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Screening and Examination of Fall Risk in Older Cancer Survivors

Huang, Min H., PT, PhD

doi: 10.1097/01.REO.0000000000000166

Board Certified Neurologic Clinical Specialist and Associate Professor, Physical Therapy Department, University of Michigan-Flint, Flint, MI

Correspondence: Min H. Huang, PT, PhD, Physical Therapy Department, University of Michigan-Flint, 2157 William S White Bldg, 303 E. Kearsley St, Flint, MI 48502 (

The author declares no conflicts of interest.

Population-based research indicates older cancer survivors have a higher fall risk (odds ratio [OR] = 1.16-1.17).1–3 Among Medicare beneficiaries, fall rate was significantly higher in cancer survivors (26.4%) than in those without cancer (21.9%)1 and prevalence of falls increased from pre- to post-diagnosis in patients with prostate cancer (12% during years 1-2 prediagnosis vs 17%-20% during years 1-4 post-diagnosis) and lung cancer (17% during years 1-2 pre-diagnosis vs 28% during years 1-2 post-diagnosis).4 Falls have severe consequences in cancer survivors. In survivors aged 65 years and older with a new cancer diagnosis, 62% to 74.2% of those with a history of falls sustained an injury.5 Fractures accounted for 78.3% of fall-related injuries in older survivors treated with chemotherapy.6 Falls were associated with lower health-related quality of life (HRQOL) and greater prospective decline in HRQOL in older survivors of cancer.7 Among older patients hospitalized following fall-related injuries, those with cancer were more likely to die regardless of cancer stage (OR = 2.58) and had longer length of stay.8

A comprehensive understanding of risk factors of falls is central to fall prevention in older survivors of cancer. Many risk factors for falls established in the general population are also associated with falls in older cancer survivors.9–11 Some factors are nonetheless unique in the oncology populations.9,10 Consistent with findings from geriatric research, older age, female gender, benzodiazepines, cognitive impairment, use of assistive device, dependency in activities of daily living (ADL) and instrumental ADL, abnormal balance and gait, lower physical performance, and prior falls increase fall risk in older cancer survivors.5,9,11–15 A history of falls is a major risk factor across oncology populations, including Medicare beneficiaries with breast (OR = 4.95) or prostate cancer (OR = 3.04),16 older cancer survivors living in the community (OR = 6.81)17 or awaiting cancer treatment (OR = 3.93),5 and adult survivors with advanced cancer (hazard ratio = 1.27).12 Population-based data showed in patients with breast cancer, sensory impairment in the feet was predictive of falls and in prostate cancer, predictors of falls included unmarried, lower physical domain of quality of life, urinary incontinence, older age at cancer diagnosis, and shorter time post-diagnosis.16 In multiple myeloma, fatigue, depression, or poorer general health increased fall risk.18 The influence of chemotherapy on fall risk is related to toxicity and dosage of agents, as well as presence of chemotherapy-induced peripheral neuropathy (CIPN) symptoms. In survivors with CIPN, a higher number of chemotherapy cycles and severity of balance problem were predictive of falls.19 Older cancer survivors treated with a doublet of neurotoxic chemotherapy had more fall-related injuries than those receiving a single neurotoxic or non-neurotoxic agent.6 Among patients receiving taxane or platinum chemotherapy, presence of CIPN symptoms, as defined by a numbness and tingling severity score of 3 or more on a 0- to 10-point scale, increased the risk of falls or near falls nearly 3 times.20 Even in long-term female survivors of cancer (post-diagnosis 5.8 ± 4.1 years), sensory symptoms of CIPN in lower extremities increased fall risk by 1.8 times.10 Other cancer-related factors, including fatigue, anemia, metastases, and brain metastasis, increase fall risk in survivors with advanced cancer stage or at inpatient oncology and palliative care settings.6,12,21,22 In survivors with advanced cancer receiving palliative care, cancer-related pain, that is, nociceptive or neuropathic pain as defined by the Edmonton Classification System for Cancer Pain, but not pain severity or incidental pain occurring as a result of movement or activity increased fall risk.12 In hospitalized patients with cancer, pain level of 4 or higher on a scale of 0 to 10 reduced fall risk.21 In contrast, pain defined by a score of 1 or more on 0- to 10-point visual analog scale increased fall risk in older survivors after a new cancer diagnosis.5 Overall, profiles of fall risk factors differ widely across studies and by cancer-related variables, such as cancer type, treatment, stage, or practice settings.

The Centers for Disease Control and Prevention created an evidence-based fall prevention initiative, STEADI (Stopping Elderly Accidents, Deaths, & Injuries).23 This geriatric model can serve as a foundation for a new framework targeting falls in the oncology populations. The STEADI algorithm first asks patients to complete a Fall Risk Questionnaire (FRQ) or answer 3 key questions: “Fell in the past year? If YES ask, How many times? Were you injured?”; “Feels unsteady when standing or walking?”; and “Worries about falling?” The FRQ has 12 questions about history of falls in the past year, feeling unsteady, worrying about falling, use of assistive device, medication, incontinence, sensation, and depression.24 For patients answering “Yes” to 2 or more questions in the FRQ or respond “Yes” to any key question, a Timed Up and Go (TUG) is recommended and 30-seconds sit to stand (30STS) and 4-Stage Balance Test are optional tests to evaluate gait, strength, and balance. Based on the screening test results and history of falls, the STEADI algorithm stratifies patients into low-, moderate-, and high-risk groups to receive individualized fall interventions. For the high-risk group, a multifactorial examination is required, including checking for postural hypotension, medications, cognition, feet and footwear, use of mobility aids, and visual acuity. Interventions for the high-risk group consist of education, vitamin D with or without calcium, physical therapy for mobility, strength, and balance, managing hypotension and medications, addressing foot problems, optimizing vision, and home safety. Patients are followed up within 30 days to review care plan, assess fall risk reduction behaviors and barriers to adherence, with transition to maintenance exercise program.23

Research supports some portion of the STEADI algorithm in the oncology populations and identified distinctive elements to be integrated into an oncology fall prevention model. STEADI screening tools, including questions about a history of falls,5,12,16,17 FRQ,25 TUG,25,26 and 30STS,27 are validated in cancer survivors. The FRQ correlated with the TUG in older cancer survivors.25 In survivors of breast cancer, the TUG demonstrated good test-retest and intrarater reliability and correlated with the Fullerton Advanced Balance Scale (FABS) and postural sway using force-plate measurements.26 In community-living cancer survivors, the TUG correlated with gait speed28 and the short version of the Activities-specific Balance Scale (ABC).29 TUG time of 14 seconds or more was associated with falls in community-living older cancer survivors.15 Poor performance of the TUG was linked to the presence of CIPN30 and falls in survivors of prostate cancer.31 In survivors of head and neck cancer, 30STS had excellent test-retest reliability and fair concurrent validity with usual gait speed.27 Psychometric evidence for 4-Stage Balance Test is lacking in oncology populations. Other screening tests commonly used in the geriatric population, including 5 times sit to stand (5TSTS) and gait speed, have good psychometrics in survivors of cancer. 5TSTS correlated with gait speed and leg strength in survivors of prostate cancer receiving androgen deprivation therapy32 and with severity of CIPN symptoms in long-term female cancer survivors.10 Ten-meter gait speed had excellent test-retest reliability in survivors of head and neck cancer.27 Slower gait speed was associated with increased severity of chemotherapy toxicity in older survivors of thoracic or colorectal cancer.33 In addition to the STEADI screening for deficits in gait, strength, and balance, screening for fall risk factors specific to cancer is warranted, such as sensory impairments from chemotherapy toxicity and cancer-related symptoms including pain, fatigue, and anemia.

The STEADI algorithm uses a multifactorial approach to examine individuals with a high fall risk based on screening results. How to stratify cancer survivors into different fall risk categories remains to be investigated. Nevertheless, additional assessment for cancer-related deficits, particularly those amendable to rehabilitation, is necessary in order to direct the treatment plan. For example, the evaluation of pain may require a multidimensional tool, such as the Edmonton Classification System for Cancer Pain, rather than a simple numerical rating scale for pain level.12 Similarly, the modified Total Neuropathy Scale (mTNS), a clinically feasible and valid measure in taxane-related CIPN,34 is useful in assessing fall risk related to chemotherapy. In breast cancer survivors, mTNS correlated with the TUG and the Sensory Organization Test,34 supporting its construct validity. Research evidence showed that cancer survivors had difficulty in integrating sensory information from different modalities, particularly when relying on the vestibular system to maintain balance.34,35 Modified Clinical Test of Sensory Interaction in Balance (mCTSIB) is a clinically feasible measure that quantifies balance control under various sensory conditions.36 Psychometrics for mCTSIB are reported in adults and in the geriatric population36,37 but has yet to be examined in cancer survivors. Balance control involves different domains, including stability limits, sensory orientation and integration, anticipatory and reactive postural control, and walking stability.38 The FABS26,30 and the Balance Evaluation System Test (BEST) and its short versions, Mini-Best and Brief-BEST,26,39,40 are comprehensive, multidimensional balance measures with demonstrated reliability and validity in cancer survivors. A self-reported measure of balance, such as the ABC and its short version, has good concurrent validity with performance-based balance tests in older cancer survivors. They provide patient-centered perspective on difficulty in balance during daily activities.29,39

In summary, older cancer survivors have unique fall risks that require further screening and examination from an oncologic perspective. More research is necessary to validate tools for fall risk associated with diverse cancer-related deficits, to stratify survivors into different fall risk categories for further examination, and to evaluate treatments targeting modifiable cancer sequelae linked to heightened fall risk.

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