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. Author manuscript; available in PMC: 2016 Jun 3.
Published in final edited form as: J Cancer Surviv. 2014 Feb 16;8(3):336–348. doi: 10.1007/s11764-014-0347-5

Health behaviors among breast, prostate, and colorectal cancer survivors: a US population-based case-control study, with comparisons by cancer type and gender

Traci J LeMasters 1,2,✉, Sundareswaran S Madhavan 3,4, Usha Sambamoorthi 5,6, Sobha Kurian 7
PMCID: PMC4892177  NIHMSID: NIHMS789869  PMID: 24532045

Abstract

Purpose

The aim of this study is to compare health behaviors between breast, prostate, female, and male colorectal cancer survivors to noncancer controls, stratified by short- and long-term survivors, and between cancer types and genders.

Methods

A 3:1 population-based sample of breast (6,259), prostate (3,609), female colorectal (1,082), and male colorectal (816) cancer survivors from the 2009 Behavioral Risk Factor Surveillance System survey were matched to noncancer controls on age, gender, race/ethnicity, income, insurance, and region of the US. The likelihood of flu immunization, physical check-up, cholesterol check, body mass index (BMI), physical activity, diet (5-A-Day), smoking, and alcohol use were compared between groups using binomial logistic regression models.

Results

Short-term breast cancer survivors were significantly more likely to meet multiple behavioral recommendations, than controls, but the likelihood decreased in the long term. Breast and female colorectal cancer survivors were up to 2.27 (95 % CI 1.90, 2.71) and 1.89 times more likely (95 % CI 1.60, 2.24) to meet the 5-A-Day and BMI recommendations, up to 0.54 times less likely (95 % CI 0.46, 0.64) to drink any alcohol, but were 0.68 times less likely (95%CI 0.49, 0.95) to meet the physical activity recommendation, compared to prostate and male colorectal cancer survivors.

Conclusions

Some cancer survivors may engage in better health behaviors shortly after diagnosis, but the majority of cancer survivors do not have better health behaviors than individuals without a history of cancer. However, a consistent pattern of behavioral differences exist between male and female cancer survivors.

Implications for Cancer Survivors

Gender differences in health behaviors among cancer survivors may be influenced by perceptions of masculinity/femininity and disease risk. Ongoing health behavioral promotion and disease prevention efforts could be improved by addressing these perceptions.

Keywords: Cancer survivors, Breast cancer, Prostate cancer, Colorectal cancer, Health behaviors, Population-based study, Case-control, Gender differences

Introduction

Obesity is a known risk factor for various primary cancers, as well as cancer recurrence and noncancer-related mortality [1–4]. High rates of obesity and obesity-related health conditions have been observed among cancer survivors, particularly among the most prevalent types of cancer survivors, breast, prostate, and colorectal [5–8]. In response, the American Cancer Society (ACS) has published guidelines for recommended health behaviors pertaining to physical activity, diet (commonly referred to as 5-A-Day), smoking, and alcohol use, intended to improve cancer survival, overall health, and health-related quality of life among cancer survivors [9]. Guideline recommendations for receipt of clinical preventive care, applicable to cancer survivors, have been published by the CDC and the United States Preventive Services Task Force (USPSTF) [10, 11]. Despite these recommendations, it remains uncertain how the health behaviors of individuals with a history of cancer differ from those without a history of cancer, and how health behaviors differ among cancer survivors by cancer type and gender.

Despite the scare of cancer, that many may consider a cue to action, cancer survivors may be no more likely to engage in recommended health behaviors, than individuals without a history of cancer; however, there is some discrepancy among the existing literature. Population-based studies conducted in the US and Australia found that survivors of breast, prostate, and colorectal cancers were no more likely to meet recommendations for physical activity, diet, smoking, and alcohol consumption health behaviors than individuals without a history of cancer [6, 12]. Yet, more recent studies among US and Korean populations found that breast, prostate, and colorectal cancer survivors were less likely to be current smokers or consume any or heavy amounts of alcohol, but while Korean cancer survivors were not more likely to engage in recommended levels of physical activity, US cancer survivors were either more likely to engage in some physical activity or no physical activity [13, 14]. Conversely, a different US population-based study reported that cancer survivors were 9 % more likely to meet the physical activity recommendation, after adjusting for demographic and health characteristics [5]. Less is known about clinical preventive care among cancer survivors. A study conducted in the UK found that breast, prostate, and colorectal cancer survivors were more likely to receive routine flu immunization, than noncancer controls, but did not differ in receipt of routine blood cholesterol tests, while breast and prostate cancer survivors were less likely to receive routine blood pressure tests [15]. Receipt of recommended clinical preventive services has not been studied among cancer survivors in the US. However, the competing demands of survivorship management and cancer surveillance may decrease the likelihood of general clinical preventive care among some cancer survivors [16].

Studies comparing health behaviors by cancer type have reported widely variable rates of recommended physical activity and 5-A-Day among prostate (29–43 % and 16–60 %), breast (20–37 % and 18–42 %), and colorectal cancer survivors (20–35 % and 16–43 %), although prostate cancer survivors were generally found to engage in higher rates of these behaviors [12, 17]. The majority of breast, prostate, and colorectal cancer survivors were reported to meet the ACS recommendation for not smoking (88–92 %), but alcohol use between cancer types has varied from study to study [5, 12, 17]. Differences in receipt of clinical preventive care between cancer types, as well as differences in lifestyle behaviors and receipt of clinical preventive care between genders among cancer survivors remain unknown. However, documented differences in lifestyle behaviors and health information seeking between breast, prostate, and colorectal cancer survivors suggest that differences in clinical preventive care are also likely to exist. Moreover, notable differences in physical activity, diet, and alcohol consumption have been reported between genders within the general population [18–20]. Therefore, it stands to reason that differences in health behaviors between genders may also exist among cancer survivors.

Given that not all cancer survivors may engage in healthy behaviors equally, counseling for health behavior change, disease prevention, and management provided to cancer survivors could benefit by understanding how survivors differ in their behaviors from similar individuals without a history of cancer, cancer type, and genders. Therefore, the purpose of this study was to address the limitations and knowledge gaps of previous research by providing comprehensive understanding of the association between history of cancer, cancer type, gender, and recommended health behaviors. Study objectives were to compare (1) the prevalence of physical activity, 5-A-Day, smoking, alcohol use, receipt of flu immunization, physical check-up, and blood cholesterol check, as recommended by the ACS, CDC, and USPSTF, pertaining to between breast, prostate, female colorectal, and male colorectal cancer survivors to their noncancer control groups matched for age, gender, race/ethnicity, income, insurance status, and region of the US; (2) the likelihood of recommended health behaviors for each cancer type, stratified by short- and long-term survivors, to noncancer controls; (3) and the likelihood of recommended health behaviors between cancer types and genders.

Methods

Study design

This study used a retrospective, cross-sectional matched case-control design. Breast, colorectal, and prostate cancer survivors were matched to noncancer controls on specific groups of age, gender, race/ethnicity, income, insurance status, and region of the US.

Data

Cancer survivors and controls were sampled from the CDC’s national 2009 Behavioral Risk Factor Surveillance System (BRFSS) survey, an annual, state-based telephone survey administered to noninstitutionalized citizens aged >18 years in all 50 states, the District of Columbia, Puerto Rico, the US Virgin Islands, and Guam, collecting data on disease prevalence, risky health behaviors, preventive health care utilization, perceived health status, access to health care services, sociodemographic, and environmental characteristics [21]. The core component is a standard set of questions administered to all states and territories. In 2009, the response rate was 52.5 %, with a total sample size of 432,607 [22, 23]. Optional modules collecting information on select topics are administered on a state by state basis. This study used data from the core component file, excluding responses from Puerto Rico, the US Virgin Islands, and Guam.

Study sample

Cancer survivors

Survivors of breast, prostate, and colorectal cancer and age at diagnosis were identified from questions about ever being diagnosed with cancer, cancer type, number of different cancer diagnoses, and age at diagnosis. Inclusion criteria were that individuals be diagnosed with only 1 type of cancer (breast, prostate, or colorectal), age >18 years, no missing responses on any of the dependent variables, and >1 year post diagnosis. The final sample consisted of 6,259 female breast, 3,609 prostate, 1,082 female colorectal, and 816 male colorectal cancer survivors.

Controls

Noncancer controls were selected from those without missing responses for any dependent variables. Logistic regressions generated propensity scores for survivors and potential noncancer controls conditional upon the probability of the individual having had cancer and belonging to specific groups of age, gender, race/ethnicity, income, insurance status, and region of the US. A 3:1 ratio of controls and survivors were matched without replacement using the greedy algorithm. Chi-square tests were performed to determine covariate balance between survivors and controls. Balance was achieved between survivors and controls for all covariates adjusted for in the matching process.

Measures

Dependent variables

ACS guidelines for recommended health behaviors are defined as receiving >150 min of moderate-to-vigorous physical activity per week, consuming >5 servings of fruits and vegetables per day (5-A-Day), not smoking, and avoiding heavy alcohol use (>2 drinks per day for men, and >1 for women). The ACS also recommends that cancer survivors maintain a healthy, normal weight, specifically a body mass index (BMI) between 18.5 and 25 kg/m2. CDC and USPSTF guidelines for recommended general preventive care vary by service, age, and risk factors, but include annual influenza (flu) immunization, annual or biannual physical check-ups, and blood cholesterol checks every 5 years or shorter intervals for individuals at increased risk for high lipid levels [10, 11]. Responses to dependent variable were dichotomized as “recommended” and “not recommended.” Specific responses for each dependent variable categorized as “recommended” or “not recommended” are as follows: physical activity (“recommended” = >150 min of moderate-to-vigorous physical activity per week, “not recommended” = <150min of moderate-to-vigorous physical activity per week); 5-A-Day (“recommended” = >5 servings of fruits and vegetables per day, “not recommended” = <5 servings of fruits and vegetables per day); smoking (“recommended” = never smoked or former smoker, “not recommended” = current smoker); alcohol use (“recommended” = <2 drinks per day for men, and < 1 for women, “not recommended” = >2 drinks per day for men, and >1 for women); BMI (“recommended” = normal weight, where 18.5 kg/m2 <BMI<25.0 kg/m2, “not recommended” = overweight, where 25.0 kg/m2 <BMI<30.0 kg/m2 or obese, where BMI >30.0 kg/m2); last flu immunization (“recommended” = <1 year, “not recommended” = >1 year or never); last physical check-up (“recommended” = <2 years, “not recommended” = >2 years or never); and last blood cholesterol check (“recommended” = <2 years, “not recommended” = >2 years or never).

Independent variables

Independent variables controlled for were age, race/ethnicity, marital status, education, employment status (employed or other, where “employed” = employed for wages or self-employed and “other” = out of work >1 year, out of work <1 year, homemaker, student, retired, or unable to work), income, insurance status, usual source of care, metro status (metro or non-metro), regions of the US (Northeast, Midwest, West, and South), activity limitations (i.e., limited in any way in any activities because of physical, mental, or emotional problems) (yes or no), and perceived general health (excellent/very good, good, fair/poor). Presence of a specific health condition was 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 heart disease (myocardial infarction, angina, or coronary heart disease), hypertension (high blood pressure), high cholesterol (adults who had their blood cholesterol checked and told it was high), diabetes (diabetes, gestational diabetes, or borderline diabetes), stroke, asthma, and arthritis.

Statistical methods

Chi-square tests compared significant differences in individual characteristics, health conditions, and health behaviors between survivors and controls, with significance set at P<.05. The probabilities of engaging in specified levels of health behaviors were compared using logistic regression models controlling for the independent variables described above. Parameter estimates calculated in the regression models are presented as adjusted odds ratios (AOR) with their corresponding 95 % confidence intervals (CI). Due to small cell sizes, responses for alcohol consumption were categorized as “drink any alcohol” or “no drinks in past 30 days.” Models comparing survivors to controls were stratified by time since diagnosis (1–5 years and >5 years). All analysis were conducted using survey procedures in SAS version 9.2 software (SAS Institute Inc., Cary, NC) to account for the complex sample design of the BRFSS.

Results

Characteristics of cancer survivors

The majority of cancer survivors were living >5 years post-diagnosis (58.7–71.6 %), and were >65 years of age (53.8–76.4 %) (Table 1). All cancer types reported more activity limitations (.001 <P<.003) and fair/poor general health (P<.001), than controls (Table 2). Breast cancer survivors reported a greater prevalence of arthritis (53.0 vs. 48.3 %; P=.001), diabetes (18.1 vs. 16.0 %; P=.036), and high cholesterol (48.8 vs. 46.3 %; P=.002) than controls. Similarly, prostate cancer survivors reported a greater prevalence of arthritis (47.8 vs. 41.7 %; P<.001), hypertension (58.3 vs. 53.9 %; P=.008), and high cholesterol (53.9 vs. 48.5 %; P<.001) than controls.

Table 1.

Description of cancer survivors and noncancer controls: Behavioral Risk Factor Surveillance System, 2009

BC BC controls P CC (female) CC controls P CC (male) CC controls P PC PC controls P
n %a n %a n %a n %a n %a n %a n %a n %a
Total 6,259 25.0 18,784 75.0 1,082 25.0 3,260 75.0 816 25.0 2,107 75.0 3,609 25.0 10,839 75.0
Time since diagnosis – – – –
  1–5 Years 1,779 28.4 – – 329 33.4 – – 298 40.1 – – 1,408 41.3 – –
  >5 Years 4,480 71.6 – – 753 66.6 – – 518 59.9 – – 2,201 58.7 – –
Age 0.289 0.961 0.962 0.126
  18–49 378 10.1 1,142 12.1 38 6.8 117 8.1 34 8.8 106 10.6 18 1.1 53 2.6
  50–54 472 10.8 1,410 10.0 54 8.2 167 8.7 37 6.5 109 6.8 63 3.4 185 2.6
  55–59 696 12.4 2,081 11.7 90 8.0 267 8.7 74 10.4 224 9.3 171 5.8 514 6.3
  60–64 887 12.9 2,689 13.9 112 10.8 338 10.4 115 15.0 347 14.7 410 13.2 1,236 13.3
  65–69 977 13.6 2,923 13.3 125 10.4 385 9.3 140 15.8 423 16.4 595 13.3 1,812 15.0
  70–74 925 11.9 2,774 12.2 186 17.0 560 15.0 125 13.7 376 12.7 729 17.8 2,163 18.4
  >75 1,924 28.3 5,765 26.9 477 38.8 1,426 39.6 291 29.8 874 29.5 1,623 45.3 4,876 41.8
Gender 1.000 1.000 1.000 1.000
  Female 6,259 100.0 18,784 100.0 1,082 100.0 3,260 100.0 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 0.0 816 100.0 2,107 100.0 3,609 100.0 10,839 100.0
Race/ethnicity 0.287 0.287 0.526 0.679
  White 5,435 80.6 16,329 81.6 943 82.9 2,844 80.1 697 80.7 2,107 80.1 3,034 78.5 9,152 78.1
  AA 405 10.1 1,216 8.0 78 10.7 229 8.9 52 10.1 151 8.2 352 12.4 1,026 13.2
  Latino 162 5.1 475 5.4 26 2.1 79 5.3 33 6.3 96 7.6 93 5.5 275 4.6
  Other 257 4.3 764 5.0 35 4.2 108 5.7 34 2.9 105 4.0 130 3.6 386 4.2
Marital status 0.124 0.306 0.419 0.161
  Married 2,965 59.7 9,023 59.0 433 56.8 1,299 52.3 522 75.4 1,611 75.3 2,486 77.2 7,232 76.3
  Widowed 1,929 22.2 6,002 22.6 434 26.6 1,320 30.6 140 11.0 372 8.9 555 10.6 1,854 11.4
  Sep/Divorced 1,009 13.2 2,756 12.2 172 13.3 495 13.2 106 9.4 329 10.8 401 9.1 1,219 8.0
  Never married 356 4.9 1,003 6.2 43 3.4 146 4.0 48 4.2 147 5.0 167 3.2 534 4.3
Education <0.001*** 0.307 0.107 0.562
  <HS 435 6.4 1,727 8.9 139 15.4 407 13.9 98 11.7 284 11.4 376 9.7 1,224 10.5
  HS grad 1,960 29.6 6,399 31.8 407 36.9 1,225 33.6 262 30.5 742 28.8 971 25.5 3,129 26.7
  Some Col/TS 1,793 27.6 5,188 27.2 314 26.0 821 25.6 189 25.4 554 20.8 791 22.8 2,367 22.5
  Col/TS Grad 2,071 36.4 5,470 32.0 222 21.7 807 26.9 267 32.4 879 39.1 1,471 42.2 4,119 40.2
Employment status 0.069 0.301 0.911 0.049*
  Employed 1,908 33.4 5,963 35.8 209 24.0 735 27.1 248 36.4 735 36.7 794 23.9 2,652 27.1
  Unemployed 4,351 66.6 12,821 64.2 873 76.0 2,525 72.9 568 63.6 1,724 63.3 2,815 76.1 8,187 72.9
Family income 0.179 0.440 0.436
  <$25,000 1,829 24.5 5,519 24.6 434 31.9 1,301 34.5 238 25.8 732 28.2 784 19.4 2,356 19.3
  $25,000–$35,000 834 10.9 2,493 12.1 144 12.3 444 13.2 114 13.5 341 11.8 499 12.0 1483 11.6
  $35,000–$50,000 919 14.7 2,742 14.5 131 12.3 395 12.3 124 14.8 367 12.8 637 17.5 1,924 17.2
  $50,000–$75,000 746 12.1 2,238 13.2 95 12.9 287 10.8 112 16.9 336 14.3 573 15.7 1,690 15.6
  >$75,000 1,066 22.9 3,202 22.9 112 13.1 342 15.5 158 22.2 475 25.5 774 25.1 2,303 25.9
  Missing/DK 865 14.8 2,590 12.6 166 17.5 491 13.7 70 6.9 208 7.3 342 10.2 1,083 10.3
Insurance status 0.772 0.893 0.742 0.832
Insured 6,029 95.8 18,105 96.0 1,048 96.0 3,153 95.9 781 96.0 2,362 95.5 3,532 97.9 10,630 98.0
  Uninsured 230 4.2 679 4.0 34 4.0 107 4.1 35 4.0 97 4.5 77 2.1 209 2.0
Usual source of care <0 .001*** 0.697 <0 .001*** <0 .001***
  Yes 6,029 96.3 17,646 93.2 1,051 94.9 3,101 94.1 769 94.6 2,227 89.2 3,473 96.5 10,039 93.2
  No 225 3.7 1,118 6.8 31 5.1 153 5.9 47 5.4 229 10.8 130 3.5 787 6.8
Region of the US 0.373 0.964 0.907 0.143
  Northeast 1,215 22.1 3,644 20.4 191 20.6 581 19.8 152 16.5 453 17.8 610 19.6 1,851 17.7
  Midwest 1,582 24.2 4,743 24.0 311 25.3 931 24.5 212 24.3 627 23.7 888 23.3 2,655 22.5
  South 1,935 33.9 5,799 34.3 363 37.1 1,107 37.7 266 40.3 812 38.8 1,146 36.3 3,491 39.9
  West 1,527 19.8 4,598 21.3 217 17.0 641 18.0 186 18.9 567 19.6 965 20.8 2,842 19.9
Metro status 0.071 0.231 0.919 0.246
  Metro 4,176 82.1 12,273 80.5 677 77.8 2,059 80.5 512 79.1 1,562 79.4 2,352 81.0 7,071 79.7
  Non-metro 2,060 17.9 6,419 19.5 402 22.2 1,183 19.5 299 20.9 888 20.6 1,242 19.0 3,718 20.3
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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

a

Weighted percentages

*

P<.05;

**

P<.01;

***

P<.001

Table 2.

Health condition s and health behaviors of cancer survivors and noncancer controls: Behavioral Risk Factor Surveillance System, 2009

BC BC controls P CC (female) CC controls P CC (male) CC controls P PC PC controls P
n %a n %a n %a n %a n %a n %a n %a n %a
Total 6,259 25 18,784 75 1,082 25 3,260 75 816 25 2,459 75 3,636 25 10,908 75
Arthritis 0 .001*** 0.102 0.071 <0 .001***
  Yes 3,525 53.0 9,811 48.3 652 60.4 1,837 55.0 350 46.4 1,055 41.1 1,805 47.8 4,686 41.7
  No 2,721 47.0 8,920 51.7 426 39.6 1,410 45.0 464 53.6 1,397 58.9 1,797 52.2 6,093 58.3
Asthma 0.607 0.979 0.003 0.675
  Yes 815 13.4 2,424 13.9 145 12.5 378 12.5 92 13.3 213 8.0 361 9.5 907 9.0
  No 5,425 86.6 16,314 86.1 932 87.5 2,874 87.5 722 86.7 2,241 92.0 3,241 90.5 9,894 91.0
Heart Disease 0.189 0.707 0.536 0.084
  Yes 648 8.8 1,988 9.7 151 12.2 410 11.6 175 19.0 574 20.3 775 20.1 2,509 22.5
  No 5,545 91.2 16,608 90.3 922 87.8 2,806 88.4 634 81.0 1,855 79.7 2,785 79.9 8,207 77.5
Diabetes 0.036* 0.419 0.211 0.758
  Yes 1,139 18.1 3,088 16.0 244 18.9 632 20.6 214 25.0 578 21.9 813 23.7 2,507 23.2
  No 5,116 81.9 15,687 84.0 838 81.1 2,627 79.4 600 75.0 1,877 78.1 2,793 76.3 8,321 76.8
Hypertension 0.796 0.295 0.094 0.008**
  Yes 3,214 46.6 9,579 46.9 626 57.0 1,848 53.5 453 53.4 1,309 48.5 2,181 58.3 6,034 53.9
  No 3,038 53.4 9,168 53.1 454 43.0 1,400 46.5 362 46.6 1,141 51.5 1,425 41.7 4,781 46.1
High Cholesterol 0.002** 0.437 0.933 <0 .001***
  Yes 3,203 48.8 9,184 46.3 547 47.4 1,665 48.5 387 49.3 1,217 49.1 1,974 53.9 5,307 48.5
  No 2,874 47.8 8,728 48.0 498 49.1 1,455 46.4 392 46.4 1,138 46.5 1,545 43.6 5,076 46.9
  No test 182 3.4 872 5.7 37 3.5 140 5.1 37 4.3 104 4.4 90 2.5 456 4.6
Stroke 0.517 0.472 0.716 0.894
  Yes 319 4.7 1,023 5.1 90 8.2 206 6.7 56 6.4 188 6.9 264 6.9 809 6.8
  No 5,923 95.3 17,712 94.9 989 91.8 3,046 93.3 757 93.6 2,266 93.1 3,333 93.1 10,809 93.2
Activity limitations <0 .001*** 0.003** <0 .001*** 0.003**
  Yes 1,986 30.4 5,270 25.4 381 37.2 980 28.3 291 39.4 713 23.9 1,103 29.3 2,939 24.9
  No 4,251 69.6 13,441 74.6 695 62.8 2,263 71.7 521 60.6 1,736 76.1 2,492 70.7 7,860 75.1
Perc. general health <0 .001*** <0 .001*** <0 .001*** <0 .001***
  Excel/very good 2,463 40.8 9,138 51.9 339 31.6 1,393 44.1 257 31.0 1,079 47.5 1,306 37.2 4,722 45.4
  Good 2,251 36.2 5,788 29.3 369 32.4 1,036 31.2 290 39.8 761 30.7 1,322 38.6 3,666 34.0
  Fair/poor 1,507 23.0 3,742 18.8 368 36.0 803 24.6 262 29.2 606 21.9 958 24.2 2,379 20.6
Flu immunization <1 Year < 0.001*** 0.755 0.431 0.002**
  Yes 4,197 63.8 11,511 57.5 744 62.2 2,104 61.2 520 60.3 1,537 57.9 2,632 71.0 7,323 65.8
  No 2,062 36.2 7,273 42.5 338 37.8 1,156 38.8 296 39.7 922 42.1 977 29.0 3,516 34.2
Physical check-up <0 .001*** 0.252 0.979 <0 .001***
  <2 years ago 5,835 93.7 17,023 91.4 1,007 94.0 2,994 91.9 743 91.2 2,218 91.3 3,408 95.5 9,939 92.9
  >2 years ago/never 424 6.3 1,761 8.6 75 6.0 266 8.1 73 8.8 241 8.7 201 4.5 900 7.1
Cholesterol check <0 .001*** 0.343 0.338 <0 .001***
  <2 years ago 5,650 91.0 16,482 87.5 975 91.6 2,879 89.6 722 90.3 2,193 88.3 3,366 94.6 9,773 91.0
  >2 years ago/never 549 9.0 2,136 12.5 92 8.4 343 10.4 89 9.7 246 11.7 216 5.4 988 9.0
Body mass index 0.989 0.408 0.289 0.961
  Normal 2,395 39.9 7,376 39.9 408 36.4 1,269 38.9 211 25.0 666 27.8 983 28.0 3,113 28.1
  Overweight/obese 3,864 60.1 11,408 60.1 674 63.6 1,991 61.1 605 75.0 1,793 72.2 2,626 72.0 7,726 71.9
Physical activity 0.324 0.002** 0.014* 0.769
  Recommended 2,591 41.2 7,839 42.6 377 30.3 1,237 38.4 318 39.8 1,144 47.1 1,687 46.6 4,992 47.1
  Not recommended 3,668 58.8 10,945 57.4 0.035* 705 69.7 2,023 61.6 0.092 498 60.2 1,315 52.9 0.603 1,922 53.4 5,847 52.9 0.652
5-A-Day
  >5 Servings/day 2,026 34.4 5,824 31.6 308 28.3 1,040 33.2 153 20.0 495 21.3 802 21.5 2,283 22.2
  <5 Servings/day 4,233 65.6 12,960 68.4 774 71.7 2,220 66.8 663 80.0 1,964 78.7 2,807 78.5 8,556 77.8
Smoking status 0.052 0.765 0.087 0.025*
  Current smoker 610 10.3 2,164 12.0 123 11.5 325 10.9 85 10.6 314 14.1 290 7.8 1,067 9.9
  Does Not Smoke 5,649 89.7 16,620 88.0 959 88.5 2,935 89.1 731 89.4 2,145 85.9 3,319 92.2 9,772 90.1
Alcohol 0.448 0.94 0.173 0.429
  Drinker any alcohol 2,535 42.7 7,387 41.6 334 36.0 1,074 35.7 410 49.9 1,243 53.9 1,834 54.6 5,485 53.2
  Does not drink 3,724 57.3 11,397 58.4 748 64.0 2,186 64.3 406 50.1 1,216 46.1 1,775 45.4 5,354 46.8
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BC breast cancer, CC colorectal cancer, PC prostate cancer, Perc perceived, Excel excellent

a

Weighted percentages

*

P<.05;

**

P<.01;

***

P<.001

Health behaviors of cancer survivors compared to noncancer controls

Compared to noncancer controls, fewer female colorectal (30.3 vs. 38.4 %; P=.002) and male colorectal cancer survivors (39.8 vs. 47.1 %; P=.014) met the physical activity recommendation, but more breast cancer survivors met the 5-A-Day recommendation (34.4 vs. 31.6 %; P=.035) and fewer prostate cancer survivors were current smokers (7.8 vs. 9.9 %; P=.025) than controls (Table 3). Additionally, more breast and prostate cancer survivors received recommended flu immunization (P<.001 and P=.002), physical check-up (P<.001 and P<.001), and cholesterol check (P<.001 and P<.001) than controls, whereas female and male colorectal did not differ from their noncancer controls in receipt of recommended general preventive care Table 3.

Table 3.

Logistic regression of the health behaviors of cancer survivors to non-cancer controls: Behavioral Risk Factor Surveillance System, 2009

Health behavior Time since diagnosis Breast cancer Colorectal cancer (female) Colorectal cancer (male) Prostate cancer
AOR 95 % CI AOR 95 % CI AOR 95 % CI AOR 95 % CI
Last flu immunization
  >1 year 1–5 years 1 – 1 – 1 – 1 –
  <1 year 1.49 (1.19, 1.86)*** 0.78 (0.52, 1.19) 1.3 (0.84, 2.04) 1.1 (0.87, 1.39)
  >1 year  >5 years 1 – 1 – 1 – 1 –
  <1 year 1.16 (1.01, 1.33)* 0.98 (0.73, 1.32) 0.78 (0.56, 1.09) 1.15 (0.95, 1.40)
Last physical check-up
  >2 years 1–5 years 1 – 1 – 1 – 1 –
  <2 years 1.18 (0.75, 1.84) 1.9 (0.90, 4.03) 0.97 (0.47, 2.00) 1.29 (0.81, 2.06)
  >2 years  >5 years 1 – 1 – 1 – 1 –
  <2 years 1.14 (0.90, 1.44) 0.93 (0.53, 1.65) 0.42 (0.24, 0.74) 1.05 (0.75, 1.47)
Last cholesterol check
  >2 years 1–5 years 1 – 1 – 1 – 1 –
  <2 years 1.35 (0.89, 2.03) 2.17 (0.74, 6.34) 0.8 (0.35, 1.79) 1.47 (0.92, 2.34)
  >2 years  >5 years 1 – 1 – 1 – 1 –
  <2 years 0.98 (0.76, 1.25) 0.68 (0.40, 1.18) 0.51 (0.28, 0.94)* 0.90 (0.64, 1.27)
Body mass index
  Overweight/obese 1–5 years 1 – 1 – 1 – 1 –
  Normal weight 0.91 (0.73, 1.13) 1.55 (0.98, 2.46) 0.68 (0.42, 1.11) 1.08 (0.85, 1.38)
  Overweight/obese  >5 years 1 – 1 – 1 – 1 –
  Normal weight 1.16 (1.01, 1.33)* 0.91 (0.67, 1.23) 1.19 (0.86, 1.64) 1.02 (0.85, 1.22)
Physical activity
  Not recommended 1–5 years 1 – 1 – 1 – 1 –
  Recommended 1 (0.81, 1.24) 1.05 (0.66, 1.67) 0.84 (0.54, 1.29) 1.05 (0.84, 1.19)
  Not recommended  >5 years 1 – 1 – 1 – 1 –
  Recommended 1.07 (0.94, 1.22) 0.72 (0.54, 0.97)* 0.8 (0.59, 1.10) 0.99 (0.85, 1.19)
5-A-Day
  <5 Servings/day 1–5 years 1 – 1 – 1 – 1 –
  >5 Servings/day 1.37 (1.11, 1.70)** 0.9 (0.57, 1.40) 0.83 (0.48, 1.43) 1.15 (0.89, 1.48)
  <5 Servings/day  >5 years 1 – 1 – 1 – 1 –
  >5 Servings/day 1.06 (0.93, 1.22) 0.8 (0.59, 1.08) 0.92 (0.67, 1.28) 0.86 (0.71, 1.04)
Smoking status
  Current smoker 1–5 years 1 – 1 – 1 – 1 –
  Does not smoke 1.59 (1.16, 2.20)** 1.37 (0.71, 2.64) 1.45 (0.84, 2.51) 1.09 (0.75, 1.57)
  Current smoker  >5 years 1 – 1 – 1 – 1 –
  Does not smoke 1.08 (0.86, 1.37) 0.97 (0.61, 1.53) 1.24 (0.68, 2.24) 1.22 (0.89, 1.67)
Alcohol consumption
  Does not drink 1–5 years 1 – 1 – 1 – 1 –
  Drink any 1.1 (0.89, 1.37) 1.05 (0.64, 1.73) 0.92 (0.60, 1.41) 1.17 (0.93, 1.47)
  Does not drink  >5 years 1 – 1 – 1 – 1 –
  Drink Any 1.1 (0.96, 1.26) 1.17 (0.83, 1.64) 0.88 (0.64, 1.22) 0.97 (0.81, 1.15)
Open in a new tab

All regressions controlled for the following covariates: race/ethnicity, age, marital status, metro status, region of US, education, employment status, income, health insurance, unusual source of care, activity limitations, perceived general health, arthritis, asthma, cardiovascular disease-metabolic syndrome, and stroke

AOR adjusted odds ratios, CI confidence intervals

*

P<.05;

**

P<.01;

***

P<.001

Among short-term cancer survivors, adjusted models showed that breast cancer survivors were 37, 59, and 49 %, respectively, more likely to meet the 5-A-Day recommendation (95%CI 1.11, 1.70), not smoke (95%CI 1.16, 2.20), and receive recommended flu immunization (95 % CI 1.19, 1.86) than controls.

Among long-term cancer survivors, breast cancer survivors were more likely to be of normal weight (AOR, 1.16; 95% CI 1.01, 1.33) and receive recommended flu immunization (AOR, 1.16; 95 % CI 1.01, 33) than controls. Long-term female colorectal cancer survivors were less likely to meet the physical activity recommendation (AOR, 0.72; 95 % CI 0.54, 0.97), while long-term male colorectal cancer survivors were 58 and 49%less likely to receive recommended physical check-up (AOR, 0.42; 95 % CI 0.24, 0.74) and cholesterol check (AOR, 0.51; 95 % CI 0.28, 0.94) than controls.

Health behaviors compared among cancer types and genders

Few differences in health behaviors emerged between cancer types, with the exception that prostate cancer survivors were more likely (AOR, 1.35; 95 % CI 1.01, 1.80) to meet the physical activity recommendation, than male colorectal cancer survivors (Table 4). However, comparisons between genders revealed that breast cancer survivors were 27 % less likely (95 % CI 0.62, 0.86) to meet the physical activity recommendation, but were more than twice as likely (AOR, 2.27; 95 % CI 1.90, 2.71) to meet the 5-A-Day recommendation, 89 % more likely to be of normal weight (95 % CI 1.60, 2.24) and 46 % less likely (95 % CI 0.46, 0.64) to drink alcohol, than prostate cancer survivors. Likewise, female colorectal cancer survivors were 32 % less likely (AOR, 0.68; 95 % CI 0.49, 0.95) to meet the physical activity recommendation, but were 73%more likely to meet the 5-A-Day recommendation (95% CI 1.21, 2.49), 88%more likely to be of normal weight (95% CI 1.34, 2.65), and 45 % less likely (95 % CI 0.45, 0.93) to drink alcohol, than male colorectal cancer survivors.

Table 4.

Logistic regression comparison of health behaviors of cancer survivors by cancer type and gender: Behavioral Risk Factor Surveillance System, 2009

Health behavior Breast cancer Prostate cancer Colorectal cancer (female) Breast cancer
vs. colorectal (female) vs. colorectal (male) vs. colorectal (male) vs. prostate
AOR 95 % CI AOR 95 % CI AOR 95 % CI AOR 95 % CI
Last flu immunization
  >1 year 1 – 1 – 1 – 1 –
  <1 year 1.22 (0.93, 1.60) 1.21 (0.91, 1.61) 1.06 (0.76, 1.50) 1.03 (0.86, 1.23)
Last physical check-up
  >2 years/never 1 – 1 – 1 – 1 –
  <2 years 0.94 (0.55, 1.60) 1.68 (0.97, 2.91) 1.7 (0.89, 3.26) 0.85 (0.61, 1.19)
Last cholesterol check
  >2 years/never 1 – 1 – 1 – 1 –
  <2 years 1 (0.59, 1.70) 1.32 (0.77, 2.25) 1.39 (0.73, 2.63) 0.88 (0.63, 1.24)
Body mass index
  Overweight/obese 1 – 1 – 1 – 1 –
  Normal weight 1.04 (0.81, 1.35) 1.01 (0.76, 1.35) 1.88 (1.34, 2.65)*** 1.89 (1.60, 2.24)***
Physical activity
  Not recommended 1 – 1 – 1 – 1 –
  Recommended 1.26 (0.98, 1.62) 1.35 (1.01, 1.80)* 0.68 (0.49, 0.95)* 0.73 (0.62, 0.86)***
5-A-Day
<5 servings/day 1 – 1 – 1 – 1 –
  >5 servings/day 1.2 (0.93, 1.54) 1 (0.72, 1.39) 1.73 (1.21, 2.49)** 2.27 (1.90, 2.71)***
Smoking status
  Current smoker 1 – 1 – 1 – 1 –
  Does not smoke 1.13 (0.77, 1.65) 1.01 (0.64, 1.58) 1.02 (0.62, 1.68) 1.25 (0.95, 1.65)
Alcohol consumption
  Does not drink 1 – 1 – 1 – 1 –
  Drink any 0.94 (0.69, 1.27) 1.13 (0.86, 1.49) 0.65 (0.45, 0.93)* 0.54 (0.46, 0.64)***
Open in a new tab

All regressions controlled for the following covariates: race/ethnicity, age, marital status, metro status, region of US, education, employment status, income, health insurance, unusual source of care, activity limitations, perceived general health, arthritis, asthma, cardiovascular disease-metabolic syndrome, and stroke

Abbreviations: AOR, Adjusted Odds Ratios; CI, Confidence Intervals

*

P<.05;

**

P<.01;

***

P<.001

Discussion

Only a minority of cancer survivors are meeting the ACS recommendations for physical activity (30.3–46.6 %), 5-A-Day (20.0–34.4 %), and healthy weight (25.0–39.9 %), while the majority refrain from smoking and receive recommended routine preventive care. Although, the estimated rates of physical activity are higher than those reported by Coups and Ostroff (2005) (19.7–29.3 %) and Bellizzi et al. (2005) (23.7–30.1 %), whose studies utilized data from the 1998 to 2001 National Health Interview Survey, they are more similar to those recently reported by Blanchard et al. (2008) (35.0–43.2 %) [5, 12, 17]. As the ACS did not publish guidelines for recommended health behaviors for cancer survivors until 2003, therefore these higher prevalence estimates may reflect a gradual adoption of the physical activity recommendation [24]. Estimates for survivors meeting the 5-A-Day, smoking, and weight recommendation are within the range of those previously reported [5, 12, 17].

Health behavior comparisons between cancer survivors and similarly matched individuals without a history suggest that short-term breast cancer survivors are more likely to meet the 5-A-Day, smoking, and flu immunization recommendation. Yet, the likelihood of these recommended health behaviors decrease between short- and long-term breast cancer survivors. Moreover, long-term colorectal cancer survivors are actually less likely to meet the physical activity recommendation or receive recommended routine preventive care, than controls. Previous research has identified associations between unhealthy behaviors and underuse of preventive services and a discontinuity of care between oncology specialist and primary care providers, as well as increasing age, and a decreasing sense of urgency to engage in healthy behaviors as the time since diagnosis increases [25, 26]. Regardless of the reason, it appears that cancer survivors become less likely to engage in recommended health behaviors as time from diagnosis increases.

Few differences were observed between cancer types, with the exception that prostate cancer survivors are 35 % more likely to meet the physical activity recommendation, compared to male colorectal cancer survivors. This finding is likely due to the physical and activity limitations often reported by colorectal cancer survivors, particularly those living with a permanent ostomy [27, 28]. However, a notable pattern of differences emerged between genders. Breast and female colorectal cancer survivors are as much as 2.27 times more likely to meet the 5-A-Day recommendation, almost 90 % more likely to be of normal weight, while less likely to drink alcohol, compared to prostate and male colorectal cancer survivors. Yet, females are about 30 % less likely to meet the physical activity recommendation, compared to the male cancer survivors. Mosher et al.’s (2009) study of lifestyle factors among older, long-term cancer survivors also found that more breast and female colorectal cancer survivors maintained a healthier diet, but engaged in lower rates of recommended physical activity, than prostate and male colorectal cancer survivors [29]. This pattern of differences in health behaviors between genders has not been limited to cancer survivors. Compared to females, higher rates of physical activity, but a greater consumption of alcohol, diets high in meat, fat, and salt, and lower in fruit and vegetables, have been observed among adult males in the general population and among individuals with chronic diseases throughout multiple countries [18–20, 30, 31]. This phenomenon may be explained by masculinity/femininity theory. This theory posits that men’s health practices are shaped by their desire to adhere to dominant masculine ideals shaped by life-long cultural norms, such as engaging in physical demanding activities, consuming red meat, and heavy alcohol use, whereas women are more likely to manage their weight through diet modification [19, 31–33].

However, adherence to gender norms may not be the only explanation for observed differences in health behaviors between genders. Various behavioral models such as the Health Belief Model are to describe the relationship between an individual’s risk perceptions and the corresponding health behavior [34]. Cardiovascular disease is the leading cause of death for both men and women, but has historically been viewed as “man’s disease” [35]. Despite efforts to raise public awareness, still only 54%of women recognize cardiovascular disease to be their leading cause of death, while many still believe that breast cancer is their potentially biggest health problem [36]. A lack of perceived susceptibility for developing cardiovascular disease may contribute to less recommended physical activity among women, compared to men. In addition to risk perceptions, a study of health-related quality of life among breast, prostate, and colorectal cancer survivors found that female cancer survivors were more likely to report unfavorable perceptions of their mental health, sleep quality, and amount of emotional support received, compared to male cancer survivors. Yet, few differences were found between genders with regards to general and physical health perceptions [37].

Interventions for health behavioral change, including diet and physical activity, have produced positive health benefits among cancer survivors [38, 39]. However, the uptake of these behaviors by cancer survivors has not been better than individuals without a history of cancer [5, 12]. Furthermore, one third of cancer survivors with cardiovascular risk factors may not be engaging in discussion or receiving counseling for health behavior change [4]. The National Cancer Survivorship Resource Center was recently created in a collaborative effort by the American Cancer Society and George Washington University Cancer Institute, and is currently developing clinical follow-up care guidelines for primary care providers that include guidance on the prevention and management of chronic diseases, with an emphasis on promoting healthy behaviors [40]. Given the need for these services among cancer survivors, this may be an area for primary care providers to take the lead role in survivorship care. Furthermore, given the current study findings, efforts to promote healthy behaviors, disease prevention, and management among cancer survivors could benefit by addressing misconceptions regarding risk of cardiovascular disease and unhealthy behaviors that may be influenced by long held notions of gender norms. Previous health behavioral interventions that addressed perceptions regarding gender roles and/or ideals among noncancer populations have demonstrated positive results [41]. Existing survivorship care models could be improved by addressing gender differences in health perceptions and behaviors. Together, these efforts could help to reduce illness burden, and improve the health and well-being of cancer survivors.

This study was limited in its ability to control for stage at diagnosis and type of treatment received among cancer survivors, factors known to affect health and health-related quality of life, and potentially health behaviors. However, these factors were not assessed for in the 2009 BRFSS. Instead, cancer survivors sampled were limited to those >1 year past diagnosis to avoid including survivors who may be undergoing intensive treatment and therefore have competing demands with engaging in certain healthy behaviors. Another limitation is that this study was unable to compare routine preventive cancer screenings since these services were also not assessed for core component of the 2009 BRFSS. Additionally, responder bias is an inherent limitation of self-reported data. Strengths of this study include the utilization of data from a recent, large national survey, with cancer survivors representing a diverse range in age and time since diagnosis. Furthermore, this study rigorously matched each cancer type to their own control group to minimize the confounding effects of individual characteristics, while adding to the extant literature by providing comprehensive comparisons of health behaviors between cancer survivors and noncancer controls, stratified by time since diagnosis, and between cancer types and genders.

In conclusion, only a minority of cancer survivors met the ACS guidelines for recommended physical activity and 5-A-Day, but most received recommended general preventive care and did not smoke. Breast cancer survivors may be more likely to meet guidelines recommended health behaviors, than similar individuals without a history of cancer, yet the likelihood of these behaviors decrease in the long term. Few distinctions in health behaviors are observed between cancer types, but the pattern of differences in health behaviors between genders suggest that male and female cancer survivors’ health behaviors may be influenced by behavioral and health perceptions associated with gender. Health behaviors, chronic disease prevention, and management among cancer survivors could be improved by the National Cancer Survivorship Resource Center’s development of survivorship care guidelines for primary care providers and by addressing gender differences in health perceptions and behaviors.

Acknowledgments

The authors would like to acknowledge that this study was funded by the WV CoHORTS Center and AHRQ grant # 1R24H5018622-01.

Footnotes

Conflict of interest The authors of this study have no conflict of interest to report.

Contributor Information

Traci J. LeMasters, Email: tlemasters@hsc.wvu.edu, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV, USA; SoP Pharmaceutical Systems and Policy, Robert C. Byrd Health Sciences Center, P.O. Box 9510, Morgantown, WV 26506-9510, USA.

Sundareswaran S. Madhavan, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV, USA SoP Pharmaceutical Systems and Policy, Robert C. Byrd Health Sciences Center, P.O. Box 9510, Morgantown, WV 26506-9510, USA.

Usha Sambamoorthi, Department of Pharmaceutical Systems and Policy, School of Pharmacy, West Virginia University, Morgantown, WV, USA; SoP Pharmaceutical Systems and Policy, Robert C. Byrd Health Sciences Center, P.O. Box 9510, Morgantown, WV 26506-9510, USA.

Sobha Kurian, 1614 Mary Babb Randolph Cancer Center, West Virginia University, P.O Box 9162, Morgantown, WV 26506-9300, USA.

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