“Influence of Social and Behavioral Determinants on Health-Related Quality of Life Among Cancer Survivors in the United States”

Abstract

Purpose:

Cancer survivors experience worse health-related quality of life (HRQoL) than non-cancer survivors. However, it is not fully understood whether social determinants of health (SDOH) and health behaviors are significantly associated with HRQoL among cancer survivors. The purpose of this study was to investigate the influence of SDOH and health behaviors on HRQoL among cancer survivors.

Methods:

We identified adult (18 years or older) cancer survivors (n=5,784) in the 2017 and 2019 Behavioral Risk Factor Surveillance System. The primary outcome (HRQoL) was defined as whether cancer survivors reported having poor mental or physical health (e.g., 14 or more mentally or physically unhealthy days). Unadjusted and adjusted logistic regression was used to compute odds ratios and 95% CIs of factors associated with poor HRQoL among cancer survivors.

Results:

More than half of the cancer survivors were non-Hispanic white, female, and 65 years or older. In the adjusted multivariable logistic models, cancer survivors who were physically active and who did not avoid care because of costs had a lower risk of poor mental and physical health. Current smokers were more likely to report poor physical health. Homeowners were less likely to report poor mental health. Daily fruit and vegetable consumption and healthcare coverage were not associated with poor HRQoL.

Conclusions:

Some SDOH (healthcare access, economic stability, and the neighborhood and built environment) and health behavior (physical activity) are associated with a lower likelihood of experiencing poor mental and/or physical health in cancer survivors. The study findings can be used to target survivors who experience suboptimal HRQoL and to inform research, public health policies, and/or programs.

Introduction

In 2019, approximately 16.9 million cancer survivors were living in the United States (US). [1] Prostate cancer (26%), lung cancer (12%), and colorectal cancer (8%) account for approximately 46% of the survivor population among men, whereas breast cancer (30%), lung cancer (13%), and colorectal cancer (8%) account for about 51% of the survivor population among women. [2] With advancements in early detection and treatments, the overall five-year relative cancer survival rate is increasing (49% from 1975–1977 vs 67% from 2010–2016) and the estimated number of cancer survivors living in the US will increase to 22.2 million by 2030. [1–3] In addition, the overall life expectancy among adults in the US has increased from 1990 (75.4 years) to 2018 (78.7 years). [4–6] Despite these positive trends, cancer survivors have not only an increased risk of cancer recurrence and secondary cancers but an increased risk of experiencing poor health-related quality of life (HRQoL) than non-cancer survivors. [7] According to the Centers for Disease Control and Prevention (CDC), “health-related quality of life is an individual’s or a group’s perceived physical and mental health over time”, whereas quality of life is defined “as an individual’s overall satisfaction with life and general sense of personal well-being.” [8, 9] For example, Trogdon et al. reported that female breast cancer survivors had a significantly lower mean number of physically healthy days, overall healthy days, and days without activity limitations than women with no history of breast cancer (2016). [10] A previous study found that men with a personal history of breast cancer were significantly more likely to experience poorer physical health, poorer mental health, and activity limitations compared to men with no personal history of breast cancer. [11]

Poor HRQoL is a significant problem of public health concern. The growing population of cancer survivors is likely to experience severe and long-term cancer treatment effects, which may negatively impact their HRQoL. Previous studies have documented multiple adverse cancer treatment effects and symptoms experienced by cancer survivors. [10, 12–15] Individuals with breast cancer suffer from body image issues, physical limitations, chronic fatigue, sleep problems, sexual dysfunction, pain and swelling from lymphedema, infertility, distress, cognitive impairment, depression and anxiety, and other side effects and symptoms. [10, 12–14] Prostate and colorectal cancer survivors experience similar adverse cancer treatment effects to breast cancer survivors with additional side effects and symptoms including pain at the surgery site, urinary and bowel dysfunction, body dissatisfaction influenced by cancer therapy (e.g., androgen deprivation therapy) and temporary or permanent ostomy. [13] Lung cancer survivors experience similar symptoms and side effects as other cancer survivors as well as respiratory problems (e.g., difficulty with breathing), and intestinal disorder. [15] These cancer-related side effects and symptoms affect the quality of life (QoL) of cancer survivors. [15]

Additionally, some studies have shown significant relationships between social determinants of health (SDOH) and QoL. For instance, sexual minority female cancer survivors with poor access to healthcare have significantly worse physical QoL, mental QoL, and difficulty concentrating compared with heterosexual female cancer survivors. [16] Santee and colleagues (2020) reported having healthcare coverage predicted better mental, but not physical HRQoL among Hispanic/Latino-American cancer survivors. [17] In the same study, higher income ($20,000 or greater) positively impacted the physical and mental HRQoL of Hispanic/Latino cancer survivors. In addition, lower educational attainment has contributed significantly to poor mental health among breast cancer survivors. [18]

Other studies have found significant associations between health behaviors (including diet, physical activity [PA], alcohol consumption, and smoking) and QoL. Current smoking, binge drinking, and physical inactivity have contributed significantly to poor mental health among adult cancer survivors. [17–19] Researchers have found that breast cancer survivors who reported a moderate intake of fruits and vegetables were less likely to experience poor mental health, whereas breast cancer survivors that reported a high intake of fruit juice were more likely to experience poor mental health. [18] On the other hand, frequent exercise and moderate to vigorous PA have been linked to better physical QoL among breast cancer survivors in Germany, [20] Hispanic/Latino cancer survivors in the US, [17] and childhood cancer survivors in China. [21] Overall, some studies have demonstrated the influences of SDOH and health behaviors on HRQoL independently among different groups of cancer survivors.

Very few studies have conducted a comprehensive analysis on the relationship between multiple SDOH (e.g., healthcare coverage, medical costs, and home ownership), health behaviors (e.g., PA, current smoking, diet, and alcohol consumption), and HRQoL in a single investigation. [17, 19] The Healthy People 2030 Framework supports the need to evaluate these relationships to help improve the health and wellbeing of all people including cancer survivors. [22, 23] Healthcare coverage and medical costs are some of CDC’s measures of healthcare access, which is one of the primary domains of SDOH. [22] Housing is one area of focus for economic stability and the neighborhood and built environment, which are two other domains of SDOH. [22] Without this analysis, it is difficult to fully understand the relative influence of social and behavioral factors on HRQoL among cancer survivors. Some health behaviors and SDOH might be strongly associated with poor HRQoL among cancer survivors. Such findings can help healthcare providers tailor survivorship care plans, direct cancer survivors to appropriate resources, and inform researchers in the development and implementation of supportive care interventions. Therefore, the aim of the current study was to examine the association between multiple health behaviors (fruit and vegetable consumption, PA, current smoking, and alcohol consumption) and SDOH (home ownership, medical costs, and healthcare coverage) and HRQoL (mental and physical health) among US adult cancer survivors. We hypothesized that the individual level social determinants of health will be strongly correlated with HRQoL than the health behaviors. The findings might be relevant to similar populations outside of the US. Our study results could be used to target healthy behaviors and inform the development of health promotion activities for similar groups in other countries.

Methods

The Behavioral Risk Factors Surveillance System (BRFSS) is a national telephone survey, which was established by CDC in 1984 (www.cdc.gov/brfss). BRFSS interviewers collect data on health-related behaviors, sociodemographic characteristics, leading preventable causes of death, and preventive health practices among non-institutionalized residents (18 years or older) in all 50 states in the US, the District of Columbia, and three US territories. The questionnaire consists of three major components: core questions, optional CDC modules, and state added questions. The BRFSS uses a random digit dialing sampling method to conduct the surveys via cell phones or landlines. More than 400,000 interviews are conducted annually. BRFSS data has been shown to be very reliable and valid. [24, 25] Since BRFSS survey data is deidentified and readily available in the public domain, Institutional Review Board (IRB) approval was not required. We conducted a secondary data analysis using BRFSS survey data to address the study objective.

Study population

The unweighted population consisted of 5,784 cancer survivors (see Figure 1). Weighting to the respective state populations, cancer survivors represented 1,467,381 adult cancer survivors (see Table 1). All races/ethnicities were included in the final analysis. The study team conducted a retrospective cross-sectional study by combining BRFSS data from 2017 and 2019. The 2017 annual survey data (N=7,602) consisted of more cancer survivors than the 2019 annual survey data (N=869) due to differences in the number of states administering the optional cancer survivorship module. Five states administered the optional cancer survivorship module in 2017 (including Georgia, Indiana, Nebraska, Michigan, and South Dakota) and only one state (Wyoming) administered the surveys in 2019. [26, 27] To ensure sufficient numbers for subgroup analyses among cancer survivors, the 2017 and 2019 survey data were merged. Survey questions about fruit and vegetable consumption and certain questions about PA were not asked in the 2018 questionnaire. Therefore, the 2018 annual survey data was excluded from this study.

Figure 1.

Flow Chart of the Final Study Population

Table 1.

Study Characteristics of Cancer Survivors in 2017 and 2019 BRFSS

	Cancer survivors
Total Weighted Study Population	1,467,381
	%
Age
18 to 64	48%
65 or older	52%
Sex
Male	45%
Female	55%
Race
Non-Hispanic White	90%
Non-Hispanic Black	7%
Hispanic	1%
Non-Hispanic Other	2%
Income
Less than $25,000	25%
$25,000 or more	75%
Education
High school or less	36%
Attended college or technical school	35%
Graduated from college or technical school	29%
Employment status
Unemployed	59%
Employed	36%
Homemaker	5%
General Health
Good or better health	73%
Fair or poor health	27%
Other health outcomes
Heart attack	16%
High blood pressure	54%
Body mass index (overweight or obese)	72%
High cholesterol	50%
Diabetes	21%
Heavy alcohol consumption
No	94%
Yes	6%
Total fruits and vegetables consumed per day
Less than 5 fruits and vegetables	84%
5 or more fruits and vegetables	16%
Total minutes of physical activity per week
Less than 150 minutes	48%
150 minutes or more	52%
Current smoker
No	85%
Yes	15%
Home ownership
Own	90%
Rent	10%
Healthcare coverage
No	4%
Yes	96%
Medical costs (could not see doctor because of costs)
No	91%
Yes	9%
Physical Health
Good or better	78%
Poor	22%
Mental Health
Good or better	88%
Poor	12%

The following survey questions were used to identify cancer survivors of all types: “(Ever told) you had skin cancer?” and “(Ever told) you had any other types of cancer?” Individuals who self-reported a personal history of skin cancer or other types of cancers were considered cancer survivors and included in the study. The survey questions used to assess the individual level measures, demographics, other health outcomes, general health, and the primary outcome variables are described in detail elsewhere. [28] Individuals who were excluded from the study met one of the following criteria: (1) had missing responses/values for any of the included variables or refused to answer any of the survey questions used in this study, (2) did not know or were not sure about their answers for any of the survey questions used in this study, or (3) the values were too high for fruit and vegetable consumption (consuming fruits >16 times and vegetables >23 times per day) (see Figure 1). [29]

Individual level measures

Primary outcomes

We examined HRQoL using CDC’s HRQoL measures. CDC’s HRQoL measures were based on self-reported physical health and mental health. Previous studies have used the same outcome variables to assess HRQoL. [17, 24] The primary outcomes to indicate HRQoL in our study were poor mental and physical health status. The following survey questions were used to measure mental and physical health: “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for how many days during the past 30 days was your mental health not good?” and “Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?” Poor mental health was defined as having 14 or more mentally unhealthy days, whereas better mental health was defined as having 0 to 13 mentally unhealthy days. Similarly, poor physical health was defined as having 14 or more physically unhealthy days, whereas better physical health was defined as having 0 to 13 physically unhealthy days. We treated physical and mental health as binary variables (better vs poor health). The cutoff for categorizing the primary outcomes have been used in previous studies and validated by CDC. [18, 19, 30]

Primary predictors

Health behaviors

The main behavioral exposures were heavy alcohol consumption, current smoking, fruit and vegetable consumption, and PA. Heavy alcohol consumption was defined by BRFSS as more than seven drinks each week for women and more than 14 drinks each week for men. Current smoking (“Yes” or “No”) was treated as a binary variable. PA was categorized as not meeting the current PA recommendations (less than 150 minutes) and meeting the current PA recommendations (150 minutes or more). Fruit and vegetable consumption was defined as the total number of fruits and vegetables consumed each day. Fruit and vegetable consumption was grouped into the following two categories based on the US dietary guidelines: less than 5 servings of fruits and vegetables per day and 5 or more servings of fruits and vegetables per day.

Social determinants of health (SDOH)

We used multiple individual level measures to represent the SDOH based on Healthy People 2030. [22] The individual level SDOH were home ownership, medical costs, and healthcare coverage. We used the term “medical costs” based on the following BRFSS survey question: Was there a time in the past 12 months when you needed to see a doctor but could not because of cost? Home ownership (“Own” or “Rent”), medical costs (“No” or “Yes”), and healthcare coverage (“No” or “Yes”) were treated as binary variables.

Other variables

The demographic factors (race/ethnicity, age, sex, income, employment status, and education), other health outcomes (including heart attack, high blood pressure, body mass index, high cholesterol, and diabetes), and general health were included as covariates in the final multivariable models. Race/ethnicity was categorized as Black (non-Hispanic), White (non-Hispanic), Hispanic, and other (non-Hispanic). Age (18 to 64 years or 65 and older), sex (male or female), income (less than $25,000 or $25,000 or more), and employment (employed or unemployed) were treated as binary variables. Cancer survivors who were retired, out of work, or unable to work were included in the unemployed category. The participants self-reported if they have ever been told by a health professional that they had high blood pressure, diabetes, high cholesterol, or heart attack. Other health outcomes (“Yes” or “No”) and general health (good/better or fair/poor) were treated as binary variables.

Statistical analysis

Descriptive statistics were used to summarize the characteristics of cancer survivors by performing weighted chi-square tests for categorical variables. We computed unweighted frequencies to obtain the total number of observations. We used weighted adjusted and unadjusted logistic regression to determine which factors were significantly associated with poor HRQoL. In Table 2, the adjusted models controlled for age, sex, race/ethnicity, income, education, employment status, general health, and other health outcomes (e.g., high blood pressure).

Table 2.

Odds ratios of having suboptimal health-related quality of life (poor mental health or poor physical health) in relation to health behaviors and social determinants of health among cancer survivors

	Poor Mental Health (N= 176,163)		Poor Physical Health (N=319,792)
	Unadjusted	Adjusted	Unadjusted	Adjusted
	OR, 95% CI	AOR, 95% CI	OR, 95% CI	AOR, 95% CI
Heavy alcohol consumption
No (ref)	-	-	-	-
Yes	0.95 (0.50, 1.80)	1.20 (0.61, 2.38)	0.45 (0.25, 0.80) *	0.59 (0.28, 1.24)
Current Smoking
No (ref)	-	-	-	-
Yes	1.86 (1.24, 2.80) *	1.37 (0.88, 2.15)	2.03 (1.48, 2.78) *	1.70 (1.15, 2.51) *
Total fruits and vegetables consumed per day
Less than 5 fruits and vegetables (ref)	-	-	-	-
5 or more fruits and vegetables	0.88 (0.57, 1.34)	0.77 (0.49, 1.21)	0.94 (0.70, 1.27)	1.07 (0.76, 1.52)
Total minutes of physical activity per week
Less than 150 minutes (ref)	-	-	-	-
150 minutes or more	0.45 (0.32, 0.63) *	0.56 (0.39, 0.80) *	0.41 (0.32, 0.52) *	0.59 (0.45, 0.77) *
Home ownership
Own	2.80 (1.82, 4.31) *	0.49 (0.28, 0.85) *	2.16 (1.50, 3.11) *	0.72 (0.44, 1.19)
Rent (ref)	-	-	-	-
Medical costs (could not see doctor because of cost)
No	0.30 (0.19, 0.47) *	0.39 (0.23, 0.65) *	0.32 (0.20, 0.50) *	0.34 (0.20, 0.58) *
Yes (ref)	-	-	-	-
Healthcare coverage
No (ref)	-	-	-	-
Yes	0.55 (0.23, 1.28)	0.50 (0.20, 1.27)	2.42 (1.15, 5.10) *	2.31 (0.93, 5.75)

Unadjusted and AOR adjusted odds ratio with 95% confidence intervals, poor mental health and physical health (poor vs better). The adjusted multivariable logistic regression models included social determinants of health (medical costs, home ownership, and healthcare coverage), health behaviors, and adjusted for age, sex, race, income, education, employment status, heart attack, high blood pressure, body mass index, high cholesterol, diabetes, and general health.

^*p value < 0.05 indicated statistical significance

To account for the complex sample design of the BRFSS, all statistical analyses were weighted to the respective state populations using CDC’s calculated weights. [31, 32] The final study population did not contain the cancer survivors from the same state in 2017 and 2019. Therefore, the original final weight of each cancer survivor in this study was used and included. The BRFSS data were analyzed adjusting for the BRFSS survey’s complex sampling procedures. [33, 34] The final BRFSS dataset included several variables that were used in the weighting process. The weighted variable included “the final weight assigned to each respondent for the landline telephone and cellular telephone combined data.” [32] All weighted analyses and models were conducted using SAS version 9.4 software (SAS Institute Inc., Cary, NC, USA). We used a significance value of 0.05 to draw statistical conclusions.

Results

Participant characteristics

Table 1 displays the characteristics of the study population. Based on the weighted results, about half of the cancer survivors (52%) were 65 years or older. Most cancer survivors (90%) identified as non-Hispanic white, had at least a college education (64%), and had healthcare coverage (96%). There were more female (55%) than male cancer survivors (45%) in the study. About 75% of the cancer survivors had an income of at least $25,000. Most cancer survivors were unemployed (59%), homeowners (90%), not heavy drinkers (94%), and not current smokers (85%). More than 70% of the cancer survivors consumed less than 5 servings a day of fruits and vegetables (84%) and reported good or better health (78%).

Unadjusted HRQoL

Unadjusted odds ratios of having suboptimal HRQoL in relation to the SDOH and health behaviors are shown in Table 2. Having healthcare coverage significantly increased the risk of poor physical health, whereas heavy drinking significantly decreased the risk of poor physical health. Being a homeowner significantly increased the risk of poor mental health. Survivors who engaged in regular PA and who did not avoid care because of costs had a significantly lower risk of poor mental and physical health. Current smoking significantly increased the risk of poor physical and mental health. Daily fruit and vegetable consumption was not significantly associated with HRQoL.

In the unadjusted analyses, compared to cancer survivors with no healthcare coverage, cancer survivors with healthcare coverage were more likely to report poor physical health (OR=2.42, 95% CI: 1.15–5.10). Heavy drinkers were less likely to experience poor physical health than non-heavy drinkers (OR=0.45, 95% CI: 0.25–0.80). Compared to renters, homeowners were more likely to report poor mental health (OR=2.80, 95% CI: 1.82–4.31) and poor physical health (OR=2.16, 95% CI: 1.50–3.11). Cancer survivors who did not avoid care because of costs were less likely to experience poor mental health (OR=0.30, 95% CI: 0.19–0.47) and poor physical health (OR=0.32, 95% CI: 0.20–0.50) than cancer survivors who avoided care because of costs. Cancer survivors who met the current PA recommendations were less likely to report poor mental health (OR=0.45, 95% CI: 0.32–0.63) and poor physical health (OR=0.41, 95% CI: 0.32–0.52). Cancer survivors who were current smokers were more likely to experience poor mental health (OR=1.86, 95% CI: 1.24–2.80) and poor physical health (OR=2.03, 95% CI: 1.48–2.78) compared with cancer survivors who were not current smokers.

Adjusted HRQoL

Adjusted odds ratios of having suboptimal HRQoL in relation to the SDOH and health behaviors are shown in Table 2. In the adjusted multivariable logistic models, healthcare coverage and heavy alcohol consumption did not remain significantly associated with any of the HRQoL outcomes. The association between current smoking and poor physical health remained significant, whereas the association between current smoking and poor mental health was not significant after covariate adjustment. Being a homeowner significantly reduced the risk of poor mental health rather than increased the risk. The associations between PA, medical costs, and HRQoL remained significant after covariate adjustment. The association between daily fruit and vegetable consumption and HRQoL did not change after covariate adjustment.

Cancer survivors who were current smokers were more likely to experience poor physical health (AOR=1.70, 95% CI: 1.15–2.51) compared with cancer survivors who were not current smokers. Compared to renters, homeowners were less likely to report poor mental health (AOR=0.49, 95% CI: 0.28–0.85). Cancer survivors who met the current PA recommendations were less likely to report poor mental health (AOR=0.56, 95% CI: 0.39–0.80) and poor physical health (AOR=0.59, 95% CI: 0.45–0.77). Cancer survivors who did not avoid care because of costs were less likely to experience poor mental health (AOR=0.39, 95% CI: 0.23–0.65) and poor physical health (AOR=0.34, 95% CI: 0.20–0.58) than cancer survivors who avoided care because of costs.

Discussion

The current study used data from a national survey to investigate the associations between individual level SDOH, health behaviors, and suboptimal HRQoL among adult cancer survivors in the US. We found that some SDOH and health behaviors were significantly associated with physical and/or mental HRQoL. The significant SDOH were medical costs and home ownership. Cancer survivors who could afford to see a doctor had a decreased risk of poor mental and physical health. Homeowners had a decreased risk of poor mental health. The significant health behaviors were current smoking and PA. Current smokers had an increased risk of poor physical health. Cancer survivors who met the current PA recommendations had a decreased risk of poor mental and physical health.

Healthcare access, economic stability, and the neighborhood and built environment are three of the primary domains of SDOH based on Healthy People 2030. [22] In the current study, we found that respondents who did not avoid care because of costs were less likely to experience poor mental and physical health than those who avoided care because of costs. Boehmer et al. found a significant association between access to care and QoL among a diverse group of cancer survivors (2019). [16] The researchers showed that poor access to care was associated with a higher risk of poor mental and physical QoL among heterosexual cancer survivors. [16] In addition, we found that home ownership significantly decreased the risk of poor mental health in the adjusted analyses, whereas the opposite effect (i.e., increased risk) was observed in the unadjusted analyses. The shift in the direction of the effects could be explained by the covariates (e.g., demographics). The findings from the unadjusted analyses should be interpreted with caution as these models did not control for other variables that might influence the outcomes and interpretations of the results. Hastert and colleagues (2021) examined the link between social needs (e.g., housing instability) and HRQoL among cancer survivors. [35] Researchers found that about 11% of the participants had concerns about not having housing in the next 2 months (i.e., housing stability). Findings showed that housing instability was associated with a clinically meaningful (5-point difference in the total FACT-G score) decrease in HRQoL. Little is known about the association between home ownership and HRQoL among adult cancer survivors in the US. Our study is one of the very few studies to examine the relationship between home ownership and HRQoL among cancer survivors in the US. Increasing the availability of financial assistance programs in healthcare settings (e.g., cancer centers), housing mobility or voucher programs, onsite social services (e.g., patient navigators) in healthcare settings, and public policies (e.g., Medicaid) are warranted to help cancer survivors with such difficulties to have healthcare access and stable housing. [35, 36]

Our study also showed that cancer survivors who engaged in healthy behaviors such as PA had a lower likelihood of poor mental health and poor physical health, whereas cancer survivors who were current smokers had a higher likelihood of poor physical health. Knobf et al. conducted a community-based exercise intervention and found significant associations between exercise and QoL among cancer survivors (2014). [37] Survivors in the exercise intervention showed significant improvements in mental wellbeing, physical function, and muscle stiffness. A population-based study showed that cancer survivors who engaged in exercise reported significantly better mental and physical health. [17] In the same population-based study, current smokers were significantly more likely to report poor mental and physical health. We found a similar association between current smoking and poor HRQoL (mental and physical health) in the unadjusted analyses as well as a similar association between current smoking and poor physical health in the adjusted analyses. However, we did not find a significant association between current smoking and poor mental health in the adjusted analyses. The previous study only included Hispanic/Latino-American cancer survivors and did not report any covariate adjustments. [17] In the current study, we adjusted for multiple covariates and included different racial and ethnic groups, which may explain the differences in the results. Regardless, our findings suggest that lifestyle interventions designed to increase PA and reduce smoking behaviors among cancer survivors may help to improve HRQoL.

Strengths and limitations

The study strengths include utilizing nationally representative data and a reliable data source. [24, 25] This national survey is based on a free-living population who responded to several demographics, behavioral, and SDOH questions. To take advantage of the BRFSS large sample selection in the US, we derived a relatively sufficient study population then explored different SDOH and health behavior factors contributing to suboptimal HRQoL, while adjusting for other variables in the weighted analyses. This study contributes to the literature by demonstrating the critical role of SDOH and health behaviors on HRQoL among a vulnerable population at an increased risk for poor HRQoL. Despite these strengths, this study has a few limitations. First, due to the cross-sectional study design, we cannot infer causation or assess temporal relationships between the individual level factors and the primary outcomes. Second, the individual level factors and primary outcomes were measured using self-report questionnaires. Cancer survivors may over report or underreport certain information (e.g., mentally unhealthy days), which may impose response or recall bias. Third, the results might be less generalizable to other racial and ethnic groups and uninsured individuals due to the homogenous sample. Fourth, the current data source does not capture cancer specific information such as types of cancer treatments, duration of diagnosis, or stage of cancer, which may influence HRQoL. Fifth, we were unable to access other SDOH (e.g., social support) due to the limited information in the secondary dataset. Regardless of these limitations, our study provides new insights into the influence of SDOH and health behaviors on HRQoL among adult cancer survivors in the US.

Conclusion

We found that cancer survivors who engaged in regular PA, who could afford to see a doctor, and who were homeowners had a lower likelihood of experiencing poor HRQoL (physical and/or mental health). However, cancer survivors who avoid care because of costs, who do not meet the PA recommendations, who are not homeowners, and who are current smokers should be the target groups for public health policies and future studies because these groups might be more likely to experience suboptimal HRQoL. To help reduce the risk of poor HRQoL, healthcare systems (including healthcare providers) should identify and address the needs of cancer survivors (e.g., provide financial assistance to uninsured patients for medical care). Researchers, clinicians, public health professionals, and survivorship care planners should continue to promote and target healthy behaviors (e.g., PA) during or after cancer treatments to help improve the HRQoL of cancer survivors. Future studies should explore other SDOH (e.g., social support) and associations between SDOH, health behaviors, and HRQoL in more diverse populations (e.g., racial and ethnic minorities).

Availability of data and material:

Behavioral Risk Factor Surveillance System (BRFSS) survey data and the questionnaires are publicly available to researchers.