malnourished 18 11.7
risk and nutritional risk/malnourished. The 15-item Geriatric Depres-
∗
sion Scale was chosen to evaluate emotional condition [25]; a score of Differences between absolute numbers are due to missing values.
five or more was considered indicative of depressive symptoms. Poly-
pharmacy was considered to be regular use of 4 or more medications while 34.4% were at nutritional risk (Table 1).
[26]. Being female (PR 1.75; 95%CI 1.07-2.85), living without a partner,
The dependent variable was the answer to the question “Compared dependence in Activities of Daily Living (ADL) and in Instrumental
to other people your age, how is your health?”. Although this question Activities of Daily Living (IADL), presence of depressive symptoms and
had five possible answers (excellent, very good, good, fair and poor), being at nutritional risk/malnourished all showed associations with
these were aggregated into two categories (Excellent/Very good/Good fair/poor self-rated health (Table 2).
and Fair/Poor), following the tendency observed in the literature, In the multiple model, functional dependence in IADL and presence
which indicates predominance of responses in the intermediate cate- of depressive symptoms were independent risk factors for self-rated
gories [27–29]. fair/poor health (Table 3).

2.2. Data analysis 4. Discussion

Descriptive analysis of the distribution of individuals into self-rated
health response groups, by study co-variable, was conducted using
measures of central tendency and dispersion for continuous variables,
and frequency distributions for categorical variables.
Prevalence ratios (PR) were calculated to assess associations be-
tween self-reported health and the independent variables, and multi-
variate analysis was performed using Poisson regression, to a ≤ 0.05
level of statistical significance.
Statistical analyses were performed using the statistical software
STATA, version 10.0 (StataCorp LP).
3. Results
Study population mean age was 68.8 (SD = 7.1) years, most were
women (53.7%), lived with a partner and had little formal education.
Self-rated health prevalences were 33.6% fair/poor (N = 51) and
66.4% good/very good/excellent (N = 101). Prevalence of dependence
in Instrumental Activities of Daily Living (IADL) was high (47.5%),
Self-rated health proves to be an important marker of the diversity
in aging and in the individual recognition of the concept of health at
this stage in life. This is reflected in the results of this study, in which a
population of elderly people with a diagnosis of haematological cancer,
fewer than 34% classified their health adversely. A similar value was
described in a study of 112 Canadians 65 years or more, with a diag-
nosis of solid (breast, colorectal or lung) tumours or haematological
cancer (lymphoma or myeloma), in which only 38 patients (33.9%)
rated their own health as poor [4]. In a study of 181 Australians with a
diagnosis of advanced-stage cancer, mean age 62 years (SD 12 years), it
was observed that 58% rated their own health as excellent, very good or
good, 28% as fair and only 14% as poor [30].
In the literature on health and aging, individuals who rated their
own health as fair or poor are observed to display a greater likelihood of
illness and death, independently of their objective health status
[1,3,31,32]. The claim appears to hold even when individuals with
cancer are rated. In a United States study, designed to assess self-rated
health as a variable indicative of health-adjusted life expectancy

31
L.M. Santiago et al. Cancer Epidemiology 51 (2017) 30–34

Table 2 likelihood of rating their own health as poor (OR 4.11; 95%CI 3.06-
Prevalence ratios for self-rated health status among elderly patients with non-Hodgkin 5.54), as compared with cancer survivors who did not mention other
lymphoma, Rio de Janeiro, Brazil, 2013 (N = 162).
adverse health conditions [11]. This result draws attention to the im-
Variables Excellent/Very Fair/Poor Crude Prevalence portance of comorbidity in the individual experience of cancer in older
good/Good N (%) Ratios patients.
N (%) (95%CI) Similar to what was seen in this study, other research has found that
self-rated health displays an association with functional dependence
Gender
Male 54 (53.5) 17 (33.3) 1 [34,35]. In a study of 2135 elderly in the municipality of São Paulo,
Female 47 (46.5) 34 (66.7) 1.75 (1.07–2.85) Brazil, presence of functional incapacity in Instrumental Activities of
Marital Status
Daily Living (IADL) was found to associate with high risk (OR 2.50,
Married/Living with 67 (66.3) 24 (47.1) 1 p < 0.01) of poor self-rated health and, when incapacity in IADL was
partner assessed jointly with incapacity in ADL, the risk was even greater (OR
Divorced/Separated/ 34 (33.7) 27 (52.9) 1.68 (1.07–2.61) 2.66, p < 0.01) [34]. Among Canadians 55 or more years old, the
Widowed/Single
predictors of poor self-rated health observed were the presence of
Educational level limitations without functional dependence (OR 1.9; 95%CI 1.2-1.9) and
Upper Secondary/ 38 (38.4) 13 (25.5) 1
with functional dependence (OR 2.8; 95%CI 1.8-4.6), in addition to
University
Lower Secondary 52 (52.5) 33 (64.7) 1.52 (0.89–2.61) male sex, psychological stress and chronic diseases, low level of
Did not attend school 9 (9.1) 5 (9.8) 1.40 (0.60–3.26) schooling and income, in a model fitted for all these variables [35].
Functional Capacity in ADL
The relation between SRH and depressive symptoms observed in
Independent 94 (93.1) 40 (80.0) 1 this study has also been described in the scientific literature on aging.
Dependent 7 (6.9) 10 (20.0) 1.97 (1.22–3.17) SRH can be found in the long list of predictors of depressive sympto-
Functional Capacity in IADL matology, among other factors such as loneliness, sensory function
Independent 71 (70.3) 13 (25.5) 1 deficits, cardiac and other chronic diseases and functional dependence
Dependent 30 (29.7) 38 (74.5) 3.61 (2.10–6.21) [36]. Among 3187 Japanese aged 65 years or older in the city of Ta-
Comorbidity in severity categories 3 and 4 katsuki, absence of depressive symptoms, assessed by the Geriatric
No 79 (78.2) 40 (78.4) 1 Depression Scale (GDS), represented a higher likelihood of good self-
Yes 22 (21.8) 11 (21.6) 1.00 (0.57–1.71) rated health (OR 2.43; 95%CI 2.01-2.94) in a model adjusted for age,
Polypharmacy (4 or more regular medications) sex and variables related to health and disability [37]. In a study of 462
No 72 (71.3) 31 (60.8) 1 elderly living in long-stay institutions across four Brazilian munici-
Yes 29 (28.7) 20 (39.2) 1.35 (0.87–2.12)
palities, the variable showing the strongest association with depressive
Depressive Symptoms symptoms was poor self-rated health (PR 1.47; 95%CI 1.31-1.66), fol-
No depressive symptoms 85 (85.9) 27 (54.0) 1
lowed by comorbidities (PR 1.34; 95%CI 1.09-1.65), hospitalizations
Depressive symptoms 14 (14.1) 23 (46.0) 2.58 (1.70–3.90)
(PR 1.26; 95%CI 1.04-1.54) and lack of friends at the institution (PR
Nutritional Risk
1.24; 95%CI 1.03-1.49) [38]. In a study of 600 community-dwelling
No nutritional risk 61 (63.5) 21 (43.8) 1
At nutritional risk/ 35 (36.5) 27 (56.3) 1.70 (1.07–2.71)
older individuals, depressive symptoms also showed the strongest as-
Malnourished sociation, after adjustment, with poor self-rated health (OR 6.57;
p < 0.001), followed by the need for caregiver support (OR 3.87;
p < 0.001) [39].
Table 3 Conspicuous among the socio-demographic variables related to self-
Poisson multiple regression model for self-rated health among elderly patients with non- rated health in the elderly are sex and marital status, which are com-
Hodgkin lymphoma, Rio de Janeiro, Brazil, 2013 (N = 162).
monly cited in the literature. In a study of 1505 individuals aged 60
Variables Adjusted Prevalence ratios* years or more, the women were more likely (OR 2.02; 95%CI 1.48-2.76)
(95%CI) than the men to rate their own health as poor/very poor [6], which is
similar to what was found in this study. On the other hand, in a Bra-
Functional Capacity in IADL (dependent) 2.96 (1.66–5.30)
zilian study based on the 2003 National Household Sample Survey, a
Depressive Symptoms (yes) 1.78 (1.15–2.75)
negative association was found between female sex and poor self-rated
* Adjusted for all variables in the model. health (OR 0.85; 95%CI 0.77-0.92), in a model including the variables
age group, education, number of chronic conditions, number of medical
(HALE), of 144 men, aged 50 years or more, with a recent diagnosis of appointments in the past year and hospital admission during the study
localised prostate cancer, life expectancy based on self-rated health was period [40]. In the study by Shooshtari et al. [35], with 3107 Canadians
observed to be on average two years greater than age-based life ex- aged 55 or more years, male sex was identified as a predictor of poor
pectancy, independently of race, family income and PSA level [30]. self-rated health (OR 1.9; 95%CI 1.3-2.8) in a model adjusted for other
Few studies in the literature were found to examine factors asso- socio-demographic and health variables. In the Japanese study by Sun
ciated with self-rated health in individuals with cancer. Accordingly, et al. [37], a response differential was observed among individuals aged
the results of this study were also compared with the literature on 65 to 74 years, with health self-rated positively more often by the
aging. women, which did not occur in the 75 or more year age group.
There are different instruments to evaluate comorbidity in cancer As regards marital status, Lima-Costa et al. [6] also found sepa-
patients [33] and the most used are the Charlson Comorbidity Index rated/divorced individuals as a group were more likely to self-rate their
and the Cumulative Illness Rating Scale – Geriatric (CIRS-G). We health adversely (OR 2.18; 95%CI 1.15-4.16). In a study of 2143 elderly
decided to use CIRS-G as it was designed to analyze comorbidity in Brazilians, those who were separated/divorced were more likely to rate
elders and it is a frequently used instrument in geriatric oncology stu- their health as poor (OR 1.08; p < 0.01) in a model that also con-
dies. Gallicchio et al. [11] studied 1261 cancer survivors to evaluate the templated sex, functional dependence, levels of schooling and income
relationship between adverse health conditions unrelated to cancer, [34]. In a study of 729 North American women, users of primary health
self-rated health and functional capacity. Cancer survivors who men- care services, 37.0% of whom were aged 65 years or more, it was in this
tioned two or more adverse health conditions displayed far greater age group that observed that health was self-rated positively least often
(78.6%) and that marital status was associated with self-rated health, in

32
L.M. Santiago et al.
that single or divorced women (OR 0.38; 95%CI 0.20-0.74) and widows
(OR 0.61; 95%CI 0.32-1.16) were less likely than married women to
rate their own health as good [41].
Given that there is a wide range of kinds of aging and that the
impact of emotional factors brought on by the inability to manage
oneself and perform everyday functions can overshadow objective
health issues, considering only chronological age and disease char-
acteristics when choosing therapeutic conducts and regimes can lead to
non-individualise treatment and unfavourable prognoses [42,43]. Stu-
dies to evaluate variables that can influence prognosis in elderly with a
diagnosis of cancer can contribute to establishing more singular and
effective treatment protocols, thus fostering better prognoses [15].
There is a vast literature on the role of self-rated health in aging,
while few studies address specifically elderly with cancer. This study is
the first investigation of self-rated health in elderly patients with cancer
in Brazil, and is also pioneering in addressing the factors associated
with it in this population.
5. Conclusion
Our results support the hypothesis that the self-assessment of one’s
health is related to multiple issues and does not depend on disease
status. The risk profile identified in this study points to the older pa-
tients at higher risk of adverse health outcomes. As self-rated health
consists in an objective question, easily answered, we recommend its
use in the oncologic care setting as part of the clinical evaluation of
older patients.
Authors’ contribution
Lívia Maria Santiago: Guarantor of study integrity, study concept,
study design, literature research, data analysis and manuscript pre-
paration.
Daniel Richard Mercante: Guarantor of study concept and literature
research, and manuscript edition/review.
Inês Echenique Mattos: Guarantor of study concept, study design,
definition of intellectual content, data analysis, manuscript edition/
review.
Funding
This work was supported by the Carlos Chagas Filho Foundation for
Research Support of the State of Rio de Janeiro (FAPERJ). The FAPERJ
did not have any role in the preparation or decision to submit this
manuscript.
Conflict of interest statement
The authors declare no conflicts of interests.
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