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. Author manuscript; available in PMC: 2016 Jun 3.
Published in final edited form as: Psychooncology. 2013 Apr 19;22(10):2270–2282. doi: 10.1002/pon.3288

A population-based study comparing HRQoL among breast, prostate, and colorectal cancer survivors to propensity score matched controls, by cancer type, and gender

Traci LeMasters 1,*, Suresh Madhavan 1, Usha Sambamoorthi 1, Sobha Kurian 2
PMCID: PMC4892175  NIHMSID: NIHMS789890  PMID: 23606210

Abstract

Background

Objectives were to compare health-related quality of life (HRQoL) between breast cancer survivors, prostate cancer survivors (PCS), and colorectal cancer survivors (CCS) to matched controls, stratified by short and long-term survivors, by cancer type, and gender.

Methods

By using the 2009 Behavioral Risk Factor Surveillance System, propensity scores matched three controls to adult survivors >1 year past diagnosis (N = 11,964) on age, gender, race/ethnicity, income, insurance status, and region of the USA Chi-square tests and logistic regression models compared HRQoL outcomes (life satisfaction, activity limitations, sleep quality, emotional support, general, physical, and mental health).

Results

Although all cancer survivors reported worse general health (p < 0.000) and more activity limitations (p < 0.004) than controls, these disparities decreased among long-term survivors. Short-term PCS and male CCS were more likely to report worse outcomes across additional domains of HRQoL than controls, but PCS were 0.61, 0.63, and 0.70 times less likely to report activity limitations, fair/poor general health, and 1–15 bad physical health days in the past month than male CCS. Breast cancer survivors and female CCS were 2.12 and 3.17, 1.58 and 1.86, and 1.49 and 153, respectively, times more likely to report rarely/never receiving needed emotional support, 1–15 bad mental health days in the past month, and not receiving enough sleep 1–15 days in the past month than PCS and male CCS.

Conclusions

Cancer survivors experience worse HRQoL than similar individuals without a history of cancer and the severity of affected HRQoL domains differ by time since diagnosis, cancer type, and gender.

Introduction

HRQoL of cancer survivors

Over two-thirds of the 12.5 million cancer survivors in the USA are now living ≥5 years post diagnosis, with survivors of breast (22%), prostate (20%), and colorectal cancer (9%) comprising over 50% of the survivor population [1,2]. Yet, many cancer survivors experience late and/or long lasting symptoms and effects attributable to the cancer, and its treatment that are detrimental to their physical, mental, psychosocial, and functional health statuses, and consequently, health-related quality of life (HRQoL). Numerous study findings have consistently documented the unique and shared symptoms and effects experienced by breast, prostate, and colorectal cancer survivors. Breast cancer survivors often experience physical limitations, pain, and swelling in the arm and/or shoulder near the surgery site, hormonal and fertility changes, chronic fatigue and sleep disturbances, anxiety and depression, sexual dysfunction, and dissatisfaction with body image. Similarly, prostate and colorectal cancer survivors often experience pain at the surgery site, chronic fatigue and sleep disturbances, anxiety and depression, sexual dysfunction. Additional symptoms include urinary and bowel dysfunction, dissatisfaction with body image due to changes in physical appearance associated with androgen deprivation therapy for prostate cancer or the presence of an ostomy among some colorectal cancer survivors, a factor also associated with additional social limitations [3–7]. Although the various domains of HRQoL affected are similar among breast, prostate, and colorectal cancer survivors, these symptoms and effects vary according to type of surgery and treatment, stage at diagnosis, time since diagnosis, age, race, income, education, available social and emotional support, and health status [3,4].

Differences in HRQoL between individuals with and without a history of cancer

Population-based studies describing differences in HRQoL between cancer survivors and individuals without a history of cancer have reported less consistent findings. Studies from the USA and Australia found that breast cancer survivors reported more activity/role limitations and worse general/global health compared with individuals without a history of cancer [8–10]. However, disagreement between studies exists regarding disparities in physical and mental health [9–11]. Although two population-based studies found that prostate cancer survivors reported more activity/role limitations and worse general, physical, and mental health compared with individuals without a history of cancer [10,12], conflicting findings between these domains of HRQoL have been reported by other studies [9,11]. Likewise, several studies have reported consistent findings regarding activity/role limitations and worse general and physical health, but no differences in mental health of colorectal cancer survivors, compared with individuals without a history of cancer [8,9,11]. Yet, a longitudinal study observed disparities in mental health, but not physical health among colorectal cancer survivors, compared with individuals without a history of cancer [13].

Differences in HRQoL between cancer types and genders

Despite the fact that breast, prostate, and colorectal cancer survivors experience similarly affecting domains of HRQoL, little is known about the variation in severity of these detriments between survivors. Two studies that compared HRQoL between cancer types reported more activity limitations and worse general health among colorectal cancer survivors, compared with breast and prostate cancer survivors; however, breast cancer survivors reported worse mental than prostate and colorectal cancer survivors [8,9].

Considerable research on HRQoL among individuals with various chronic diseases and serious health conditions have observed notable differences between genders [14–17]. However, studies of gender differences in HRQoL among cancer survivors have primarily been limited to survivors of colorectal and head and neck cancers. Findings from two studies of long-term colorectal cancer survivors found that women reported worse physical and mental health, and more sleep disturbances and fatigue than men [6,18]. Although cancer type cannot be controlled for when comparing breast and prostate cancer survivors, both cancers are gender and hormone-specific, predominantly occurring in individuals aged ≥65 years, and have relatively high 5-year survival rates (89% and 99.2%, respectively) compared with other cancers [1]. Therefore, if a pattern of differences in HRQoL between breast and prostate cancer survivors was similar to those observed between female and male colorectal cancer survivors, it would suggest that the differences are a function of gender.

Statement of the problem and study aims

The differences in findings reported by studies comparing HRQoL between cancer survivors and individuals without a history of cancer may be attributable to differences in sample size, sample selection (age, short-term or long-term survivors only, and country of origin), and study design (matched case–control comparison or no matching). Studies that utilized a comparison group matched on few variables and therefore may have not completely eliminated the observed differences in characteristics between cancer survivors and non-cancer controls. Moreover, work by Harrop et al. has highlighted that vast majority of published research regarding the HRQoL of cancer survivors has focused on breast cancer survivors [19]. Consequently, the association between a history of cancer, cancer type, gender, and HRQoL among breast, prostate, and colorectal cancer survivors remains unclear.

Therefore, the primary goal of this study was to determine the unique health care needs of cancer survivors by comparing a range of HRQoL outcomes among short and long-term breast, prostate, and colorectal cancer survivors to groups of non-cancer controls matched to each cancer type on many important variables, between cancer types, and genders using a large and nationally representative US sample. Specific study aims were as follows: (i) to compare the prevalence of HRQoL outcomes, specifically life satisfaction, perceived level of emotional support, activity limitations, perceived general health, perceived physical health, perceived mental health, and sleep quality between breast, prostate, female colorectal, and male colorectal cancer survivors to their non-cancer controls matched on age, gender, race/ethnicity, income, insurance status, and region of the USA using propensity scores; (ii) to compare the odds of specific HRQoL outcomes for each cancer type to their non-cancer controls by fitting adjusted logistic regression models stratified by time since diagnosis (1–5 and >5 years) to determine changes in HRQoL over the course of the cancer survivorship continuum; and(iii) to compare the odds of specific HRQoL outcomes between cancer types (breast cancer vs. female colorectal and prostate vs. male colorectal) and gender (female vs. male colorectal and breast vs. prostate) to determine differences in HRQoL associated with cancer type and gender.

Methods

Study design

This study used a retrospective, cross-sectional matched case–control design. Breast, colorectal, and prostate cancer survivors were matched on various categories of age, gender, race/ethnicity, income, insurance status, and region of the USA.

Data

Cancer survivors and controls were derived from the Centers for Disease Control’s national 2009 Behavioral Risk Factor Surveillance System (BRFSS) survey [20]. The BRFSS is an annual, state-based telephone survey administered to non-institutionalized citizens aged 18 years and older in all 50 states, the District of Columbia, Puerto Rico, the US Virgin Islands, and Guam. The survey collects information pertaining to disease prevalence, risky health behaviors, preventive health care utilization, perceived health status, access to health care services, sociodemographic, and environmental characteristics. The core component is a standard set of questions administered to all states and territories. In 2009, the response rate was 52.5%, resulting in a total sample size of 432,607 [21,22]. Optional modules collect additional information on selected topics and are administered on a state by state basis. This study only utilized data from the core component file, excluding responses from Puerto Rico, the US Virgin Islands, and Guam.

Study sample

Cancer survivors

Breast, prostate, and colorectal cancer survivors were identified by the following questions in the Cancer Survivors section of the core module: “Have you ever been told by a doctor, nurse, or other health professional that you had cancer?” and “What type of cancer was it?” The question, “At what age were you told that you had cancer?” allowed for the calculation of time since diagnosis by subtracting the age at diagnosis from the currently reported age. The question “How many different types of cancer have you had?” allowed for the identification of primary cases of breast, prostate, or colorectal cancers. Inclusion criteria were survivors of a primary case of breast, prostate, or colorectal cancer only, (cases of colon and rectal cancer combined), age >18 years at the time of diagnosis, and survivors >1 year post diagnosis to avoid the competing interest of possible ongoing treatment. Male breast cancer survivors and individuals with a missing response for any HRQoL outcome were excluded from the sample. Questions regarding the stage at diagnosis, type of treatment received, or presence of an ostomy among colorectal cancer survivors were not asked in the survey and therefore could not be controlled for in this study. The final sample consisted of 6393 breast, 3636 prostate, 1111 female colorectal, and 824 male colorectal cancer survivors.

Controls

Similar to survivors, non-cancer controls selected were age >18 years and without missing responses for any dependent variables. Logistic regressions generated propensity scores for survivors and potential non-cancer controls conditional upon the probability of the individual having had cancer and belonged to various categories of age, gender, race/ethnicity, income, insurance status, and region of the USA. A 3:1 ratio of controls to survivors was matched without replacement using the greedy algorithm, also known as nearest neighbor matching. In this algorithm, the first control that is matched to a case is the one with the most similar propensity score to the case. All cases are matched to a first set of controls, followed by a second and third round of matching. After matching, Chi-square tests were performed to determine covariate balance between survivors and non-cancer controls. Balance was achieved between survivors and controls for all covariates adjusted for in the matching process. Additionally, there was no difference in marital and metro statuses between survivors and non-cancer controls. However, breast cancer survivors are more frequently reported being a college/technical school graduate than their non-cancer controls (36.5% vs. 32.1%) (p < .000) and prostate cancer survivors more frequently reported being unemployed than their non-cancer controls (76.2% vs. 73.1%) (p = .049).

Measures

Dependent variables

Measures of HRQoL consisted of the following: (i) general health (excellent/very good, good, fair/poor); (ii) activity limitations (yes or no) because of physical, mental, or emotional problems; (iii) number of days physical health was not good during the past 30 days (none, 1–15 days, 16–30 days); (iv) number of days mental health was not good during the past 30 days (none, 1–15 days, 16–30 days); (v) number of days did not get enough sleep during the past 30 days (none, 1–15 days, 16–30 days); (vi) how often received social support (always/usually, sometimes, rarely/never); and (vii) life satisfaction (very satisfied/satisfied or dissatisfied/very dissatisfied).

Independent variables

This study was conceptualized using Ronald M. Andersen’s Behavioral Model of Health Services Use framework to examine the association between health care environment, predisposing, enabling, need factors, and HRQoL outcomes. Andersen’s model is often used to guide studies of health behaviors and health outcomes [23]. Under this theory, an individual’s health care use and outcomes, in our case HRQoL, are influenced by his or her predisposing characteristics including age, gender, race/ethnicity (White, African American, Latino, and Other), education, and time since diagnosis (1–5 and >5 years); and enabling resources including marital status, employment status (employed and unemployed, where for this study “employed” = employed for wages or self-employed, and “unemployed” = out of work >1 year, out of work <1 year, homemaker, student, retired, or unable to work), insurance status, income, and usual source of care. The BRFSS assesses whether an individual has a usual source of care by asking, “Do you have one person you think of as your personal doctor or health care provider?” The external health care environment factors included metro status (metro or non-metro) and region of the USA. (Northeast, Midwest, West, and South), as defined by the US Census [24]. Need factors were presence of cancer and specific health conditions that confirmed with an affirmative response to the question “Has a doctor, nurse, or other health professional ever told you that you had any of the following?” Health conditions controlled for were arthritis, asthma, diabetes (diabetes, gestational diabetes, or borderline diabetes), hypertension, high cholesterol (adults who had their blood cholesterol checked and told it was high), heart disease (myocardial infarction, angina or coronary heart disease), and stroke.

Statistical methods

Chi-square tests compared significant differences in HRQoL measures by predisposing, enabling, need, and external health care environment factors between survivors and non-cancer controls, with significance set at p ≤ .05. Odds ratios for HRQoL measures were estimated using adjusted binary and multinomial logistic regressions. Binary logistic regression was used to model life satisfaction (very satisfied/satisfied) and activity limitations (yes). Multinomial logistic regression was used to model level of emotional support (rarely/never and sometimes), perceived general health (fair/poor and good), perceived physical health (>15 days and 1–15 days), perceived mental health (>15 days and 1–15 days), and sleep quality (>15 days and 1–15 days). Outcomes modeled are shown in parenthesis.

Regressions comparing survivors to non-cancer controls were stratified by time since diagnosis (1–5 years and >5 years). All models were adjusted for predisposing, enabling, need, and external healthcare environment factors. Adjusted odds ratios (AOR) and corresponding 95% confidence intervals (CI) of cancer compared with non-cancer controls, cancer type, and gender are presented in tables. All analyses were conducted using survey procedures in SAS version 9.2 software (SAS Institute Inc., Cary, NC, USA), to account for the complex sample design of the BRFSS. This study was conducted using de-identified, secondary data and meets West Virginia University Internal Review Board requirements for protocol approval exemption as “not human subjects research”. All investigators have been Human Subjects Research and Health Insurance Portability and Accountability Act certified through the Collaborative Institutional Training Initiative.

Results

Description of cancer survivors

Table 1 provides a description of survivors by their predisposing, enabling, and external health care environment characteristics. The majority of survivors were living >5 years post diagnosis (58.8–71.1%). The mean years since diagnosis for breast, female colorectal, male colorectal, and prostate cancers were 11.9, 11.5, 10.1, and 8.1 years, respectively. Most were 65 years of age and older (54.0–76.4%), white (78.6–83.3%), married (56.4–77.1%), unemployed (63.8–76.6%), and insured (95.7–97.9%).

Table 1.

Description of cancer survivors and non-cancer controls behavioral risk factor surveillance system, 2009.

BC BC controls CC (female) CC controls CC (Male) CC controls PC PC controls
N Wt. % N Wt. % N Wt. % N Wt. % N Wt. % N Wt. % N Wt. % N Wt. %
All 6393 25.0 19179 75.0 Sig. p value 1111 25.0 3333 75.0 Sig. p value 824 25.0 2472 75.0 Sig. p value 3636 25.0 10908 75.0 Sig. p value
Time since diagnosis (years) — — — —
  1–5 1807 28.9 — — 340 33.6 — — 303 40.2 — — 1418 41.2 — —
  >5 4586 71.1 — — 771 66.4 — — 521 59.8 — — 2218 58.8 — —
Age (years) 0.426 0.967 0.936 0.151
  18–49 390 10.2 1170 12.0 40 6.8 120 8.0 36 8.8 108 10.9 18 1.1 54 2.6
  50–54 477 10.6 1432 10.0 57 8.2 170 8.6 37 6.5 111 6.8 63 3.4 189 2.7
  55–59 703 12.2 2119 11.7 90 7.8 270 8.6 75 10.4 225 9.3 171 5.8 516 6.3
  60–64 906 13.0 2716 13.7 114 10.6 342 10.4 115 14.9 347 14.6 412 13.2 1240 13.2
  65–69 989 13.4 2959 13.2 129 10.4 388 9.2 141 15.8 425 16.4 602 13.3 1815 14.8
  70–74 938 11.9 2820 12.2 190 16.7 570 15.0 126 13.7 377 12.7 735 17.8 2175 18.3
  ≥ 75 1990 28.7 5963 27.2 491 39.5 1473 40.1 294 29.9 879 29.4 1635 45.3 4919 42.0
Gender 1.000 1.000 1.000 1.000
  Female 6393 100.0 19179 100.0 1111 100.0 3333 100.0 0 0.0 0 0.0 0.0 0.0 0.0 0.0
  Male 0 0.0 0 0.0 0 0.0 0 0.0 824 100.0 2472 100.0 3636 100.0 10908 100.0
Race/ethnicity 0.280 0.281 0.456 0.561
  White 5559 80.6 16681 81.6 971 83.3 2913 80.3 704 80.7 2116 79.8 3057 78.6 9203 77.7
  AA 407 9.9 1226 7.9 78 10.5 231 8.8 53 10.2 154 8.2 355 12.4 1039 13.3
  Latino 163 5.2 483 5.4 26 2.1 79 5.2 33 6.3 97 7.9 93 5.5 277 4.6
  Other 264 4.3 789 5.1 36 4.2 110 5.6 34 2.8 105 4.0 131 3.6 389 4.4
Marital status 0.107 0.296 0.401 0.192
  Married 3019 59.4 9174 58.9 442 56.4 1321 52.0 524 75.0 1614 75.3 2501 77.1 7263 75.8
  Widowed 1978 22.3 6169 22.8 446 26.8 1362 30.9 142 11.1 377 8.9 561 10.6 1877 11.6
  Sep/Divorced 1030 13.4 2813 12.1 178 13.4 501 13.0 107 9.4 334 10.8 405 9.1 1228 8.3
  Never Married 366 4.9 1023 6.2 45 3.4 149 4.1 51 4.4 147 5.0 169 3.3 540 4.3
Education 0.000*** 0.367 0.114 0.606
  <HS 445 6.4 1762 8.8 142 15.2 415 13.9 99 11.7 287 11.4 385 9.7 1235 10.5
  HS Grad 2008 29.6 6537 31.9 414 36.4 1256 33.6 264 30.5 747 28.8 979 25.4 3151 26.7
  Some Col/TS 1832 27.5 5297 27.2 324 26.6 836 25.6 193 25.5 557 21.0 795 22.7 2382 22.5
  Col/TS Grad 2108 36.5 5583 32.1 231 21.9 826 26.9 268 32.3 881 38.9 1477 42.1 4140 40.3
Employment status 0.062 0.332 0.822 0.049 *
  Employed 1935 33.1 6054 35.5 216 23.9 747 26.8 248 36.2 736 36.9 795 23.8 2662 26.9
  Unemployed 4458 66.9 13125 64.5 895 76.1 2586 73.2 576 63.8 1736 63.1 2841 76.2 8246 73.1
Family income 0.191 0.585 0.433 0.993
  <$25,000 1884 24.9 5658 24.6 442 31.9 1331 34.6 245 26.2 738 28.3 798 19.5 2383 19.7
  $25,000–$35,000 849 10.9 2545 12.1 150 12.2 454 13.1 114 13.4 342 11.7 501 12.1 1492 11.6
  $35,000–$50,000 932 14.6 2788 14.6 136 12.5 402 12.2 124 14.7 370 12.8 641 17.5 1934 17.2
  $50,000–$75,000 758 12.0 2267 13.1 96 12.6 288 10.6 112 16.8 336 14.2 575 15.7 1694 15.5
  >$75,000 1084 22.8 3253 22.8 117 13.5 348 15.3 158 22.1 476 25.7 776 25.0 2312 25.8
  Missing/DK 886 14.8 2668 12.7 170 17.3 510 14.2 71 6.9 210 7.3 345 10.2 1093 10.2
Insurance status 0.769 0.893 0.707 0.790
  Insured 6156 95.8 18482 96.0 1076 95.7 3221 95.9 789 96.0 2374 95.5 3557 97.9 10697 98.0
  Uninsured 237 4.2 697 4.0 35 4.3 112 4.1 35 4.0 98 4.5 79 2.1 211 2.0
Usual source of care 0.000*** 0.651 0.000*** 0.000***
  Yes 6151 96.0 18007 93.2 1078 94.9 3169 94.0 776 94.6 2238 89.2 3498 96.4 10099 93.2
  No 236 4.0 1149 6.8 33 5.1 157 6.0 48 5.4 231 10.8 132 3.6 795 6.8
Region of the USA 0.406 0.954 0.921 0.170
  Northeast 1235 22.0 3710 20.4 198 21.0 594 20.1 153 16.4 454 17.7 615 19.6 1861 18.0
  Midwest 1609 24.1 4825 23.8 319 25.2 953 24.5 213 24.3 632 23.7 893 23.4 2670 22.4
  South 1972 33.8 5926 34.3 373 36.9 1125 37.4 271 40.3 818 39.0 1156 36.2 3522 39.8
  West 1577 20.1 4718 21.5 221 16.8 661 18.0 187 19.0 568 19.5 972 20.8 2855 19.9
Metro status 0.067 0.300 0 893 0.274
  Metro 4264 82.1 12525 80.5 693 77.9 2099 80.2 516 79.1 1570 79.4 2368 81.0 7119 79.8
  Non-metro 2106 17.9 6562 19.5 414 22.1 1216 19.8 303 20.9 893 20.6 1253 19.0 3739 20.2
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BC, breast cancer; CC, colorectal cancer; PC, prostate cancer; AA, African American; Sep, separated; HS, high school; Grad, graduate; Col, college; TS, technical school; DK, don’t know; Perc, perceived; excel, excellent.

Asterisks represent significant differences compared with the reference group.

***

p < .001.

**

p < .01.

*

p < .05.

HRQoL of cancer survivors compared with non-cancer controls

Prevalence comparisons of HRQoL outcomes between survivors and their non-cancer controls are presented in Table 2. All cancer types reported more activity limitations and poorer general health than non-cancer controls; however, male and female colorectal cancer survivors reported the greatest prevalence of activity limitations [(39.4% vs. 23.9%) (p < .000) and (37.0% vs. 28.4%) (p = .003)] and poorer general health [(28.7% vs. 21.2%) (p < .000) and (34.8% vs. 23.3%) (p < .000)] compared with their non-cancer controls. Additionally, male colorectal cancer survivors reported more bad physical health days (p = .004) and less life satisfaction (p = .025) than their non-cancer controls, whereas female colorectal cancer survivors reported more bad mental health days (p = .039) than their non-cancer controls. Prostate cancer survivors reported more days of not enough sleep (p = .021) than their non-cancer controls.

Table 2.

Comparison of health-related quality of life of cancer survivors and non-cancer controls behavioral risk factor surveillance system, 2009.

BC BC controls CC (female) CC controls CC (male) CC controls PC PC controls
N Wt. % N Wt. % N Wt. % N Wt. % N Wt. % N Wt. % N Wt. % N Wt. %
All 6393 25.0 19179 75.0 Sig.
p value		 1111 25.0 3333 75.0 Sig.
p value		 824 25.0 2472 75.0 Sig.
p value		 3636 25.0 10908 75.0 Sig.
p value
Life satisfaction 0.221 0.608 0.025* 0.377
  Very satisfied/satisfied 5713 94.8 17147 95.5 968 95.9 2949 95.3 717 92.7 2188 95.9 3239 96.5 9783 97.0
  Dissat/very dissat 299 5.2 825 4.5 45 4.1 141 4.7 32 7.3 106 4.1 141 3.5 317 3.0
Receive needed emotional support 0.413 0.280 0.085 0.196
  Always/usually 353 6.0 1228 6.8 73 6.2 237 8.4 87 12.7 253 10.7 404 10.2 1264 11.9
  Sometimes 725 11.7 2190 12.3 137 13.8 411 12.1 111 16.2 304 12.1 411 12.8 1173 11.5
  Rarely/never 4934 82.3 14554 80.9 803 80.0 2442 79.5 551 71.0 1737 77.2 2565 77.0 7663 76.6
Activity limitations <0.001*** 0.004** 0.001*** 0.005**
  Yes 2043 30.6 5401 25.6 389 37.0 1011 28.4 296 39.4 720 23.9 1117 29.3 2972 25.2
  No 4328 69.4 13702 74.4 716 63.0 2305 71.6 524 60.6 1742 76.1 2505 70.7 7896 74.8
Perceived general health <0.001*** <0.001*** <0.001*** <0.001***
  Excellent/very good 2426 41.7 8976 52.8 333 32.3 1364 44.9 243 31.8 1038 48.5 1260 38.1 4534 46.1
  Good 2162 36.5 5531 29.1 351 32.9 990 31.7 266 39.5 700 30.4 1238 38.9 3419 33.8
  Fair/poor 1424 21.8 3465 18.1 329 34.8 736 23.3 240 28.7 556 21.2 882 23.1 2147 20.2
Days perceived physical health bad in past month 0.146 0.133 0.004** 0.712
  None 3505 59.4 11229 62.0 546 52.1 1858 58.3 461 60.5 1529 68.7 2205 67.0 6931 68.3
  1–15 1746 28.7 4697 27.2 298 32.6 835 28.7 184 28.2 474 20.1 781 22.4 2113 21.4
  >15 761 11.9 2046 10.8 169 15.3 397 13.0 104 11.3 291 11.2 394 10.6 1056 10.3
Days perceived mental health bad in past month 0.550 0.039* 0.368 0.118
  None 4248 69.9 13061 70.0 734 67.2 2299 72.6 609 79.5 1885 82.0 2813 82.9 8624 85.2
  1–15 1367 23.5 3855 24.2 210 24.5 644 23.0 103 15.8 291 12.9 438 13.5 1103 11.2
  >15 397 6.5 1056 5.9 69 8.3 147 4.4 37 4.7 118 5.1 129 3.6 373 3.6
Days did not get enough sleep in past month 0.844 0.170 0.367 0.021*
  None 2594 41.0 7941 40.6 469 41.0 1505 46.7 397 50.7 1234 51.6 1908 55.8 6049 59.4
  1–15 2540 43.5 7710 44.3 379 42.3 1206 39.4 245 34.8 779 36.6 1116 33.4 3202 32.1
  >15 878 15.5 2321 15.1 165 16.7 379 13.9 107 14.6 281 11.7 356 10.8 849 8.4
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Asterisks represent significant differences compared with the non-cancer controls based on chi-square tests.

BC, breast cancer; CC, colorectal cancer; PC, prostate cancer; Dissat, dissatisfied.

***

p < .001.

**

001 ≤ p < .01.

*

.01 ≤ p < .05.

Odds of HRQoL outcomes for short and long-term cancer survivors compared with their non-cancer controls are presented in Table 3. Among short-term survivors, male colorectal cancer survivors were 2.62 times more likely (95% CI: 1.72–3.99) to report activity limitations compared with their non-cancer controls, followed by female colorectal (AOR = 2.25, 95% CI: 1.45–3.51) and breast cancer survivors (AOR = 1.41, 95% CI: 1.11–1.80). Male and female colorectal cancer survivors were 3.67 (95% CI: 2.09–6.47) and 3.51 (95% CI: 2.09 5.92) times more likely to perceive their general health as fair/poor versus excellent/very good compared with their non-cancer controls, followed by breast (AOR = 3.26, 95% CI: 2.43–4.37) and prostate cancer survivors (AOR= 1.72, 95% CI: 1.26–2.35). Female colorectal cancer survivors were 1.64 times more likely (95% CI: 1.06–2.54) to report bad physical health 1–15 days versus none in the past month, whereas male colorectal cancer survivors were 2.00 times more likely (95% CI: 1.17–3.42) to report bad mental health 1–15 days versus none in the past month than their non-cancer controls. Prostate cancer survivors were more likely to report bad mental health 1–15 days versus none in the past month (AOR = 1.40, 95% CI: 1.01–1.93), rarely/never versus always/usually receiving emotional support (AOR = 1.5, 95% CI: 1.01–2.16), and not enough sleep >15 days versus none in the past month (AOR= 1.61, 95% CI: 1.13–2.29) than their non-cancer controls.

Table 3.

Adjusted odds ratios and 95% confidence intervals for cancer type from binary and multinomial logistic regressions on health-related quality of life by time since diagnosis behavioral risk factor surveillance system, 2009.

Breast cancer Colorectal cancer (female) Colorectal cancer (male) Prostate cancer
AOR 95% CI Sig. AOR 95% CI Sig. AOR 95% CI Sig. AOR 95% CI Sig.
Activity limitations
  Yes 1–5 years 1.41 [1.11, 1.80] ** 2.25 [1.45, 3.51] *** 2.62 [1.72, 3.99] *** 1.09 [0.83, 1.43]
>5 years 1.18 [1.04, 1.35] * 1.23 [0.89, 1.70] 1.70 [1.23, 2.36] ** 1.17 [0.97, 1.40]
Life satisfaction
  Very satisfied/satisfied 1–5 years 0.89 [0.58, 1.36] 3.32 [1.21, 9.13] * 1.78 [0.62, 5.10] 0.96 [0.54, 1.73]
>5 years 0.96 [0.71, 1.28] 0.62 [0.36, 1.04] 0.33 [0.17, 0.65] ** 0.97 [0.65, 1.46]
Receive needed emotional support
  Rarely/never 1–5 years 0.89 [0.57, 1.38] 1.41 [0.69, 2.87] 0.93 [0.45, 1.95] 1.48 [1.01, 2.16] *
>5 years 1.21 [0.91, 1.60] 1.10 [0.67, 1.81] 0.70 [0.41, 1.20] 1.01 [0.79, 1.28]
  Sometimes 1–5 years 0.69 [0.42, 1.13] 1.15 [0.49, 2.71] 1.20 [0.52, 2.76] 1.78 [1.08, 2.95] *
>5 years 1.17 [0.84, 1.61] 1.22 [0.68, 2.18] 0.99 [0.53, 1.85] 0.98 [0.71, 1.35]
Perceived general health
  Fair/poor 1–5 years 3.26 [2.43, 4.37] *** 3.51 [2.09, 5.91] *** 3.67 [2.09, 6.47] *** 1.72 [1.26, 2.35] ***
>5 years 1.38 [1.15, 1.65] *** 1.91 [1.30, 2.79] *** 1.91 [1.26, 2.90] ** 1.21 [0.96, 1.53]
  Good 1–5 years 2.42 [1.91, 3.06] *** 2.04 [1.19, 3.49] ** 1.81 [1.05, 3.13] * 1.52 [1.17, 1.97] **
>5 years 1.44 [1.23, 1.68] *** 1.25 [0.89, 1.76] 2.24 [1.59, 3.17] *** 1.27 [1.05, 1.54] *
Days perceived physical health bad in past month
  >15 1–5 years 1.31 [0.94, 1.83] 1.05 [0.58, 1.90] 1.57 [0.85, 2.91] 0.95 [0.63, 1.44]
>5 years 1.09 [0.90, 1.32] 1.36 [0.91, 2.04] 1.00 [0.63, 1.60] 1.00 [0.77, 1.31]
  1–15 1–5 years 1.17 [0.93, 1.46] 1.64 [1.06, 2.54] 1.56 [0.95, 2.55] 0.97 [0.75, 1.25]
>5 years 1.05 [0.90, 1.22] 1.21 [0.87, 1.70] * 1.77 [1.23, 2.55] ** 1.06 [0.86, 1.30]
Days perceived mental health bad in past month
>15 1–5 years 1.18 [0.75, 1.85] 0.91 [0.44, 1.89] 1.06 [0.55, 2.05] 1.41 [0.79, 2.52]
>5 years 1.03 [0.80, 1.34] 1.58 [0.92, 2.70] 1.27 [0.62, 2.60] 0.68 [0.44, 1.03]
1–15 1–5 years 1.00 [0.79, 1.26] 0.88 [0.54, 1.43] 2.00 [1.17, 3.42] * 1.40 [1.01, 1.93] *
>5 years 0.99 [0.84, 1.15] 1.31 [0.87, 1.98] 1.16 [0.75, 1.80] 1.13 [0.89, 1.45]
Days did not get enough sleep in past month
  >15 1–5 years 1.25 [0.92, 1.69] 1.54 [0.83, 2.86] 1.24 [0.69, 2.23] 1.61 [1.13, 2.29] **
>5 years 0.99 [0.81, 1.21] 1.23 [0.81, 1.86] 1.28 [0.84, 1.96] 1.12 [0.84, 1.48]
  1–15 1–5 years 1.16 [0.93, 1.46] 1.22 [0.78, 1.91] 1.09 [0.70, 1.69] 1.25 [0.99, 1.58]
>5 years 0.93 [0.81, 1.07] 1.23 [0.91, 1.67] 1.04 [0.73, 1.48] 0.98 [0.81, 1.17]
Open in a new tab

Reference categories for dependent variables are as follows: activity limitations (No), life satisfaction (very dissatisfied/dissatisfied), received needed emotional support (usually/always), perceived general health (excellent/very good), days perceived physical health bad in past month (0 days), days perceived mental health bad in past month (0 days), and days did not get enough sleep in past month (0 days).

AOR, adjusted odds ratios; CI, confidence intervals.

***

p < .001.

**

.001 ≤ p < .01.

*

.01 ≤ p < .05.

Among long-term survivors, male colorectal (AOR= 1.70, 95% CI: 1.23–2.36) and breast cancer survivors (AOR= 1.18, 95% CI: 1.04–1.35) were still more likely to report activity limitations than their non-cancer controls. Male and female colorectal cancer survivors were both 1.91 times more likely (95% CI: 1.26–2.90 and 1.30–2.79, respectively) to perceive their general health as fair/poor versus excellent/very good compared with their non-cancer controls. Long-term male colorectal cancer survivors were also 1.77 times more likely (95% CI: 1.23–2.55) to report bad physical health 1–15 days versus none than their non-cancer controls.

HRQoL comparisons by cancer type and gender

Odds of HRQoL outcomes by cancer type and gender are presented in Table 4. Between cancer types, breast cancer survivors were 0.68 times less likely (95% CI: 0.50–0.93) to perceive their general health as fair/poor versus excellent/very good than female colorectal cancer survivors. Prostate cancer survivors were 0.63 times less likely (95% CI: 0.45–0.88) to perceive their general health as fair/poor versus excellent/very good, 0.70 times less likely (95% CI: 051–0.95) to report bad physical health 1–15 days versus none in the past month, and 0.61 times less likely (95% CI: 0.45–0.83) to report activity limitations than male colorectal cancer survivors.

Table 4.

Adjusted odds ratios and 95% confidence intervals for cancer type from binary and multinomial logistic regressions on health-related quality of life among cancer survivors by cancer type and gender behavioral risk factor surveillance system, 2009.

Breast cancer
versus colorectal (female)		 Prostate cancer
versus colorectal (male)		 Colorectal cancer (female)
versus colorectal (male)		 Breast cancer
versus prostate
OR 95% CI Sig. OR 95% CI Sig. OR 95% CI Sig. OR 95% CI Sig.
Activity limitations
  Yes 0.89 [0.69,1.15] 0.61 [0.45, 0.83] ** 0.63 [0.45,0.87] ** 0.96 [0.80,1.14]
Life satisfaction
  Very satisfied/satisfied 0.90 [0.57,1.40] 1.68 [0.85,3.31] 2.20 [1.11,4.35] * 1.03 [0.71,1.50]
Receive needed emotional support
  Rarely/never 0.95 [0.60,1.49] 1.38 [0.88,2.18] 3.17 [1.76,5.71] *** 2.12 [1.58,2.84] ***
  Sometimes 0.87 [0.53,1.43] 0.99 [0.57,1.70] 1.91 [0.99,3.69] 1.56 [1.08,2.24] *
Perceived general health
  Fair/poor 0.68 [0.50,0.93] * 0.63 [0.45,0.88] ** 0.79 [0.53,1.17] 0.81 [0.65,1.01]
  Good 1.06 [0.77,1.46] 0.79 [0.57,1.09] 0.67 [0.45,0.98] * 0.87 [0.72,1.05]
Days perceived physical health bad in past month
  >15 0.79 [0.57,1.09] 0.89 [0.59,1.36] 1.27 [0.81,1.99] 1.05 [0.81,1.36]
  1–15 0.80 [0.59,1.07] 0.70 [0.51,0.95] * 1.18 [0.82,1.70] 1.35 [1.13,1.62] **
Days perceived mental health bad in past month
  >15 0.89 [0.55,1.44] 0.91 [0.49,1.70] 1.39 [0.77,2.53] 1.43 [0.96,2.11]
  1–15 0.81 [0.55,1.19] 0.94 [0.65,1.35] 1.86 [1.16,2.98] ** 1.58 [1.28,1.94] ***
Days did not get enough sleep in past month
  >15 0.84 [0.59,1.20] 0.88 [0.59,1.33] 1.14 [0.73,1.76] 1.33 [1.04,1.70] *
  1–15 0.89 [0.65,1.21] 0.98 [0.73,1.32] 1.53 [1.06,2.21] * 1.49 [1.26,1.77] ***
Open in a new tab

Reference categories for dependent variables are as follows: activity limitations (no), life satisfaction (very dissatisfied/dissatisfied), received needed emotional support (usually/always), perceived general health (excellent/very good), days perceived physical health bad in past month (0 days), Days perceived mental health bad in past month (0 days), and days did not get enough sleep in past month (0 days).

Asterisks represent significant differences compared with the reference group.

***

p < .001.

**

.001 ≤ p < .01.

*

.01 ≤ p < .05.

Comparing genders within the gender-neutral (colorectal cancer), women were 0.67 times less likely (95% CI: 0.45–0.98) to perceive their general health as good versus excellent/very good and 0.63 times less likely to report activity limitations (95% CI: 0.45–0.87) and were more than twice as likely to be very satisfied/satisfied with their life (AOR = 2.20, 95% CI: 1.11–4.35) than male colorectal cancer survivors. Yet, women were 1.86 times more likely (95% CI: 1.16–2.98) to report bad mental health 1–15 days versus none in the past month, 3.17 times more likely (95% CI: 1.76–5.71) to report rarely/never versus always/usually receiving emotional support, and 1.53 times more likely (95% CI: 1.06–2.21) to report not enough sleep 1–15 days versus none in the past month.

Between the gender-specific cancers (breast and prostate), breast cancer survivors were 1.35 (95% CI: 1.13–1.63), 1.58 (95% CI: 1.28–1.94), 2.12 (95% CI: 1.58–2.84), and 1.49 (95% CI: 1.26–1.77) times more likely to report bad physical and mental health 1–15 days versus none in the past month, rarely/never versus always/usually receiving emotional support, and not enough sleep 1–15 days versus none in the past month, respectively, than prostate cancer survivors.

Discussion

HRQoL comparisons to non-cancer controls

The current study of a large population-based sample of breast, prostate, and colorectal cancer survivors found that all cancer types reported more activity limitations and worse general health compared with individuals without a history of cancer matched on many important characteristics. However, colorectal cancer survivors reported the most activity limitations and worst general and physical health compared with their non-cancer controls and with breast and prostate cancer survivors. Other associations between a history of cancer and HRQoL varied according to time since diagnosis, cancer type, and gender.

Among short-term cancer survivors, prostate and colorectal cancer survivors reported the most domains of HRQoL to be adversely affected compared with their non-cancer controls. This was especially so among prostate and male colorectal cancer survivors. Albeit, male and female colorectal cancer survivors had the highest odds for activity limitations and fair/poor general health compared with controls, a finding most likely associated with the invasive nature of colorectal surgery, treatment effects, and the likelihood of a stoma. However, short-term prostate and male colorectal cancer survivors reported additional disparities in HRQoL life specific to emotional support, mental health, and sleep, the majority of which do not persist into the long-term survivorship period. A recent study demonstrated the association between social/emotional support and improved psychological well-being among short-term prostate cancer survivors, independent of disease and treatment-related factors [25]. However, research has shown that women engage in more coping behaviors and seek more social/emotions support than men do [26,27]. Men may avoid seeking social/emotional support because they view the behavior as conflicting with traditional ideals of gender and masculinity. Moreover, their psychological distress may be compounded by the sexual dysfunction experienced by prostate and male colorectal cancer survivors, another stress to their ideals of masculinity [12,28–30].

Among long-term survivors, male colorectal cancer survivors reported worse outcomes on more measures of HRQoL compared with their non-cancer controls, than the other cancer types, reporting more activity limitations, poorer general health, poorer physical health, and less life satisfaction. A similar trend was also observed among long-term female colorectal cancer survivors. Likewise, a recent 10-year longitudinal study of HRQoL among German colorectal cancer survivors found that survivors reported poorer HRQoL for most measures compared with controls, with disparities in HRQoL worsening over time [13]. Persistent or worsening disparities in HRQoL between short and long-term colorectal cancer survivors may be due to the unmet continuation of bothersome symptoms and effects such as constipation, diarrhea, pain, fatigue, and dyspnea, and unmet expectations for improvements in treatment-related outcomes over time [13,31–33]. Colorectal cancer patients are often treated with surgical proctectomy resulting in a temporary ostomy. However, these ostomies become permanent for many colorectal cancer survivors, especially survivors of lower rectal cancer, with rates of permanent ostomy as high as 50% [34].

HRQoL comparisons by cancer type and gender

Between cancer types, breast cancer survivors reported better general health than female colorectal cancer survivors, and prostate cancer survivors reported less activity limitations, better general health, and physical health than male colorectal cancer survivors. Similar to the differences in HRQoL observed between colorectal cancer survivors and non-cancer controls, these HRQoL differences between breast and prostate compared with colorectal cancer survivors are most likely due to treatment-related physical symptoms and outcomes specific to colorectal cancer [13,31,34].

Between genders, women reported poorer HRQoL outcomes specific to psychosocial well-being. Female colorectal cancer survivors reported less emotional support, poorer mental health, and less sleep than male colorectal cancer survivors. Likewise, breast cancer survivors also reported less emotional support, poorer physical health, poorer mental health, and less sleep than prostate cancer survivors. Similar findings were found in several studies of gender differences among colorectal cancer survivors with ostomies. Women reported higher rates of depression, anxiety, poor sleep quality, and fatigue than men [6,7,35]. What is more, a recent study comparing symptom prevalence across multiple types of cancers found that breast cancer survivors reported depression, anxiety, and difficulty sleeping at almost twice the rate of prostate cancer survivors [36]. Comparable differences in HRQoL between genders have also been observed among individuals with other chronic diseases, such as coronary heart disease and HIV/AIDS [14,37]. However, this disparity in mental health between genders is not limited to individuals with chronic disease, as women in general the general population demonstrate higher rates of depression, anxiety, and sleep disturbances than men [38].

Despite the fact that women reported worse mental health, men cancer survivors reported more activity limitations and less life satisfaction than women. In similar fashion, men experiencing chronic pain from fibromyalgia also report greater physical-role limitations than women [39]. Among the general population, men consistently report higher rates of leisure-time physical activity than women do. Furthermore, physical activity has been positively associated with life satisfaction in men [40–42]. What is more, many prostate and male colorectal cancer survivors experience sexual dysfunction and may perceive it as a threat to their masculinity [30,43]. Hence, if male cancer survivors in this study felt unable to return to the same level of physically demanding and/or sexual activity they had engaged in prior to their cancer diagnosis, it may explain why they reported more activity limitations and less life satisfactions than women.

This study was conducted using a large sample of data from a recent population-based survey. Cancer survivors represented a diverse range in age and time since diagnosis. The method of propensity score matching used to match cases to controls was chosen to provide rigorous control of confounding bias. This study compared a variety of HRQoL outcomes that encompassed the physical, mental, emotional domains, as well as functional and symptomatic outcomes. These measures were compared with matched non-cancer controls for each cancer type and between cancer types and genders. Moreover, this study was also able to compare short and long-term survivors to non-cancer controls. However, this comparison of short and long-term survivors was not able to be conducted in a longitudinal nature but rather by division of point-in-time measures among a cross-sectional sample. Furthermore, information regarding stage at diagnosis and type of treatment received were not available in the 2009 BRFSS; therefore, their effects could not be controlled for they have shown to be important predictors of HRQoL outcomes among cancer survivors and are worth noting. Individuals diagnosed with more advanced stages of cancer are often limited to more invasive and intense treatment options that are associated with more severe symptoms and side effects. Studies comparing outcomes between breast cancer survivors who underwent breast conserving surgery versus mastectomy have shown that mastectomy is associated with decreased upper body functioning, satisfaction with body image, sexual, role, and emotional well-being [44–46]. Prostate cancer survivors diagnosed at an advanced stage, who underwent radical prostatectomy versus external beam radiation, or received androgen deprivation therapy, experience worse mental health, emotional and social well-being, and sexual and urinary dysfunction, whereas bowel dysfunction is more common among men who underwent external beam radiation therapy [28,47,48]. Similarly, colorectal cancer survivors diagnosed at an advanced stage report worse HRQoL outcomes; however, the severity of bowel and urinary dysfunction, mental health, emotional and social well-being, and sexual dysfunction vary according to type of treatment received and presence or absence of a permanent ostomy [29,49]. Another limitation of the current study is that it was conducted using self-reported data that may contain responder bias. Finally, HRQoL of survivors who have died could not be included in the study. It remains unknown how their HRQoL would have impacted the study findings.

Conclusions

Although the proportion and association of stage and diagnosis among this sample are unknown, this study has demonstrated that a large population-based sample of survivors of breast, colorectal, and prostate cancers experience a diminished HRQoL throughout the survivorship continuum. Yet, it is evident that the HRQoL among breast, prostate, and colorectal cancer survivors is differentially associated with type of cancer, time since diagnosis, and gender. All cancer survivors reported more activity limitations and perceived their general health to be worse than their non-cancer controls, with prostate and male colorectal cancer survivors experiencing worse HRQoL in the short term, and colorectal cancer survivors, especially the men, continuing to experience worse HRQoL in the long term. Among cancer types, colorectal cancer survivors experience a worse HRQoL than breast and prostate cancer survivors, with respect to activity limitations, and general and physical health. Yet, regardless of cancer type, female survivors experience worse psychosocial outcomes compared with men, whereas men perceived themselves to be more limited, of worse general health, and less satisfied with their lives. Perceptions of gender roles and masculinity associated with coping behaviors may explain differences in HRQoL between genders.

The majority of research concerning health interventions among cancer survivors has focused on modifying lifestyle factors. Although physical activity may be helpful for improving physical functioning and fatigue, it may not be as effective for improving other aspects of HRQoL such as mental health, social/role functioning, sexual functioning, and emotional coping. The National Cancer Institute’s Facing Forward to education cancer survivors how to manage treatment side effects and their affects on various domains of HRQoL, as well as stress management coping strategies, may be a step in the right direction towards improving HRQoL among cancer survivors [50]. Yet, the effectiveness of such an intervention could be improved by building upon these educational points by addressing the unique needs of different types of cancer survivors and genders, particularly coping mechanisms. Furthermore, health care providers may not be as prepared to handle the HRQoL aspects of survivorship care, as they are the clinical aspects [51]. Educational information targeted to health care providers may better equip them to initiate the HRQoL care process with their patient and either provide or direct them to appropriate the appropriate resources.

As the population of cancer survivors continues to grow, so will the need for monitoring and management of the HRQoL among cancer survivors. Whether follow-up care is received from oncology specialists or primary care physicians, it is important that all health care providers recognize the declines in HRQoL experienced by cancer survivors and how they may differ from one another with respect to cancer type and/or gender to provide individual care tailored according to the unique needs of each survivor. Cancer survivors may be furthermore empowered by being provided information and resources for the management adverse treatment effects and coping mechanisms.

Acknowledgments

The study authors acknowledge partial financial funding by the WV CoHORTS Center and AHRQ Grant # 1R24H5018622-01.

Footnotes

Conflicts of interest

The authors have indicated no potential conflicts of interest.

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