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Health Behaviors of Cancer Survivors: Examining Opportunities for Cancer Control Intervention

From the Cancer Prevention Fellowship Program, Division of Cancer Prevention, and Office of Cancer Survivorship, National Cancer Institute, Bethesda; and Information Management Services Inc, Silver Spring, MD.

Address reprint requests to Keith M. Bellizzi, PhD, MPH, MA, Office of Cancer Survivorship, Division of Cancer Control and Population Sciences, National Cancer Institute, 6116 Executive Blvd, Suite 404, Bethesda, MD 20892; e-mail: bellizzk{at}mail.nih.gov

	ABSTRACT

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

 
PURPOSE: A population-based investigation was conducted to examine the prevalence of health behaviors (smoking, alcohol use, physical activity, and cancer screening) of cancer survivors by age, time since diagnosis, and cancer site. Understanding health behaviors of survivors is imperative, as many survivors are living longer and are at risk for cancer recurrence, second cancers, and complications from treatment.

METHODS: Using the National Health Interview Survey, this study examined the prevalence of smoking and alcohol use as well as whether cancer survivors (n = 7,384) are meeting current recommendations for physical activity and cancer screening compared with noncancer controls (n = 121,347).

RESULTS: Cancer survivors are similar to controls with respect to smoking status and alcohol consumption after adjusting for group differences. However, younger survivors (18 to 40 years) are at greater risk for continued smoking than controls. Survivors are 9% more likely to meet physical activity recommendations compared with controls. ² tests indicate no significant differences in smoking, alcohol consumption, and physical activity by time since diagnosis, but differences by cancer site exist. Female cancer survivors are 34% and 36% more likely to meet mammogram and Papanicolaou smear screening recommendations, respectively, compared with controls. Similar screening patterns were found for prostate-specific antigen screening in men.

CONCLUSION: This study provides benchmark approximations of the prevalence of risky health behaviors of survivors by time since diagnosis and cancer site. As part of the collective effort to reduce late effects of cancer treatment, oncologists may be in the best position to offer initial guidance for promoting healthy lifestyle behaviors among cancer survivors.

	INTRODUCTION

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In 2004, an estimated 1.4 million Americans will be diagnosed with cancer, joining approximately 9.8 million existing survivors.¹ Because of advancements in early detection and treatment, many adult cancer survivors can expect to live for decades. Despite these encouraging projections, cancer survivors are at an increased risk for recurrence, secondary cancers, late effects of treatment, and a variety of symptoms that can adversely affect quality of life.^2-7 Thus investigators are now focusing on ways to attenuate secondary health problems of cancer survivors. One area receiving increased attention among researchers is the postdiagnosis health behaviors of cancer survivors. Tertiary prevention, including smoking cessation and reducing alcohol intake, along with increasing levels of physical activity and cancer screening, may play a key role in controlling the adverse sequelae of cancer and treatment.^5,8-10

Several studies exist on the health behaviors of cancer survivors,^11-18 including Demark-Wahnefried et al's study¹¹ of 978 cancer survivors that found 58% of prostate and breast cancer survivors engaged in routine exercise after treatment; however, 8% of survivors continued to smoke. Similarly, Pinto et al¹² found that 67% of women treated for breast cancer (n = 86) reported regular moderate to intense exercise after treatment. In another study, Pinto et al¹³ found that among 74 head and neck cancer patients who smoked before their cancer diagnosis, 35% continued to smoke after surgery. Although these studies and others are an important contribution to the literature, they are often geographically restricted, rely on convenience samples, and are subject to selection bias.

The few population-based studies regarding health behaviors of cancer survivors in the United States provide a somewhat different picture.^19-22 Although not the primary focus of the study by Hewitt et al,¹⁹ these researchers found that nearly 20% of cancer survivors (n = 4,878) currently smoked in their analysis of a nationally representative survey that included survivors with a range of cancer types. Another population-based study that examined physical activity found that breast cancer survivors (n = 335) were 42% more likely than healthy controls to engage in vigorous physical activity and that 13% of breast cancer survivors continued to smoke after diagnosis, which was less than the smoking rate (21.9%) for noncancer controls.²² Findings from the Childhood Cancer Survivor Study show that among 9,709 pediatric cancer survivors, now older than 18 years, 19% of males and 15% of females were current smokers.²⁰ A more recent population-based study conducted by Coups and Ostroff²¹ estimated population-based prevalence of selected behavioral risk factors among cancer survivors (n = 1646) using the National Health Interview Survey (NHIS; 2000). These researchers found smoking rates to be higher in young survivors (37.7%) compared with noncancer controls (26.2%) while finding no significant differences in physical activity level or risky alcohol use between groups. Coups and Ostroff²¹ also examined the prevalence of health behaviors by cancer site and found little variability in behavioral patterns, with the exception of smoking. They found a high prevalence of smoking in cervical (46.0%) and uterine cancer survivors (29.4%).

The research reported here extends the focus of these population-based studies by combining 4 years of NHIS providing sufficient power for identifying subgroup (cancer type) differences in health behaviors. Second, this research examines health behaviors by time since diagnosis to assess patterns of health behaviors in survivors. Third, our work examines a broad range of health behaviors, including physical activity, smoking, alcohol use, and the less often examined cancer screening practices of survivors. This information can assist oncologists and primary care clinicians in addressing potentially problematic health behaviors of cancer survivors who are at high risk for developing complications from cancer and its treatment.

Using a cross-sectional study design and a population-based data set, the present observational study examined (1) the prevalence of smoking and alcohol use in cancer survivors compared with individuals with no history of cancer; (2) whether cancer survivors meet the American College of Sports Medicine (ACSM) and United States Center for Disease Control (CDC) recommendations for physical activity compared with controls; (3) whether the health behaviors delineated above differ by cancer site and time since diagnosis; and (4) the prevalence of sex- and age-appropriate use of breast (mammography), cervical (Papanicolaou [Pap] smear), and prostate (prostate-specific antigen [PSA] test) cancer screening in survivors compared with controls.

	METHODS

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Source of the Data
The NHIS is the primary source of information on the health of noninstitutionalized United States civilian households.²³ NHIS, a population-based survey, is administered once a year and has been collecting health-related data since 1957. The NHIS consists of two parts: (1) the basic module, which contains three components—the family core, the sample adult core, and the sample child core; and (2) supplements, which refer to a set of current health topics that vary with each survey. A wide range of health information is available, including cancer history, presence of chronic conditions, health behaviors, cancer screening behaviors, functional limitations, and important demographic characteristics.

Sampling is done using a state-stratified, multistage design to achieve a nationally representative sample of the noninstitutionalized civilian population in the United States.²³ The Hispanic and black populations are oversampled in an effort to allow for more precise estimates. The United States Census Bureau is the data collection agent. Data are collected by means of in-person interviews at participants' homes by approximately 400 trained Census field representatives. From each family in the NHIS, one sample adult and one sample child are randomly selected. In this study we analyzed data from the sample adult core ( 18 years). Each year of NHIS data represents a different population sample. The final response rate for the adult sample component was 74.0% in 1998, 69.6% in 1999, 72.1% in 2000, and 73.8% in 2001.

Participants
Of the 128,731 sample adults questioned, 7,384 reported a history of cancer. There were 210 respondents who had unknown cancer (excluding nonmelanoma skin cancer) status. This includes refused, not ascertained, and don't know responses to the questions, "Have you ever had cancer?" and "What kind of cancer?" These cases were excluded from analyses. Respondents were included as a cancer survivor if they (1) were ever diagnosed with cancer, and (2) were older than 18 years at the time of participation in the study. Unfortunately, current cancer status could not be ascertained from NHIS data and it could not be determined whether survivors currently had symptoms of cancer or were currently being treated. Respondents were excluded from all analyses if they reported being diagnosed with superficial nonmelanoma skin cancers (n = 1,437). Multiple cancer diagnoses were reported from 672 respondents. These respondents were kept in all analyses.

Measures
Demographic and health characteristics. Self-reported information were included on sex, race/ethnicity, education, family income, body-mass index (BMI) index (BMI less than 25 kg/m² is considered normal; BMI between 26 and 29 kg/m² is considered overweight, and 30 kg/m² is considered obese), functional limitations resulting from chronic illness, health insurance coverage, current health status compared with 12 months back from the time of completing the survey, current age, and age at diagnosis. For those respondents who reported a history of cancer, cancer site was obtained. Time since diagnosis was calculated by subtracting years between age at interview and reported age at initial diagnosis. If multiple cancer diagnoses were reported, age at first diagnosis was used to calculate time since diagnosis. The time since diagnosis variable had some error associated with it because of some individuals erroneously reporting years since diagnosis instead of age at diagnosis. Thus corrections for this reporting error were made.

Physical activity. Physical activity was measured using the following variables: (1) the frequency of moderate and vigorous physical activity (per week) and (2) the duration (in minutes) of each physical activity reported. This study based the measurement of physical activity on the CDC and the ACSM recommendations for physical activity.²⁴ According to the CDC/ACSM, recommended physical activity level consists of 30 minutes or more of moderate activity at least 5 days a week or 20 minutes of vigorous physical activity at least 3 days a week. This approach differs from previous recommendations in that recent research suggests the amount of activity is more important than the specific form that the physical activity takes.^24-26 For analyses, recommended physical activity level was coded as 1 if participants reported meeting current recommendations. Otherwise, physical activity level was coded as 0 for not meeting recommendations for physical activity level.

Smoking behavior. Smoking behavior was measured using respondents' self-reported smoking status. The NHIS asked respondents to indicate their current smoking status (current smoker, former smoker, or lifelong abstainer). This method of measuring smoking status in the current study was based on methods used in past studies of smoking behaviors in cancer survivors.^19,22 For descriptive purposes, we also obtained information regarding smoking frequency. Smoking status was coded as 1 if the respondent indicated "current smoker." Otherwise, smoking status was coded as 0 if the respondent indicated "former smoker" or "lifelong abstainer."

Alcohol behavior. Current alcohol use (average consumption) was measured by obtaining information related to respondents' self-reported alcohol behavior. Specifically, "lifetime abstainer," "former," "current infrequent," "current light," "current moderate," and "current heavy" were used as the measure of alcohol status. The NHIS defined lifetime abstainer as less than 12 drinks in lifetime; former was defined as 12+ drinks in lifetime but none in the past year; current infrequent was defined as 12+ drinks in lifetime, 12+ drinks in 1 year, and one to 11 drinks in past year; current light was defined as 12+ drinks in lifetime, 12+ drinks in 1 year, and three drinks per week in past year; current moderate was defined as 12+ drinks in lifetime, 12+ drinks in 1 year, and, for men, more than three drinks per week up to 14 drinks per week or, for women, more than three drinks per week up to seven drinks per week; and current heavy was defined as 12 drinks in lifetime, 12+ drinks in 1 year, and, for men, more than 14 drinks per week in past year or, for women, more than seven drinks per week in past year. Although no universally agreed on recommendations exist for alcohol consumption in survivors, there is some agreement that survivors who consume alcohol are generally urged to limit its use to one (for females) to two (for males) drinks per day.²⁷ For our analyses, alcohol status was coded as 1 if respondents reported being moderate to heavy drinkers. Otherwise, alcohol status was coded as 0.

Screening behaviors. Screening behaviors of cancer survivors were analyzed according to the United States Preventive Services Task Force (USPSTF)²⁸ recommendations for mammogram and Pap smear screening and the American Urological Association's PSA recommendations.²⁹ The NHIS asked respondents if they have ever had a mammogram (Pap smear, PSA) test. If respondents reported yes, they were asked the year of their most recent test. The USPSTF recommends mammogram screening every 12 to 33 months for women older than 40 years, even though mortality reduction evidence is strongest for women 50 to 69 years of age.²⁸ Thus mammogram screening was assessed by examining those age groups (40 to 49, 50 to 69, > 70 years). Screening for breast cancer was coded as 1 if participants were screened with a mammogram test within the last 2 years and 0 if they were not. NHIS collects data on most recent cancer screening in years, thus we were only able to approximate the USPSTF recommendations for mammography. USPSTF recommends Pap smear screening for women at least once every 3 years after onset of sexual activity.²⁸ Hence all female cancer survivors were assessed as one age group (> 18 years) and compared with controls. Pap smear was coded as 1 if screened within the last 3 years. Otherwise, Pap smear screening was coded as 0. Although USPSTF found evidence that PSA can detect early-stage prostate cancer, they suggest the evidence is inconclusive whether early detection improves health outcomes.²⁸ However, the American Urological Association²⁹ recommend annual screening for men beginning at age 50 years. Thus PSA screening was examined beginning at age 50 years and was coded as 1 if screened within the last year; otherwise, PSA screening was coded as 0. We excluded breast cancer cases from our analysis of the mammography screening question, prostate cancer cases from the PSA question, and gynecologic (cervical, uterus, and ovarian) cancer cases from the Pap smear screening question.

Data Analysis Methods
The data collected in the NHIS are obtained through a complex sample design involving stratification, clustering, and multistage sampling. All estimates presented are weighted to provide national estimates. Variance estimates for proportions and logistic regression model odds ratios were calculated using Survey Design and Analysis (Research Triangle Institute; Research Triangle Park, NC) to take into account the complex design of the survey. Descriptive statistics and ² tests were used to examine demographic characteristics and differences between the cancer group and the noncancer group according to age, sex, education, income, ethnicity, BMI, limitations on activities, perceived health status, and health insurance status. Given the large sample size, we used a stringent P value and only covariates significant at .001 were included in multivariate models.

To examine the first question, descriptive statistics and logistic regression models are presented to indicate whether current smoking status, alcohol status, and physical activity differ between cancer survivors and respondents without a history of cancer. A logistic regression model is also presented to examine the second question, namely, whether cancer survivors are meeting the CDC/ACSM recommendations for physical activity compared with controls. To answer the third question, multiple ² analyses with Bonferroni adjustments were conducted to examine statistically significant differences between health behaviors by time since diagnosis and cancer site. The last question, whether rates of mammogram, Pap smear, and PSA screening behaviors differ between cancer survivors and noncancer controls, was addressed using logistic regression.

	RESULTS

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Characteristics of Cancer Survivors
² analyses showed that self-identified cancer survivors compared with respondents with no reported history of cancer were significantly more likely to be older (52.7% v 17.4% age 65 years), white (88.5% v 73.4%), female (60.6% v 51.6%), to report functional limitations (59.2% v 29.1%), and less likely to report their health status as excellent (14.4% v 33.0%; Table 1). Cancer survivors and those reporting no history of cancer were similar with respect to education, BMI, income, and current health insurance coverage. Table 2 shows the distribution of cancer sites and years since diagnosis among cancer survivors.

Are Cancer Survivors Meeting Physical Activity Recommendations?
The proportion of cancer survivors who met the CDC/ACSM recommendations for physical activity level was 29.6%, compared with 36.6% for those without a history of cancer (Table 3). Cancer survivors 18 to 40 years of age were more likely to meet the CDC/ACSM recommendations (37.6%) than survivors age 40 to 64 years of age (33.0%) and survivors 65 years of age (24.9%). After adjusting for demographic and health characteristics, including functional limitations, multivariate logistic regression analysis found cancer survivors were 9% more likely to meet the CDC/ACSM physical activity recommendations compared with those respondents with no history of cancer (OR = 1.09; 95% CI, 1.03 to 1.16).

Does Smoking Status, Physical Activity, and Alcohol Use Differ by Time Since Diagnosis and Across Cancer Sites?
Although multiple ² tests of health behaviors by year since diagnosis (< 1, 1, 2 to 4, 5 to 9, and 10 years) indicated no significant differences after making adjustments for multiple comparisons, we did find interesting trends. Current smoking use was highest (23.3%) in the first year from diagnosis and showed a downward trend (19.4%) in the years after diagnosis, with a slight upward spike (22.7%) in longer-term survivors ( 10 years). With respect to physical activity, survivors 2 to 4 years after diagnosis and 5 to 9 years after diagnosis were more likely to meet physical activity recommendations (32.6% and 33.3%, respectively) compared with survivors less than 1 year from diagnosis (26.9%) and 1 year after diagnosis (27.7%). Also of note, survivors 5 to 9 years after diagnosis were more likely to meet physical activity levels (33.3%) compared with those survivors more than 10 years from diagnosis (29.5%).

As shown in Table 4, multiple ² tests with Bonferroni adjustments for multiple comparisons show several significant differences in health behaviors by cancer site. The rates of smoking in breast, prostate, and colorectal cancer survivors were significantly lower than those of noncancer controls (23.6%). The gynecologic cancers (37.3%) and lung, larynx, and pharynx combined (20.6%) seem to be driving the high smoking rates in cancer survivors. We see a higher proportion of breast (28.7%), prostate (30.1%), and gynecologic (29.4%) cancer survivors meeting current physical activity recommendations compared with the other sites. Lastly, a higher proportion of prostate (22.3%), lung, larynx, and pharynx (24.1%) cancer survivors are consuming moderate-to-heavy alcohol. As shown in Table 3, health behaviors differ by age. For instance, smoking rates are higher in younger age groups, and it is possible that some of these differences by cancer site may in part be attributed to differences in age distributions by site.

	DISCUSSION

TOP ABSTRACT INTRODUCTION METHODS RESULTS DISCUSSION Authors' Disclosures of... REFERENCES

Almost three fourths of cancer survivors are not meeting recommendations for physical activity. These findings differ from previous research that found that 67% of breast cancer survivors¹² and 58% of prostate and breast cancer survivors¹¹ engage in routine exercise after treatment. Perhaps these differences could be explained by the characteristics of the respective samples. For instance, patients in the above two studies were from higher economic and educational backgrounds compared with the patients in the current nationally representative study; hence the cancer survivors in the cited studies might have had fewer barriers to activities. Our physical activity findings also differ from the previous population-based study that used 1 year of NHIS data.²¹ Our study found survivors were more likely to meet recommended levels of physical activity compared with controls, whereas the study by Coups and Ostroff²¹ noted no significant differences between survivors and controls across the three age groups, with the exception of the higher prevalence of physical inactivity in 40- to 64-year-old survivors (74.2%) compared with controls (69.2%). We suspect the differences found between studies are due to our adjusting for statistically significant differences in reported functional limitations between survivors and controls.

Although our physical activity findings for both cancer survivors and noncancer controls are representative of an existing national trend and raise major concerns for the overall health of the United States population, many cancer survivors may be at increased risk for chronic conditions as a result of their treatment,^6,9,37 partly as a function of their inactivity. The Agency for Healthcare Research and Quality released a new report on the effectiveness of exercise on cancer survivors' health.³⁸ The report concluded that physical activity can improve a cancer survivors' physiologic and psychosocial health, including cardiorespiratory fitness, fatigue, and tiredness, and quality of life. Similarly, recently released findings from the Nurses Health Study show that physical activity can increase the odds of disease survival in breast cancer survivors.⁹

The United States Department of Health and Human Services recently published revised physical activity guidelines for Americans,³⁹ suggesting that our nationally representative sample of survivors and controls are even further away from meeting recommended levels than what is reported in this study. Although physical activity guidelines exist for cancer survivors, such as the American Cancer Society report³⁹ on nutrition and physical activity, survivors may not be aware of these recommendations. Cancer survivors could benefit from short informational fact sheets describing current physical activity recommendations. Oncologists may be in the best position to provide guidance, resource support, and motivation for engaging in the appropriate amount of exercise based on the survivor's unique health and functional abilities. Research has shown that physician-delivered exercise promotion messages are a powerful catalyst in motivating exercise behavior change.⁴⁰ Additionally, clinical trials have shown physician-delivered health promotion interventions to be effective in improving fitness level and adherence in the general population.^41,42

With respect to alcohol use, we identified differences in consumption by cancer site. Most notably, our findings show a higher proportion of moderate-to-heavy alcohol use in prostate and lung, larynx, and pharynx cancer survivors. However, given the lack of universally accepted alcohol recommendations for cancer survivors, our intent is not to draw firm conclusions from these findings. Perhaps, older cancer survivors are consuming alcohol for its known cardiovascular benefits. Nevertheless, these findings should at the very least alert clinicians to the fact that some cancer survivors will consume moderate-to-heavy alcohol after their diagnosis. Clinicians' ability to manage survivors' medication use may become important as the risk for adverse reactions from multiple medications, prescribed by multiple providers, increase with alcohol use.⁴³ Findings from this study indicate that 20% of cancer survivors 65 years of age reported drinking 7 days a week, which is also similar to those individuals without a history of cancer (18.6%). This pattern of alcohol behavior found in the present study may raise special concern for older survivors, as adults 65 years of age (12% of the United States population in 2004) account for 34% of consumers of all prescription medicines and 30% of consumers of all nonprescription medications.⁴⁴

Perhaps the most encouraging finding from our analyses is that female cancer survivors were 34% and 36% more likely than noncancer controls to meet the USPSTF recommendations for mammogram and Pap smear screening, respectively. Similarly, male cancer survivors in our analyses were 32% more likely that controls to meet PSA screening recommendations. Although the efficacy of PSA screening has not been demonstrated, it is apparent that male cancer survivors are either seeking PSA screening or physicians are recommending this test as part of their care. The differences in cancer screening patterns between survivors and noncancer controls are likely due to close follow-up care for survivors as opposed to the standard of care or perhaps lack of care for those without cancer. Recent data suggest clinicians are the most influential vehicles for promoting behavioral change in cancer screening patterns,⁴⁵ which likely accounted for our study finding higher screening rates in cancer survivors versus individuals without a history of cancer. Perhaps oncologists and primary care physicians can capitalize on their demonstrated aptitude to influence cancer screening behaviors by expanding their message to include guidance for other healthy lifestyle behaviors.

There are several limitations to using NHIS data to examine health behaviors of cancer survivors. First, this study relied on self-reported data. Hence the rates of reported smoking and alcohol consumption might have been underestimated, whereas physical activity levels and screening to some degree might have been overestimated as a result of social desirability. Second, because of the cross-sectional nature of this data, we are unable to examine prediagnosis health behaviors. Although cancer survivors and noncancer controls seem to smoke and drink at similar rates, we are unable to assess whether survivors may have reduced their prediagnosis exposure to these harmful lifestyles and are headed in the right direction as a result of their diagnosis. To that end, oncologists may be successfully intervening if they are reducing smoking rates in pharynx cancer patients from 85% to 20%, for example. The nature of NHIS data does not allow that exploration. A third limitation of the study is that the NHIS did not allow us to ascertain current cancer care status. Thus we were unable to determine the percentage of cancer survivors who were actively dealing with treatment or recurrent/advanced disease versus those living disease and/or symptom free. It is possible that the physical activity findings were skewed toward inactivity if cancer survivors were actively dealing with disease. Lastly, cancer survivors who live in nursing homes, long-term care facilities, or hospice are not included in the survey, so the extrapolation of our findings is limited to noninstitutionalized United States civilians.

This study provides oncologists and clinicians who provide cancer care with population-based benchmark approximations regarding risky health behaviors that cancer survivors are engaging in by age, time since diagnosis, and cancer site. We suggest that the post-treatment patient debriefing provides a teachable moment^35,46 when cancer survivors are more receptive and willing to take an active role in their post-treatment care. As part of the larger collective health promotion effort, oncologists may be in the best position to provide initial direction and guidance to their patients during the course of, and after, cancer treatment. A recent study has found less than one quarter of physicians provide health promotion counseling to their patients.¹⁰ Oncologists can capitalize on their influential position and play a critical role in the uptake and maintenance of positive health behaviors by simply providing survivors with the knowledge that they are at an increased risk for developing long-term complications from their treatment and offering guidance and appropriate referrals for managing those risks. Cancer survivors are now living longer and represent a rapidly growing population, especially in coming years as the baby boom generation ages. Thus we need to recognize the health behavior practices of survivors and use this information to increase the knowledge of survivors and practitioners and to develop targeted behavioral interventions that can help survivors manage the adverse consequences of cancer and its treatment.

	Authors' Disclosures of Potential Conflicts of Interest

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The authors indicated no potential conflicts of interest.

	NOTES

 
Authors' disclosures of potential conflicts of interest are found at the end of this article.

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Submitted April 1, 2005; accepted August 23, 2005.

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