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Disability in activities of daily living among adults with cancer: A systematic review and meta-analysis

  • Josephine Neo
    Correspondence
    Corresponding authors at: Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Denmark Hill, London, SE5 9PJ, UK. (M. Maddocks). Occupational Therapy Department, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore, (J. Neo).
    Affiliations
    Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore

    Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Denmark Hill, London SE5 9PJ, United Kingdom
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  • Lucy Fettes
    Affiliations
    Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Denmark Hill, London SE5 9PJ, United Kingdom
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  • Wei Gao
    Affiliations
    Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Denmark Hill, London SE5 9PJ, United Kingdom
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  • Irene J. Higginson
    Affiliations
    Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Denmark Hill, London SE5 9PJ, United Kingdom
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  • Matthew Maddocks
    Correspondence
    Corresponding authors at: Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Denmark Hill, London, SE5 9PJ, UK. (M. Maddocks). Occupational Therapy Department, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, 308433, Singapore, (J. Neo).
    Affiliations
    Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, Denmark Hill, London SE5 9PJ, United Kingdom
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Open AccessPublished:October 28, 2017DOI:https://doi.org/10.1016/j.ctrv.2017.10.006

      Highlights

      • Activities of Daily Living (ADLs) are essential to live independently within society.
      • One-third of adults with cancer have difficulty performing basic ADLs.
      • Half of adults with cancer require assistance to perform instrumental ADLs.
      • The most commonly affected ADLs include walking and transfers, housework, shopping and transportation.

      Abstract

      Introduction

      People with cancer frequently report limitation in Activities of Daily Living (ADLs); essential activities required to live independently within society. Although several studies have assessed ADL related disability, variability in assessment, setting, and population means evidence is difficult to interpret. We aimed to determine the prevalence of ADL related disability, overall and by setting, and the most commonly affected ADLs in people living with cancer.

      Methods

      We searched twelve databases to June 2016 for observational studies assessing ADL disability in adults with cancer. Data on study design, population, ADL instruments and disability (difficulty with or requiring assistance in ≥1 activity) were extracted, summarised, and pooled to estimate disability prevalence with 95% confidence intervals (95% CI) overall and by setting.

      Results

      Forty-three studies comprising 19,246 patients were included. Overall, 36.7% (95% CI 29.8–44.3, 18 studies) and 54.6% (95% CI 46.5–62.3, 15 studies) of patients respectively reported disability relating to basic and instrumental ADLs. Disability was marginally more prevalent in inpatient compared to outpatient settings. The Katz Index (18 studies) and Lawton IADL Scale (11 studies) were the most commonly used instruments. Across the activities studied, the most frequently affected basic ADLs were personal hygiene, walking and transfers, and instrumental ADLs were housework, shopping and transportation.

      Conclusions

      About one-third and half of adults with cancer respectively have difficulty or require assistance to perform basic and instrumental ADLs. These findings highlight the need for rehabilitation focused on functional independence, and underscore the importance of professionals skilled in occupational assessment and therapy within cancer services.

      Keywords

      Introduction

      With advances in screening and therapies, people are increasingly living longer with the consequences of cancer and its treatment. Patients with cancer frequently report a sustained symptom burden, exercise intolerance, and physical deconditioning, all of which can threaten everyday independence [
      • Silver J.K.
      • Baima J.
      • Mayer R.S.
      Impairment-driven cancer rehabilitation: an essential component of quality care and survivorship.
      ]. Activities of daily living (ADLs) refer to the essential activities an individual is required to perform to live independently within society [
      • Covinsky K.
      Aging, arthritis, and disability.
      ,

      Fricke J. Activities of daily living. In: Stone JH, Blouin M, editors. International encyclopedia of rehabilitation; 2010.

      ]. Activities are categorized into basic ADLs; referring to personal care activities such as feeding, toileting, washing, and dressing, as well as instrumental ADLs; referring to extended tasks such as meal preparation, using public transportation, doing household chores, and grocery shopping [
      • Fillenbaum G.G.
      • Smyer M.A.
      The development, validity, and reliability of the OARS multidimensional functional assessment questionnaire.
      ,
      • Katz S.
      • Ford A.B.
      • Moskowitz R.W.
      • Jackson B.A.
      • Jaffe M.W.
      Studies of illness in the aged. The index of adl: a standardized measure of biological and psychosocial function.
      ,
      • Lawton M.P.
      • Brody E.M.
      Assessment of older people: self-maintaining and instrumental activities of daily living.
      ,
      • Verbrugge L.M.
      • Jette A.M.
      The disablement process.
      ]. Performing ADLs is necessary to maintain independent living, well-being and health related quality of life [
      • Covinsky K.
      Aging, arthritis, and disability.
      ,

      Christiansen C, Baum CM, Bass-Haugen J. Occupational therapy: performance, participation, and well-being: NJ: Slack Thorofare; 2005.

      ,

      Christiansen CH, Hammecker CL. Self care. In: Bonder BR, Wagner MB, editors. Functional performance in older adults. Philadelphia: F.A. Davis; 2001. p. 155–175.

      ]. Disability relating to ADLs (difficulty with or requiring assistance in at least one activity) has been associated with poorer quality of life, and in older adults is predictive of mortality [
      • Manton K.G.
      A longitudinal study of functional change and mortality in the United States.
      ]. It follows therefore, that where disability relating to ADLs exists, addressing it should be a core goal of clinical management.
      Although multiple studies assessing ADL disability in cancer have been published, the variability among study populations, settings, and measures makes it difficult to interpret the evidence. Landmark studies have used ADL disability to characterise functional decline at the end of life, for example Lunney et al. [
      • Lunney J.R.
      • Lynn J.
      • Foley D.J.
      • Lipson S.
      • Guralnik J.M.
      Patterns of functional decline at the end of life.
      ] observed rapid disability following a high level of ADL performance, and Gill et al. [
      • Gill T.M.
      • Gahbauer E.A.
      • Han L.
      • Allore H.G.
      Trajectories of disability in the last year of life.
      ] demonstrated more varied trajectories of disability. Whilst these studies highlight the severe impact of cancer on ability to manage ADLs, both were limited to a community setting and late phase of illness. Earlier in the cancer trajectory, individuals tend to experience more disability in instrumental ADLs compared to basic ADLs [
      • Girones R.
      • Torregrosa D.
      • Diaz-Beveridge R.
      Comorbidity, disability and geriatric syndromes in elderly breast cancer survivors. Results of a single-center experience.
      ,
      • Mohile S.G.
      • Xian Y.
      • Dale W.
      • Fisher S.G.
      • Rodin M.
      • Morrow G.R.
      • et al.
      Association of a cancer diagnosis with vulnerability and frailty in older Medicare beneficiaries.
      ], which supports the notion that instrumental ADLs require a higher level of functional ability [
      • Whittle H.
      • Goldenberg D.
      Functional health status and instrumental activities of daily living performance in noninstitutionalized elderly people.
      ]. Evidence regarding which activities are most commonly affected in cancer questions the original hierarchy of ADL proposed by Katz. For example, both eating [
      • Fodeh S.J.
      • Lazenby M.
      • Bai M.
      • Ercolano E.
      • Murphy T.
      • McCorkle R.
      Functional impairments as symptoms in the symptom cluster analysis of patients newly diagnosed with advanced cancer.
      ] and bathing [
      • Girones R.
      • Torregrosa D.
      • Diaz-Beveridge R.
      Comorbidity, disability and geriatric syndromes in elderly breast cancer survivors. Results of a single-center experience.
      ] are commonly affected by cancer, despite these tasks being considered the easiest and most difficult ADLs respectively [
      • Katz S.
      • Ford A.B.
      • Moskowitz R.W.
      • Jackson B.A.
      • Jaffe M.W.
      Studies of illness in the aged. The index of adl: a standardized measure of biological and psychosocial function.
      ,
      • Katz S.
      • Akpom C.A.
      A measure of primary sociobiological functions.
      ].
      To our knowledge, no review has systematically examined ADL-related disability in adults living with cancer. A better understanding of disability profiles and patterns regarding ADLs, including in the context of cancer stage and settings, would allow clinicians to target rehabilitation interventions, shape policy around rehabilitation services, and equip researchers with a knowledge base on which to develop treatments to reduce ADL disability. This review aimed to identify instruments, items, and reporting of ADL disability in people with cancer; to determine the prevalence of ADL disability overall and by setting; and describe the most commonly affected basic and instrumental ADLs in this group.

      Method

      Design

      The systematic review was planned in accordance with the Centre for Reviews and Dissemination [

      (CRD) Cfrad. Systematic reviews: CRD's guidance for undertaking reviews in health care. York (UK): Centre for Reviews and Dissemination, University of York; 2009.

      ] guidance on conducting reviews and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement [
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      ].

      Inclusion and exclusion criteria

      Studies of adult populations (≥18 years), with a primary clinical or histological diagnosis of cancer were included. Studies of paediatric populations (<18 years) were excluded as they are recognized as a distinct population with different ADL requirements from adults. Cancer survivors were also excluded as the term survivor has been defined in multiple ways, from those living with cancer to those cured and free of any disease [
      • Feuerstein M.
      Defining cancer survivorship.
      ]. Studies employing any measure of ADL disability were included. We did not consider studies only employing measures of global functional status, e.g. ECOG Performance Status, or physical limitation, e.g. walk tests. All prospective and retrospective observational study designs were eligible, including cohort studies, cross-sectional studies, longitudinal studies, case series, and chart reviews.

      Search strategy

      An electronic search strategy using a combination of full-text search terms and MeSH terms was developed for MEDLINE and adapted where necessary for all other databases. Search terms included “cancer” or “carcinoma” AND “functional disabilities”, “functional outcomes” or “functional impairment” AND “observational studies”, “cohort studies” or “longitudinal studies” All search terms were used as full-text, with use of truncation symbol to retrieve variations in the terminology. (Supplement, Appendix 1.)
      A systematic literature search was conducted in 12 electronic databases from inception to June 2016: MEDLINE; EMBASE; CINAH; ASSIA (Applied Social Sciences Index and Abstracts); PsychINFO; Social Policy and Practice; IBBS (International Bibliography of the Social Science); Science Direct; Social Service Abstract; Sociological Abstract; Scopus; Web of Science Core Collection. Grey literature was searched on six databases: OpenGrey (System for Information on Grey Literature); ProQuest Dissertations & Theses; Web of Science Conference Proceedings; Scopus Conference Proceedings; HMIC (Health Management Information Consortium); Global Health. No time restrictions were applied. Restrictions were applied to studies in human subjects published in English language.
      Search alerts were set up regularly for updates of relevant new publications in each database up to November 2016, and hand searching was conducted up to October 2016. The first author (J.N.) scanned reference lists, and performed forward and backward citation tracking of included studies. Experts in the field of cancer and disability were also contacted via email to seek potentially relevant research material, including ongoing and unpublished research.

      Data collection and analysis

      Selection of studies

      An online reference management system (Refworks) was used to manage electronic database hits and remove duplicates. Eligibility criteria were first applied to the title and abstracts. Full-text articles were retrieved for titles/abstracts that meet the review criteria or when information in the title and abstract was insufficient to determine eligibility. The appraisal of articles against inclusion and exclusion criteria was agreed between the first (J.N.) and last (M.M.) authors, with any disagreements regarding the studies resolved via discussion.

      Assessment of methodological quality in included studies

      Studies selected for inclusion of specific items of ADL disability were assessed for methodological quality using Loney’s critical appraisal tool [
      • Loney P.L.
      • Chambers L.W.
      • Bennett K.J.
      • Roberts J.G.
      • Stratford P.W.
      Critical appraisal of the health research literature: prevalence or incidence of a health problem.
      ], designed to assess quality and susceptibility to bias in articles determining the incidence or prevalence of a clinical issue. The tool covers eight criteria; description of study subjects, random sample, unbiased sampling frame, adequate sample size, standardised measures, unbiased assessors, adequate response rate, and confidence intervals and subgroup analysis. A point is allocated for the presence of each criterion. A higher score indicates higher methodological quality.

      Data extraction and analysis

      A standardised data extraction form was developed, piloted, and data from eligible studies was extracted (J.N. and M.M) to retrieve data on study design, setting, sample characteristics, instruments of ADL disability, and characteristics of ADL related disability.
      Normally distributed variables were summarised by mean and standard deviation. For studies with multiple subgroups within the sample, data were aggregated into a single group using the formula devised by the Cochrane Collaboration for combining means and standard deviations of groups [

      Higgins J, Green S. Cochrane handbook for systematic reviews of interventions; 2011 [2015].

      ]. Where mean was not reported, mean and standard deviation was estimated from its median and range using the formula devised by Hozo and colleagues [
      • Hozo S.P.
      • Djulbegovic B.
      • Hozo I.
      Estimating the mean and variance from the median, range, and the size of a sample.
      ]. When the range was not available for calculation of mean, median was assumed as mean for studies of sufficiently large sample size. Categorical variables e.g. cancer type, were summarised by percentage of participants in the highest occurring category.
      Data on overall and specific ADL disability prevalence were summarised by mean and 95% confidence intervals calculated using Wilson’s method (Confidence Interval Analysis version 2.1.2 software). Disability prevalence was determined overall, and by inpatient/outpatient setting as patients admitted to hospital or care home might be more dependant in ADLs. Data on number of ADL disability and total ADL disability score were summarised as mean and standard deviations. Figures were produced using Graphpad Prism software 7.0b. A meta-analysis was conducted to synthesise the results from multiple studies into a single prevalence point for disability relating to basic and instrumental ADLs, overall and by setting, using Cochrane Collaboration’s RevMan software [

      Higgins J, Green S. Cochrane handbook for systematic reviews of interventions; 2011 [2015].

      ].

      Results

      Study retrieval

      Our search of the literature retrieved 13,432 articles. After de-duplication and title/abstract screening, 83 full-text articles were retrieved for further appraisal, of which 43 separate studies were included (Fig. 1, see Supplement, Appendix 2 for excluded studies). All studies were included for narrative review of instruments and items of ADL disability. Data from eighteen and fifteen studies respectively were used for meta-analyses for pooled estimates of basic ADL and instrumental ADL disability.

      Characteristics of included studies and sample participants

      See Table 1 for information on characteristics of all included studies. Most studies were conducted from 2000 onwards (n = 32), in the US and Canada (n = 21), Europe (n = 19), or Asia (n = 3). The majority of studies (n = 24) recruited participants from outpatient settings, e.g. home care, clinics, or community-dwelling adults. Data from a total of 19,246 participants were available, with individual study samples sizes ranging from 45 to 6822. Participants were heterogeneous with regards to primary cancer type (breast, colorectal, lung, gastrointestinal, etc.) and cancer treatment status.
      Table 1Characteristics of included studies for narrative review.
      First author/year/

      country
      Study designSettingADL outcome measuresSample characteristics
      Sample size (n)Age

      Mean ± SD (years)
      Male (%)Ethnicity (%)Cancer type (% of sample)Cancer stage (% of sample)PS (%)Treatment (%)
      Bentley

      2013

      UK
      • Bentley R.
      • Hussain A.
      • Maddocks M.
      • Wilcock A.
      Occupational therapy needs of patients with thoracic cancer at the time of diagnosis: findings of a dedicated rehabilitation service.
      Cross-sectionalOutpatientOccupational Performance Problem List26071 ± 1062White (90)NSCLC (81)NSCLC IV (55)ECOG 0 (28)Palliative (79)
      Chen

      2007

      USA
      • Chen J.H.
      • Chan D.C.
      • Kiely D.K.
      • Morris J.N.
      • Mitchell S.L.
      Terminal trajectories of functional decline in the long-term care setting.
      Retrospective cohortInpatientMDS – ADL6391 ± 633nsnsnsnsns
      Cheville

      2008

      USA
      • Cheville A.L.
      • Troxel A.B.
      • Basford J.R.
      • Kornblith A.B.
      Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer.
      Cross-sectionalOutpatientOARS – ADL and IADL16356 ± 10White (71)Breast (100)IV (26)nsns
      Cole

      2000

      USA
      • Cole R.P.
      • Scialla S.J.
      • Bednarz L.
      Functional recovery in cancer rehabilitation.
      Retrospective case seriesInpatient

      FIM

      Motor Measure
      20071 ± 1246nsBlood-related (17)

      Lung (17)
      III (72)nsCurative (76)
      Corsonello

      2010

      Italy
      • Corsonello A.
      • Pedone C.
      • Carosella L.
      • Corica F.
      • Mazzei B.
      • Incalzi R.A.
      Health status in older hospitalized patients with cancer or non-neoplastic chronic diseases.
      ObservationalInpatientKatz ADL139865–79 years (45%)63nsGI (30)NAnsns
      Deckx 2015 Belgium; Netherlands

      • Deckx L.
      • van den Akker M.
      • Daniels L.
      • De Jonge E.T.
      • Bulens P.
      • Tjan-Heijnen V.C.
      • et al.
      Geriatric screening tools are of limited value to predict decline in functional status and quality of life: results of a cohort study.
      Prospective observational cohortInpatientKatz ADL

      Lawton IADL
      13477.1
      SD not specified in study
      21nsBreast (69)II (54)nsSurgery (93)
      Deeg

      2005

      Netherlands
      • Deeg D.J.
      Longitudinal characterization of course types of functional limitations.
      Prospective longitudinalOutpatientOECD – 3 activities254nsnsnsnsnsnsns
      de Miguel Sánchez

      2006

      Spain
      • de Miguel Sanchez C.
      • Elustondo S.G.
      • Estirado A.
      • Sanchez F.V.
      • de la Rasilla Cooper C.G.
      • Romero A.L.
      • et al.
      Palliative performance status, heart rate and respiratory rate as predictive factors of survival time in terminally ill cancer patients.
      Prospective longitudinalOutpatientKatz ADL9872 ± 1261nsGI (28)Metastases (87)PPS score 50 (33)ns
      Derks

      2004

      Netherlands
      • Derks W.
      • De Leeuw R.
      • Winnubst J.
      • Hordijk G.J.
      Elderly patients with head and neck cancer: physical, social and psychological aspects after 1 year.
      Prospective longitudinalOutpatientADL and IADL questionnaires12145–60 years (61%)64nsOral cavity (46)nsKPS 90–100 (87)Surgical (76)
      Echteld

      2004

      Netherlands
      • Echteld M.A.
      • Deliens L.
      • Van Der Wal G.
      • Ooms M.E.
      • Ribbe M.W.
      Palliative care units in The Netherlands: changes in patients' functional status and symptoms.
      Prospective longitudinalInpatientRAI-MDS-PC35573 ± 1345nsLung (20)nsnsns
      Extermann

      1998

      USA
      • Extermann M.
      • Overcash J.
      • Lyman G.H.
      • Parr J.
      • Balducci L.
      Comorbidity and functional status are independent in older cancer patients.
      Prospective cohortOutpatientKatz ADL

      Lawton IADL
      20376 ± 8
      Means estimated using median, range, and sample size Hozo et al. [23].
      39nsBreast (34)Metastatic (47)ECOG 1 (53)ns
      Finalyson

      2012

      USA
      • Finlayson E.
      • Zhao S.
      • Boscardin W.J.
      • Fries B.E.
      • Landefeld C.S.
      • Dudley R.A.
      Functional status after colon cancer surgery in elderly nursing home residents.
      Retrospective cohortInpatientMDS – ADL682283 ± 832White (86)nsnsnsns
      Flood

      2006

      USA
      • Flood K.L.
      • Carroll M.B.
      • Le C.V.
      • Ball L.
      • Esker D.A.
      • Carr D.B.
      Geriatric syndromes in elderly patients admitted to an oncology-acute care for elders unit.
      Retrospective descriptiveInpatientKatz ADL

      Lawton IADL
      96 (Katz ADL)

      91 (Lawton IADL)
      74 ± 648White (77)Lung (30)nsnsns
      Gill

      2010

      USA
      • Gill T.M.
      • Gahbauer E.A.
      • Han L.
      • Allore H.G.
      Trajectories of disability in the last year of life.
      LongitudinalOutpatient4-item ADL questionnaire7482 ± 539White (91)nsnsnsns
      Girones

      2012

      Spain
      • Girones R.
      • Torregrosa D.
      • Gomez-Codina J.
      • Maestu I.
      • Tenias J.M.
      • Rosell R.
      Lung cancer chemotherapy decisions in older patients: the role of patient preference and interactions with physicians.
      ProspectiveOutpatient5-item Katz ADL

      Lawton IADL
      8377 ± 598nsNSCLC (76)III (41)ECOG 1 (40)ns
      Given

      1994

      USA
      • Given C.W.
      • Given B.A.
      • Stommel M.
      The impact of age, treatment, and symptoms on the physical and mental health of cancer patients. A longitudinal perspective.
      Prospective longitudinalOutpatientKatz ADL Lawton IADL11163 ± 750nsGI (29)nsnsCT + Other (78)
      Greimel

      2000

      Austria
      • Greimel E.R.
      • Freidl W.
      Functioning in daily living and psychological well-being of female cancer patients.
      ProspectiveOutpatientALLTAG9856 ± 13
      Means estimated using median, range, and sample size Hozo et al. [23].
      0nsCervical (47)nsnsSurgery (51)
      Guadagnoli

      1991

      USA
      • Guadagnoli E.
      • Mor V.
      Daily living needs of cancer outpatients.
      Cross-sectionalOutpatientTelephone interviews on ADL/IADL41365–75 years (29%)29White (98)Breast (47)nsnsPalliative (63)
      Hamaker

      2011

      Netherlands
      • Hamaker M.E.
      • Buurman B.M.
      • van Munster B.C.
      • Kuper I.M.
      • Smorenburg C.H.
      • de Rooij S.E.
      The value of a comprehensive geriatric assessment for patient care in acutely hospitalized older patients with cancer.
      Prospective observational cohortInpatientKatz ADL

      Modified Katz IADL
      29278 ± 9
      Means estimated using median, range, and sample size Hozo et al. [23].
      51nsnsMetastases (43)nsns
      Huijberts

      2016

      Netherlands
      • Huijberts S.
      • Buurman B.M.
      • de Rooij S.E.
      End-of-life care during and after an acute hospitalization in older patients with cancer, end-stage organ failure, or frailty: a sub-analysis of a prospective cohort study.
      Prospective cohortInpatientModified Katz ADL15176 ± 746Dutch (91)nsnsnsns
      Hunter

      2012

      USA
      • Hunter E.G.
      • Baltisberger J.
      Functional outcomes by age for inpatient cancer rehabilitation: a retrospective chart review.
      RetrospectiveInpatientFIM Motor Measure21561 ± 1649nsnsnsnsns
      Hurria

      2006

      USA
      • Hurria A.
      • Hurria A.
      • Zuckerman E.
      • Panageas K.S.
      • Fornier M.
      • D'Andrea G.
      • et al.
      A prospective, longitudinal study of the functional status and quality of life of older patients with breast cancer receiving adjuvant chemotherapy.
      Prospective longitudinalOutpatientKatz ADL

      Lawton IADL
      5071 ± 6
      Means estimated using median, range, and sample size Hozo et al. [23].
      51White (80)Breast (100)IIA (49)nsLumpectomy (63)
      Kanesvaran

      2014

      China
      • Kanesvaran R.
      • Wang W.
      • Yang Y.
      • Wei Z.
      • Jia L.
      • Li F.
      • et al.
      Characteristics and treatment options of elderly Chinese patients with cancer as determined by Comprehensive Geriatric Assessment (CGA).
      ProspectiveInpatient5-item ADL questionnaire

      OARS – IADL
      80376 ± 8
      Means estimated using median, range, and sample size Hozo et al. [23].
      60Han (95)Lung (33)IV (56)nsCT (44)
      Kim

      2011

      Korea
      • Kim Y.J.
      • Kim J.H.
      • Park M.S.
      • Lee K.W.
      • Kim K.I.
      • Bang S.M.
      • et al.
      Comprehensive geriatric assessment in Korean elderly cancer patients receiving chemotherapy.
      ProspectiveOutpatientMBI

      Lawton IADL
      6572 ± 4
      Means estimated using median, range, and sample size Hozo et al. [23].
      75nsColorectal (34)IV (49)ECOG 0–1 (89)Palliative CT (74)
      Korouklian

      2010

      USA
      • Koroukian S.M.
      • Xu F.
      • Bakaki P.M.
      • Diaz-Insua M.
      • Towe T.P.
      • Owusu C.
      Comorbidities, functional limitations, and geriatric syndromes in relation to treatment and survival patterns among elders with colorectal cancer.
      Retrospective database reviewOutpatientADLs recorded in the OASIS100975–79 years (26%)43Non-African American (92)Colorectal (100)Localised (74)nsns
      Lindahl-Jacobsen

      2015

      Denmark
      • Lindahl-Jacobsen L.
      • Hansen D.G.
      • Waehrens E.E.
      • la Cour K.
      • Sondergaard J.
      Performance of activities of daily living among hospitalized cancer patients.
      Cross-sectionalInpatientADL – Q11870 ± 1035nsLung (29)nsKPS score 50–70 (86)ns
      Lindsey

      1994

      USA
      • Lindsey A.M.
      • Larson P.J.
      • Dodd M.J.
      • Brecht M.L.
      • Packer A.
      Comorbidity, nutritional intake, social support, weight, and functional status over time in older cancer patients receiving radiotherapy.
      Prospective longitudinalOutpatientFAI ADL and IADL4572 ± 7
      Means estimated using median, range, and sample size Hozo et al. [23].
      36White (91)Lung (57)nsnsns
      Luciani

      2008

      USA
      • Luciani A.
      • Jacobsen P.B.
      • Extermann M.
      • Foa P.
      • Marussi D.
      • Overcash J.A.
      • et al.
      Fatigue and functional dependence in older cancer patients.
      Retrospective cross sectionalOutpatientKatz ADL

      Lawton IADL
      21479 ± 537nsnsnsECOG 0 (62)ns
      Lunney

      2003

      USA
      • Lunney J.R.
      • Lynn J.
      • Foley D.J.
      • Lipson S.
      • Guralnik J.M.
      Patterns of functional decline at the end of life.
      Prospective longitudinalOutpatientInterview on 7 ADLs89778 ± 763White (80)nsnsnsns
      Marcinak

      1996

      USA
      • Marciniak C.M.
      • Sliwa J.A.
      • Spill G.
      • Heinemann A.W.
      • Semik P.E.
      Functional outcome following rehabilitation of the cancer patient.
      Retrospective case seriesInpatientFIM Motor Measure15957 ± 1749nsPrimary intracranial (45)nsnsSurgery (86)
      McCarthy

      2000

      USA
      • McCarthy E.P.
      • Phillips R.S.
      • Zhong Z.
      • Drews R.E.
      • Lynn J.
      Dying with cancer: patients' function, symptoms, and care preferences as death approaches.
      Prospective cohortOutpatient7-item Modified Katz Index ADL106364 ± 8
      Means estimated using median, range, and sample size Hozo et al. [23].
      61White (84)NSCLC (70)nsnsCT (61)
      McEwen

      2012

      Canada
      • McEwen S.E.
      • Elmi S.
      • Waldman M.
      • Bishev M.
      Inpatient oncology rehabilitation in Toronto: a descriptive 18-month retrospective record review.
      Retrospective record reviewInpatientFIM Motor Measure15373 ± 1341nsColorectal (29)nsnsns
      Movsas

      2003

      USA
      • Movsas S.B.
      • Chang V.T.
      • Tunkel R.S.
      • Shah V.V.
      • Ryan L.S.
      • Millis S.R.
      Rehabilitation needs of an inpatient medical oncology unit.
      Prospective cohortInpatientFIM Motor Measure5561 ± 17
      Means estimated using median, range, and sample size Hozo et al. [23].
      nsnsHematologic (40)Metastatic (69)nsns
      O’Hare

      1993

      USA
      • O'Hare P.A.
      • Malone D.
      • Lusk E.
      • McCorkle R.
      Unmet needs of black patients with cancer posthospitalization: a descriptive study.
      LongitudinalOutpatientESDS63≥65 years (48%)38nsnsnsnsns
      Ögce

      2008

      Turkey
      • Ogce F.
      • Ozkan S.
      Changes in functional status and physical and psychological symptoms in women receiving chemotherapy for breast cancer.
      Longitudinal descriptiveOutpatientIFS-CA101>50 years (50%)0nsBreast (100)Localised (52)nsMastectomy (98)
      Repetto

      2002

      Italy
      • Repetto L.
      • Fratino L.
      • Audisio R.A.
      • Venturino A.
      • Gianni W.
      • Vercelli M.
      • et al.
      Comprehensive geriatric assessment adds information to Eastern Cooperative Oncology Group performance status in elderly cancer patients: an Italian Group for Geriatric Oncology Study.
      Prospective

      cross-sectional
      InpatientKatz ADL

      Lawton IADL
      36376 ± 8
      Means estimated using median, range, and sample size Hozo et al. [23].
      46nsBreast (31)Localised (40)ECOG < 2 (74)ns
      Retornaz

      2007

      France
      • Retornaz F.
      • Seux V.
      • Sourial N.
      • Braud A.C.
      • Monette J.
      • Bergman H.
      • et al.
      Comparison of the health and functional status between older inpatients with and without cancer admitted to a geriatric/internal medicine unit.
      Retrospective chart reviewOutpatientKatz ADL

      4-item IADL scale
      14479 ± 746nsBreast (18)Metastases (75)nsNone (58)
      Retornaz

      2008

      France
      • Retornaz F.
      • Seux V.
      • Pauly V.
      • Soubeyrand J.
      Geriatric assessment and care for older cancer inpatients admitted in acute care for elders unit.
      Retrospective chart reviewInpatientKatz ADL

      4-item IADL scale
      18680 ± 748nsBreast (15)Metastases (71)nsNone (46)
      Serraino

      2001

      Italy
      • Serraino D.
      • Fratino L.
      • Zagonel V.
      Prevalence of functional disability among elderly patients with cancer.
      Cross-sectionalInpatientKatz ADL



      Lawton IADL
      30376 ± 8
      Means estimated using median, range, and sample size Hozo et al. [23].
      60nsHaematological neoplasia (60)

      nsECOG 0–1 (62)ns
      Silver

      2010

      Brazil
      • Silver H.J.
      • de Campos Graf Guimaraes C.
      • Pedruzzi P.
      • Badia M.
      • Spuldaro de Carvalho A.
      • Oliveira B.V.
      • et al.
      Predictors of functional decline in locally advanced head and neck cancer patients from south Brazil.
      Prospective longitudinalOutpatientKatz ADL

      6-item Lawton IADL
      6061 ± 1288White (95)Mouth (40)IV (35)nsSurgery (82)

      RT (82)
      Stafford

      1997

      USA
      • Stafford R.S.
      • Cyr P.L.
      The impact of cancer on the physical function of the elderly and their utilization of health care.
      Cross-sectionalOutpatient

      6-item ADL questionnaire

      6-item IADL questionnaire
      164775
      SD not specified in study
      33nsBreast (24)nsnsns
      Tay

      2009

      Singapore
      • Tay S.S.
      • Ng Y.S.
      • Lim P.A.
      Functional outcomes of cancer patients in an inpatient rehabilitation setting.
      Prospective cohortInpatientFIM5857 ± 1662nsSolid tumour (86)nsnsRT (25.9)
      Ulander

      1997

      Sweden
      • Ulander K.
      • Jeppsson B.
      • Grahn G.
      Quality of life and independence in activities of daily living preoperatively and at follow-up in patients with colorectal cancer.
      ExploratoryOutpatientKatz Index and Hulter-Asberg's IADL index8670 ± 1354nsColorectal (100)Metastases (44)nsns
      All values rounded to the nearest whole number.
      ns = not stated.
      Abbreviations: ADL: Activities of Daily Living; ADL – Q: Activities of Daily Living Questionnaire; CT: Chemotherapy; ECOG: Eastern Cooperation Oncology Group; GI: Gastrointestinal; IADL: Instrumental Activities of Daily Living; KPS: Karnofsky Performance Status; NHS: National Health Service ; ns; not specified; NSCLC: Non squamous cell lung carcinoma; OT: Occupational therapy; PCU: Palliative Care Unit; RAI – MDS – PC: Resident Assessment Instrument – Minimum Data Set – Palliative Care; RAI-PC: Inter Resident Assessment Instrument - Palliative Care; PPS: Palliative Performance Scale; PS: Performance status; SF-36: 36-Item Short Form Health Survey.
      a Means estimated using median, range, and sample size Hozo et al.
      • Hozo S.P.
      • Djulbegovic B.
      • Hozo I.
      Estimating the mean and variance from the median, range, and the size of a sample.
      .
      b SD not specified in study

      Instruments, items and reporting of ADL disability

      In all studies, ADL disability was defined as having difficulty with or requiring assistance in at least one activity. Most studies used standardised and validated instruments, however, close to one-quarter of studies (n = 9/43) used questionnaires and/or scales constructed specifically for the study, with items from a parsimonious selection of ADL. The most commonly used ADL instruments were the Katz Index of Independence to assess basic ADLs (n = 18), and the Lawton IADL scale (n = 11) to assess for instrumental ADLs. For both measures, deviation from the standardised protocol, with use of fewer or additional question items was commonly observed.

      Methodological quality assessment

      For articles reporting the prevalence of disability in specific items of ADL, the median (range) methodologic score was 5 (4–6) out of a possible 8. Participant characteristics were generally adequately described, whilst the participation response rate and characteristics of patients declining participation were less frequently reported. A post-hoc decision was made not to use quality criteria in any sensitivity analysis due to the heterogeneity across studies.

      ADL disability in adults with cancer

      Disability relating to basic ADLs

      Eighteen studies provided information about performance of basic ADLs. The mean [95% CI] prevalence of disability was 36.7% [29.8–44.3] for the overall population (see Fig. 2). There was a wide range of prevalence estimates for basic ADL disability across both inpatient (14–53%) and outpatient settings (0–86%) and significant heterogeneity across study-specific estimates (I2 96% for both, p < .001). The pooled mean estimate was not statistically different according to setting (inpatient 32.0% [24.0–41.3] vs. outpatient 41.2% [31.2–51.9], p = .19).
      Figure thumbnail gr2
      Fig. 2Prevalence of disability in basic and instrumental ADL by study. Red lines indicate inpatient settings and black lines outpatient settings.

      Disability relating to instrumental ADLs

      Fifteen studies provided information about instrumental ADLs. The mean [95% CI] prevalence of disability was 54.6% [46.5–62.3] for the overall population (see Fig. 2). Again, there was a wide range of prevalence estimates for disability across both inpatient (44–77%) and outpatient settings (13–75%) and significant heterogeneity across study-specific estimates (I2 91 and 97%, both p < .001). The pooled mean estimates of disability according to study setting were borderline statistically different (inpatient 62.8% [55.2–69.8] vs. outpatient 46.1% [31.9–61.0], p = .05).

      Number of ADLs affected and ADL disability scores

      In the inpatient setting, the number of basic ADLs requiring assistance ranged from 4.7 to 5.0, and instrumental ADLs ranged from 3.0 to 4.7. In the outpatient setting, the number of basic ADLs requiring assistance ranged from 0.6 to 4.0, and instrumental ADLs ranged from 0.9 to 3.1 (Table 2). Seventeen studies provided mean total scores using a standardised instrument, which may be useful to inform future trial design. Study specific estimates from commonly used instruments across different cancer types, stages, and clinical settings are shown in Table 3.
      Table 2Characteristics of studies and number of ADL disabilities.
      First authorClinical settingADL outcome measuresBasic ADL

      (mean ± SD)
      Instrumental ADL

      (mean ± SD)
      Retornaz

      2008
      • Retornaz F.
      • Seux V.
      • Pauly V.
      • Soubeyrand J.
      Geriatric assessment and care for older cancer inpatients admitted in acute care for elders unit.
      Inpatient6-item Katz ADL

      4-item IADL scale
      5.0 ± 2.3
      Median was reported in study, and assumed as mean.
      3.0 ± 1.6
      Median was reported in study, and assumed as mean.
      Cheville

      2008
      • Cheville A.L.
      • Troxel A.B.
      • Basford J.R.
      • Kornblith A.B.
      Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer.
      OutpatientOARS – 7-item ADL and 7-item IADL1.8 ± 0.82.4 ± 2.1
      Girones

      2012
      • Girones R.
      • Torregrosa D.
      • Gomez-Codina J.
      • Maestu I.
      • Tenias J.M.
      • Rosell R.
      Lung cancer chemotherapy decisions in older patients: the role of patient preference and interactions with physicians.
      Outpatient5-item Katz ADL

      6-item Lawton IADL
      4.0 ± 1.03.0 ± 2.0
      Lunney

      2003
      • Lunney J.R.
      • Lynn J.
      • Foley D.J.
      • Lipson S.
      • Guralnik J.M.
      Patterns of functional decline at the end of life.
      OutpatientInterview on 7 ADLs0.7
      SD not specified.
      ns
      McCarthy

      2000
      • McCarthy E.P.
      • Phillips R.S.
      • Zhong Z.
      • Drews R.E.
      • Lynn J.
      Dying with cancer: patients' function, symptoms, and care preferences as death approaches.
      Outpatient7-item Modified Katz ADL1.3
      Median was reported in study, and assumed as mean. Multiple groups were combined into one group using Cochrane formula.
      ns
      Silver

      2010
      • Silver H.J.
      • de Campos Graf Guimaraes C.
      • Pedruzzi P.
      • Badia M.
      • Spuldaro de Carvalho A.
      • Oliveira B.V.
      • et al.
      Predictors of functional decline in locally advanced head and neck cancer patients from south Brazil.
      Outpatient6-item Katz ADL

      6-item Lawton IADL
      0.6 ± 1.73.1 ± 3.3
      Stafford

      1997
      Outpatient6-item ADL questionnaire

      6-item IADL questionnaire
      1.0
      SD not specified.
      0.9
      SD not specified.
      All values rounded to nearest decimal place.
      Abbreviations: ADL: Activities of Daily Living; IADL: Instrumental Activities of Daily Living; ns; not stated; OARS: The Older Americans Resource and Services
      a Median was reported in study, and assumed as mean.
      b Median was reported in study, and assumed as mean. Multiple groups were combined into one group using Cochrane formula.
      c SD not specified.
      Table 3Characteristics of studies and total ADL disability score.
      First authorClinical settingADL outcome measuresRangeBasic ADL (mean ± SD)Instrumental ADL (mean ± SD)
      Chen

      2007
      • Chen J.H.
      • Chan D.C.
      • Kiely D.K.
      • Morris J.N.
      • Mitchell S.L.
      Terminal trajectories of functional decline in the long-term care setting.
      InpatientMDS – ADL0–2812.6 ± 9.6ns
      Cole

      2000
      • Cole R.P.
      • Scialla S.J.
      • Bednarz L.
      Functional recovery in cancer rehabilitation.
      InpatientFIM Motor Measure0–10043.7 ± 6.3
      Means combined from multiple samples using Cochrane formula for combing groups.
      ns
      Finalyson

      2012
      • Finlayson E.
      • Zhao S.
      • Boscardin W.J.
      • Fries B.E.
      • Landefeld C.S.
      • Dudley R.A.
      Functional status after colon cancer surgery in elderly nursing home residents.
      InpatientMDS – ADL0–2812.7 ± 8.2ns
      Flood

      2006
      • Flood K.L.
      • Carroll M.B.
      • Le C.V.
      • Ball L.
      • Esker D.A.
      • Carr D.B.
      Geriatric syndromes in elderly patients admitted to an oncology-acute care for elders unit.
      InpatientKatz Index

      Lawton IADL
      6–18

      8–21
      13.1 ± 2.719.7 ± 5.0
      Hunter

      2012
      • Hunter E.G.
      • Baltisberger J.
      Functional outcomes by age for inpatient cancer rehabilitation: a retrospective chart review.
      InpatientFIM Motor Measure13–9161 ± 17ns
      Marcinak

      1996
      • Marciniak C.M.
      • Sliwa J.A.
      • Spill G.
      • Heinemann A.W.
      • Semik P.E.
      Functional outcome following rehabilitation of the cancer patient.
      InpatientFIM Motor Measure0–10042.6
      SD not specified in study.
      ns
      McEwen

      2012
      • McEwen S.E.
      • Elmi S.
      • Waldman M.
      • Bishev M.
      Inpatient oncology rehabilitation in Toronto: a descriptive 18-month retrospective record review.
      InpatientFIM Motor Measure13–9158.0 ± 10.6ns
      Movsas

      2003
      • Movsas S.B.
      • Chang V.T.
      • Tunkel R.S.
      • Shah V.V.
      • Ryan L.S.
      • Millis S.R.
      Rehabilitation needs of an inpatient medical oncology unit.
      InpatientFIM Motor Measure13–9172.0 ± 14.0ns
      Tay

      2009
      • Tay S.S.
      • Ng Y.S.
      • Lim P.A.
      Functional outcomes of cancer patients in an inpatient rehabilitation setting.
      InpatientFIM18–12670.9 ± 18.0ns
      Lindsey

      1994
      • Lindsey A.M.
      • Larson P.J.
      • Dodd M.J.
      • Brecht M.L.
      • Packer A.
      Comorbidity, nutritional intake, social support, weight, and functional status over time in older cancer patients receiving radiotherapy.
      OutpatientFAI ADL and IADL13–26

      15–29
      25.5 ± 1.228.2 ± 1.5
      Cheville

      2009
      • Cheville A.L.
      • Troxel A.B.
      • Basford J.R.
      • Kornblith A.B.
      Prevalence and treatment patterns of physical impairments in patients with metastatic breast cancer.
      OutpatientFIM Mobility scale5–3530.2 ± 5.8ns
      Derks

      2004
      • Derks W.
      • De Leeuw R.
      • Winnubst J.
      • Hordijk G.J.
      Elderly patients with head and neck cancer: physical, social and psychological aspects after 1 year.
      OutpatientADL and IADL questionnairesns19.9
      Means combined from multiple samples using Cochrane formula for combing groups.
      ,
      SD not specified in study.
      17.5
      Means combined from multiple samples using Cochrane formula for combing groups.
      ,
      SD not specified in study.
      Hurria

      2006
      • Hurria A.
      • Hurria A.
      • Zuckerman E.
      • Panageas K.S.
      • Fornier M.
      • D'Andrea G.
      • et al.
      A prospective, longitudinal study of the functional status and quality of life of older patients with breast cancer receiving adjuvant chemotherapy.
      Outpatient6-item Katz ADL

      Lawton IADL
      6–18

      8–21
      18.0
      SD not specified in study.
      21.0
      SD not specified in study.
      All values rounded to nearest decimal place. For all outcome measures, except MDS-ADL, a lower score reflects dependence, while a higher score reflects independence.
      Abbreviations: ADL: Activities of Daily Living; FAI: Functional Assessment Inventory; FIM: Functional Independence Measure; MDS – ADL: Minimum Data Set Activity of Daily Living; IADL: Instrumental Activities of Daily Living; IFS – CA: Inventory of Functional Status-Cancer; ns; not stated; OECD: Organisation for Economic Co-operation and Development.
      a Means combined from multiple samples using Cochrane formula for combing groups.
      b SD not specified in study.

      Disability in specific ADLs

      Among eight basic ADLs assessed, disability relating to personal hygiene was the most prevalent, followed by disability related to walking, transfers, and bathing. In four of the studies on walking, two reported a prevalence of disability ≥ 50%. The least affected activities were eating and stair climbing (Fig. 3). Among eight instrumental ADLs assessed, disability relating to housework was most prevalent, followed by disability related to shopping and transportation. Where performance in housework was assessed, four of six studies found ≥ 50% of patients reporting disability. The least affected activities were telephone use, handling finances, and medication management (Fig. 4).
      Figure thumbnail gr3
      Fig. 3Prevalence of disability in specific basic ADLs. Red lines indicate inpatient settings and black lines outpatient settings.
      Figure thumbnail gr4
      Fig. 4Prevalence of disability in specific instrumental ADLs. Red lines indicate inpatient settings and black lines outpatient settings.

      Discussion

      This systematic review of 43 observational studies, with 19,246 patients, reveals that about one-third of adults with cancer respectively require assistance to perform basic ADLs and about one-half require assistance to perform instrumental ADLs. Although a wide range of instruments, item and scales were used, our analysis of specific ADLs demonstrates that limitations most frequently related to the basic ADLs of personal hygiene, walking and transfer, and the instrumental ADLs of housework, shopping and transportation. Our findings highlight substantial need for rehabilitation services that focus on maintaining functional independence, and underscore an important role for professionals skilled in occupational assessment and therapy.

      Measurement of ADL disability

      The most common instruments in measuring ADL disability were the Katz Index of Independence in ADL and the Lawton IADL Scale. Some studies included fewer or additional ADL items using modifications of these standardised measures. A small but significant proportion of studies utilised questionnaire of selected ADL items. The use of selected items to assess ADL performance has been advocated for in clinical practice. Roehrig and colleagues [
      • Roehrig B.
      • Hoeffken K.
      • Pientka L.
      • Wedding U.
      How many and which items of activities of daily living (ADL) and instrumental activities of daily living (IADL) are necessary for screening.
      ] recommended geriatricians to use six ADL items instead of 18 items when conducting screening assessment of frail older people. This recommendation was made based on analysis of ADL data from 327 patients entered into a forward selection model. Six ADL items were sensitive in identifying 98.5% of patients with ADL related disability. Deviations from the use of standardised measures and use of self-constructed questionnaires are stumbling blocks to the advancement of science in the study of disability, as data on ADL disability could not be compared across studies or pooled together to increase power.

      Reporting of ADL related disability

      All the studies used dependency, defined as having difficulty to do an activity or having someone’s help in at least one ADL, as an indicator of disability. A measure of dependency provides an indicator of disability, but is not a measure of disability itself [
      • Verbrugge L.M.
      • Jette A.M.
      The disablement process.
      ]. Disability is often measured by the degree of difficulty (none, some, a lot, unable) or the level of help needed (minimum assistance, moderate assistance, maximum assistance) with a task. Much information about the severity of disability is therefore lost when a measure of dependency is used. Verbrugge and Jette’s [
      • Verbrugge L.M.
      • Jette A.M.
      The disablement process.
      ] critiqued that whilst dependency measures the need for an intervention to reduce disability, it is not discriminative in capturing the characteristics of disability, and therefore not able to provide patient-specific information about rehabilitation needs or home care support needs.

      Characteristics of ADL related disability

      Prevalence of ADL disability

      ADL related disability was highly prevalent among adults living with cancer. Approximately one-third (37%) and half (55%) of those studied experienced difficultly of required assistance to complete basic and instrumental ADLs respectively. These findings are not unexpected as literature has previously discussed the severe impact of cancer and its treatment on ADL performance. For example, Mohile et al. [
      • Mohile S.G.
      • Xian Y.
      • Dale W.
      • Fisher S.G.
      • Rodin M.
      • Morrow G.R.
      • et al.
      Association of a cancer diagnosis with vulnerability and frailty in older Medicare beneficiaries.
      ] and Stafford et al. [
      • Stafford R.S.
      • Cyr P.L.
      The impact of cancer on the physical function of the elderly and their utilization of health care.
      ] found 41% and 44% of older community-dwelling people with cancer experienced difficulty with at least one ADL. Given the high incidence of cancer worldwide, and the resultant inability to manage ADLs, management of ADL related disability should arguably be a core part of oncology practice.
      There was significant heterogeneity across study-specific prevalence estimates for disability relating to basic and instrumental ADLs. This finding likely relates to differences in the characteristics of each study. A systematic review by Harrison et al. [
      • Harrison J.D.
      • Young J.M.
      • Price M.A.
      • Butow P.N.
      • Solomon M.J.
      What are the unmet supportive care needs of people with cancer? A systematic review.
      ] on care needs at different phases of cancer experience found unmet care needs in ADL ranged widely (1–73%). Further analysis showed that care needs for ADLs changed according to the point in the cancer trajectory: at diagnosis (5–10%), during treatment (5–73%), post-treatment (41–47%); and during the terminal stages of illness (1–52%). This heterogeneity sheds new light on the controversy surrounding the impact of cancer and its treatment on ADLs, which warrants further study.

      ADL disability higher in inpatients than outpatient

      The prevalence of disability related to instrumental ADLs was higher in studies of inpatients compared to outpatients. Similarly, Retornaz et al. [
      • Retornaz F.
      • Seux V.
      • Sourial N.
      • Braud A.C.
      • Monette J.
      • Bergman H.
      • et al.
      Comparison of the health and functional status between older inpatients with and without cancer admitted to a geriatric/internal medicine unit.
      ] found 75% of 144 older people with cancer admitted to hospital with instrumental ADL disability while Jolly et al. [
      • Jolly T.A.
      • Deal A.M.
      • Nyrop K.A.
      • Williams G.R.
      • Pergolotti M.
      • Wood W.A.
      • et al.
      Geriatric assessment-identified deficits in older cancer patients with normal performance status.
      ] found only 23% of similar but community-dwelling group reported disability. One would expect more disability in inpatients as the inability to perform instrumental ADLs at home may be one reason for admission [
      • Boyd C.M.
      • Ricks M.
      • Fried L.P.
      • Guralnik J.M.
      • Xue Q.L.
      • Xia J.
      • et al.
      Functional decline and recovery of activities of daily living in hospitalized, disabled older women: the Women's Health and Aging Study I.
      ]. Such information may be useful to plan and evaluate strategies to prevent disability in outpatient oncology settings.

      A hierarchical relationship in ADL

      The most commonly affected basic ADL was personal hygiene, such as grooming and brushing teeth, though this finding should be interpreted with caution as the activity was only assessed in one study. Walking and transfers were also commonly affected and these finding corroborate previous studies [
      • Mohile S.G.
      • Xian Y.
      • Dale W.
      • Fisher S.G.
      • Rodin M.
      • Morrow G.R.
      • et al.
      Association of a cancer diagnosis with vulnerability and frailty in older Medicare beneficiaries.
      ,
      • Stafford R.S.
      • Cyr P.L.
      The impact of cancer on the physical function of the elderly and their utilization of health care.
      ]. Many clinicians would intuitively agree as walking and transfers as mobility tasks are physically demanding. The least affected basic ADL was eating, consistent with the order of loss in ADL functions proposed by Katz and colleagues [
      • Katz S.
      • Ford A.B.
      • Moskowitz R.W.
      • Jackson B.A.
      • Jaffe M.W.
      Studies of illness in the aged. The index of adl: a standardized measure of biological and psychosocial function.
      ,
      • Katz S.
      • Akpom C.A.
      A measure of primary sociobiological functions.
      ].
      Concerning instrumental ADLs, household management was most commonly affected, exemplified by the findings from Mohile et al. and Stafford et al. [
      • Mohile S.G.
      • Xian Y.
      • Dale W.
      • Fisher S.G.
      • Rodin M.
      • Morrow G.R.
      • et al.
      Association of a cancer diagnosis with vulnerability and frailty in older Medicare beneficiaries.
      ,
      • Stafford R.S.
      • Cyr P.L.
      The impact of cancer on the physical function of the elderly and their utilization of health care.
      ]. In general, instrumental ADLs requiring physical function were more commonly affected than those requiring cognitive functions. This may represent a bias in the selection and recruitment of patients into studies, e.g. excluding those without capacity to consent, but may reflect that patients still perform cognitive tasks despite the loss of physical functions. Engaging patients in cognitive activities to maintain independence in instrumental ADL is encouraged.

      Strengths and limitations

      There are several strengths to this review. We developed a detailed protocol that ensured consistency and transparency in the review processes. Publication bias was minimised by utilising more than one source of information and methods to locate published and unpublished studies. Our searches were not restricted to a certain discipline and spanned health and social care databases. We also took steps to minimise judgment errors and bias, with authors’ independently extracting and reviewing data. There were challenges in reaching out to experts to identify grey literature and when requesting additional data from the retrieved articles or published abstracts, which could have led to the omission of relevant on-going studies. Due to lack of time, resource (financial and expertise) and facilities for translation, we could only screen and include studies published and written in English language.

      Future work

      To advance the science of future studies relating to ADL disability, we encourage researchers and clinicians to work towards a consensus on the definition of disability to influence more uniform measurement of ADL disability.
      We strongly advocate for the use of standardised, validated instruments over local variations. Use of validated tools which consider ADLs, for example the Lawton IADL Scale or the Functional Independence Measure, would allow data to be reliably compared across future studies and populations. We suggest that subjective measures of dependency used as proxies for disability, or simply summing the number of ADLs that require assistance, does not portray the full nature or extent of ADL related disability. Future research in this field could consider the degree of difficulty, type and level of assistance required to perform specific activities. Finally, intervention studies targeting the maintenance of ADL in people living with cancer, including advanced and progressive disease, should select valid and sensitive scales to help identify, develop and evaluate the best approaches.

      Conclusions

      This systematic review has identified the nature and prevalence of ADL related disability in adults living with cancer. Overall, about one-third and half of adults with cancer respectively have difficulty or require assistance to perform basic and instrumental ADLs across both inpatient and outpatients settings. Our findings provide useful insights for health care professionals to plan and deliver rehabilitation services, and highlight a particular need for rehabilitation focused on functional independence. The most frequently affected ADLs were personal hygiene, walking and transfers, housework, and shopping and transportation. This understanding can help clinicians focus attention and anticipate problems on activities most commonly affected by cancer. Our findings also underscore the importance of professionals skilled in occupational assessment and therapy in cancer care.

      Declaration of interests

      MM and IJH received funding from the National Institute for Health Research and from Cicely Saunders International. MM received personal fees from Helsinn and Chugai UK outside the submitted work. JN, LF and GW declare no competing interests. These funders had no role in review design, data analysis, data interpretation, or writing of this report. The corresponding author had full access to articles reporting data used in the review and had final responsibility for the decision to submit for publication.

      Competing interests

      None of the authors have any competing interests to declare.

      Acknowledgements

      This work was supported by Cicely Saunders International and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLARHC) South London at King’s College Hospital NHS Foundation Trust. IJH is an NIHR Emeritus Senior Investigator. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

      Contributors

      Substantial contributions to the conception and design of the study: JN, MM; substantial contribution to the acquisition of Data: JN, LF, MM; Analysis and interpretation of the data: JN, GW, LF, IJH, MM; First draft of the manuscript: JN, MM; Revision of the manuscript critically for important intellectual content: All authors; Approval of the final manuscript: All authors; Accountability for all aspects of the work: JN, MM.

      Appendix A. Supplementary material

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