This cross-sectional study uses data from the Behavioral Risk Factor Surveillance System to evaluate adherence to the American Cancer Society (ACS) nutrition and physical activity guidelines among cancer survivors.
Key Points
Question
How well do individuals who have completed cancer treatment adhere to the American Cancer Society nutrition and physical activity guidelines for cancer survivors?
Findings
In this cross-sectional study using data from the Behavioral Risk Factor Surveillance System for 10 020 cancer survivors, only 4% of cancer survivors adhered to all 4 American Cancer Society guidelines, with the mean number of guidelines met being 2.0.
Meaning
The findings suggest that there remains a gap between ideal and observed adherence to healthy behavior guidelines among cancer survivors.
Abstract
Importance
The American Cancer Society’s (ACS’s) nutrition and physical activity guidelines are intended to reduce morbidity and mortality among cancer survivors, but to our knowledge, adherence to these guidelines has not been systematically quantified.
Objective
To evaluate adherence to and factors associated with adherence to lifestyle modification guidelines among cancer survivors.
Design, Setting, and Participants
This cross-sectional study used data from the Behavioral Risk Factor Surveillance System using survey administration years 2017 (surveys completed between January 2017 and March 2018), 2019 (surveys completed between January 2019 and December 2019), and 2021 (surveys completed between January 2021 and February 2022). The study included people who had completed cancer treatment at any point prior to the given survey administration year. Data were analyzed from September 19, 2022, to December 12, 2022.
Main Outcomes and Measures
The primary outcome was adherence to current ACS guidelines for physical activity, body mass index, alcohol use, and fruit and vegetable intake. Factors associated with adherence rates to the guidelines, including age, sex, race and ethnicity, location, and educational level, were evaluated using linear regression. Complex survey weights were used.
Results
A total of 10 020 respondents (57% female; mean [SE] age, 64.2 [0.3] years) reported completion of cancer treatment, representing 2.7 million US individuals over 3 years. Of these respondents, 9121 completed questionnaires for all 4 metrics measured. A total of 72% (95% CI, 71%-74%) of cancer survivors met criteria for adequate physical activity, 68% (95% CI, 66%-69%) did not have obesity, 12% (95% CI, 11%-13%) ate adequate fruits and vegetables, and 50% (95% CI, 49%-52%) did not drink alcohol. In total, 4% (95% CI, 3%-4%) of cancer survivors adhered to all 4 guidelines, with the mean number of guidelines met being 2.0 (95% CI, 2.0-2.1). Factors associated with greater adherence included female sex, older age, Black race, higher educational level, and residence in Western US states.
Conclusions and Relevance
In this cross-sectional study, 4% of cancer survivors fully adhered to current ACS recommendations. Improved understanding of guideline adherence and its determinants may guide oncologists and general internists in providing recommendations for their patients who have completed cancer treatments.
Introduction
There are an estimated 18.5 million cancer survivors in the US, a number that is expected to increase due to advancement in cancer treatment, improved screening protocols, and an aging population.1,2,3,4 Oncologists and primary care physicians are increasingly faced with the challenge of supporting health and longevity in patients who have completed cancer-directed therapy, transitioning from disease-directed treatment to ongoing wellness.
Previous work2,3,4 has identified modifiable factors associated with risk for cancer recurrence and overall survival after completion of treatment. Using these risk factors, the American Cancer Society (ACS) provided specific nutrition and activity guidelines for cancer survivors. These guidelines include having a nonobese weight, engaging in regular physical activity, following a healthy diet, and avoiding alcohol.2 Evidence suggests that as cancer survivors increase the number of these healthy behaviors, length of survival increases.3,4
While there is some evidence that cancer survivors may show improvement in certain healthy behaviors,5,6 overall adherence to these lifestyle guidelines is unknown, as are factors that may be associated with adherence. An increased understanding of guideline adherence would better equip health care practitioners to support healthy behaviors in patients who have survived cancer.
Methods
Study Design and Setting
In this cross-sectional study, data were obtained from the Centers for Disease Control and Prevention’s Behavioral Risk Factor Surveillance System (BRFSS), a nationwide self-reported, telephone-based survey that collects data on health-related behaviors and chronic disease of US adults aged 18 years or older. The Beth Israel Deaconess Medical Center institutional review board approved these analyses of publicly available, deidentified data as exempt and without the need for informed consent. The study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.
Study Population
The study population included survey responses from BRFSS administration years 2017 (surveys completed between January 2017 and March 2018), 2019 (surveys completed between January 2019 and December 2019), and 2021 (surveys completed between January 2021 and February 2022), the most recent years that included cancer survivorship modules. Individuals were included if they reported ever being diagnosed with cancer and having completed cancer treatment. As the cancer survivorship module was optional, the sample was restricted to the 17 states and 2 territories that used this module, which included states and territories distributed across all census regions (Northeast, South, Midwest, West, and US territories) (eTable in Supplement 1).
Data Collection
Adherence to the guidelines was evaluated in the 4 aforementioned domains, with ACS guidelines mapped onto available BRFSS data. Resultant healthy behaviors evaluated were having a nonobese weight (defined as body mass index [calculated as weight in kilograms divided by height in meters squared] <30), engaging in exercise (defined as any physical activity in the past 30 days), maintaining adequate fruit and vegetable consumption (defined as eating vegetables ≥2.5 times per day and fruit ≥1.5 times per day based on the US Dietary Guidelines, recommended by the ACS), and avoiding alcohol (defined as no alcohol intake).
Statistical Analysis
Data were analyzed from September 19, 2022, to December 12, 2022. A composite score was created by adding the total number of healthy behaviors. Multivariable linear regression was performed on the variables of age, sex, census region, educational level, and race and ethnicity to determine factors associated with guideline adherence. The race and ethnicity categories included American Indian or Alaska Native, non-Hispanic; Asian, non-Hispanic; Black, non-Hispanic; Hispanic; White, non-Hispanic; and other, non-Hispanic (other was a categorical variable without subgroup options). Race and ethnicity were obtained by self-report. They were analyzed to understand how uptake of recommended healthy behaviors may differ between different ethnic and racial identities, which might reveal disparities. Data analysis was performed in Stata, version 17 (StataCorp LLC) using complex survey weights provided by the BRFSS. Two-sided P < .05 was considered significant.
Results
Demographics
A total of 10 020 people in the dataset completed cancer treatment, representing 2.7 million US individuals over 3 years (Table 1). Mean (SE) age of cancer survivors was 64.2 (0.3) years (range, 18-80 years; winsorized), with 57% being female and 43% being male. Mean (SE) age at cancer diagnosis was 53.2 (0.3) years. Of the patients, 1% were American Indian or Alaska Native; 1%, Asian; 5%, Black; 7%, Hispanic; 84%, White; and 2%, other race. Of the 10 020 patients who completed cancer treatment, 9121 (91%) completed questionnaires for all 4 metrics measured.
Table 1. Patient Demographics.
| Characteristic | Patients (n = 10 020)a |
|---|---|
| Age, mean (SE), y | 64.2 (0.3) |
| Sex | |
| Female | 57 |
| Male | 43 |
| Race and ethnicity | |
| American Indian or Alaska Native, non-Hispanic | 1 |
| Asian, non-Hispanic | 1 |
| Black, non-Hispanic | 5 |
| Hispanic | 7 |
| White, non-Hispanic | 84 |
| Other, non-Hispanicb | 2 |
Data are presented as weighted percentage of patients unless otherwise indicated.
Other was a categorical variable without subgroup options.
Guideline Adherence
A total of 72% (95% CI, 71%-74%) of cancer survivors met criteria for adequate physical activity, 68% (95% CI, 66%-69%) did not have obesity, 12% (95% CI, 11%-13%) ate adequate fruits and vegetables, and 50% (95% CI, 49%-52%) did not drink alcohol (Table 2). In total, 4% (95% CI, 3%-4%) of cancer survivors adhered to all 4 guidelines, with the mean number of guidelines met being 2.0 (95% CI, 2.0-2.1). When comparing guideline adherence in the sample with that in the general population, after adjusting for age, race and ethnicity, region, and educational level, those who had cancer had –0.101 (95% CI, –0.140 to 0.060) fewer healthy behaviors than those who had not (P < .001).
Table 2. Cancer Survivors’ Adherence to Lifestyle Guidelinesa.
| Guideline | Patients who were adherent, % (95% CI) |
|---|---|
| Physical activity | 72 (71-74) |
| Nonobese weight | 68 (66-69) |
| Avoiding alcohol | 50 (49-52) |
| Adequate produce | 12 (11-13) |
| All | 4 (3-4) |
The mean number of guidelines met was 2.0 (95% CI, 2.0-2.1).
Factors Associated With Guideline Adherence
Women had more healthy behaviors than men (coefficient [SE], 0.14 [0.03]; P < .001). Older age was associated with increased healthy behaviors (coefficient [SE], 0.05 [0.01] per increase in decade; P = .001), and Black individuals had more healthy behaviors than White individuals (coefficient [SE], 0.20 [0.08]; P = .02). Higher educational level was associated with more healthy behaviors; those with a college degree had more healthy behaviors than those who had graduated high school (coefficient [SE], –0.14 [0.04]; P = .001). Region also had an association, with individuals in the West having more healthy behaviors than those in the Midwest (coefficient [SE], 0.21 [0.03]; P < .001) (Table 3).
Table 3. Characteristics Associated With Guideline Adherencea.
| Characteristic | Coefficient (SE) | P value |
|---|---|---|
| Female | 0.14 (0.03) | <.001 |
| Age, per decade increase | 0.05 (0.01) | .001 |
| Race and ethnicity | ||
| American Indian or Alaska Native, non-Hispanic | −0.31 (0.14) | .03 |
| Asian, non-Hispanic | 0.18 (0.14) | .21 |
| Black, non-Hispanic | 0.20 (0.08) | .02 |
| Hispanic | 0.01 (0.11) | .91 |
| White, non-Hispanic | Reference | NA |
| Other, non-Hispanicb | 0.07 (0.10) | .48 |
| Educational level | ||
| College graduate | Reference | NA |
| Completed elementary school | 0.03 (0.16) | .86 |
| Some high school | −0.20 (0.09) | .02 |
| High school graduate | −0.14 (0.04) | .001 |
| Some college or technical school | −0.11 (0.04) | .003 |
| Refused to answer | −0.55 (0.65) | .39 |
| Region | ||
| Midwest | Reference | NA |
| Northeast | 0.05 (0.06) | .43 |
| South | 0.03 (0.06) | .59 |
| West | 0.21 (0.03) | <.001 |
Abbreviation: NA, not applicable.
Multivariate regression was used to evaluate characteristics associated with American Cancer Society guideline adherence.
Other was a categorical variable without subgroup options.
Discussion
Healthy lifestyle practices are essential for cancer survivors, yet this study found that only 4% of cancer survivors adhered to current ACS recommendations, which is lower than suspected based on previous work.5,6 Our work benefited from using a statewide-representative dataset across the US and included individuals who completed treatment in a period ranging from the past year to many years prior; thus, we believe that the low adherence identified in our study gives important insight into health behaviors across the spectrum of cancer survivorship. This is essential information for both oncologists and general internists, as it reveals that there may remain a gap between published guidelines regarding behavioral modifications for cancer survivors and uptake of these behaviors. When adjusting for sociodemographics, people who had ever had cancer had slightly lower healthy behaviors than those who had never been diagnosed with cancer, which should be explored in future work.
Our work revealed that certain factors, specifically female sex, older age, Black race, college-level education, and Western region, were associated with increased healthy behaviors. This information could be used to help identify patients who may require more lifestyle change counseling during follow-up appointments. While Black race was associated with increased healthy behaviors in this dataset, this does not negate important work showing disparities in cancer outcomes among racial and ethnic minority individuals and deserves additional study into the complex landscape of survivorship specific to these individuals.7 It will be important for future work to explore why these factors may influence uptake of healthy behaviors and to focus on systematic and effective methods to counsel these patients using risk-communication strategies.
Limitations
Limitations of this study include the self-reported nature of the BRFSS, that the BRFSS is not a cancer-specific questionnaire and does not have sufficient size to include subgroup analysis by cancer type, and that the cancer survivorship module was optional and only administered in a subset of states and territories. Since we were limited by the BRFSS question wording, we were unable to perfectly apply the recommendations made by the ACS as discussed in the Methods section. For example, to evaluate whether a person engaged in regular physical activity, the closest available question was whether a person had exercised in the preceding 30 days. The nutrition questionnaire asked how many times per day fruits and vegetables were eaten, which is an imperfect correlation to the recommendation of 1.5 and 2.5 cups of fruit and vegetables, respectively. Last, due to modular limitations, we could not directly compare adherence among cancer survivors with that in the general population, but rather we compared adherence between anyone who had ever been diagnosed with cancer and the general population.
Conclusions
Many factors contribute to adherence to healthy behaviors after completion of cancer treatment. This cross-sectional study found that only 4% of cancer survivors fully adhered to current ACS recommendations. While we identified some factors associated with adherence that may aid in targeting recommendations, it is essential for oncologists and general internists to improve widespread and systematic counseling on these guidelines to improve uptake of healthy behaviors in this vulnerable patient population.
eTable. States and Territories Included in Data set by Census Region
Data Sharing Statement
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Associated Data
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Supplementary Materials
eTable. States and Territories Included in Data set by Census Region
Data Sharing Statement
