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” = <150 min 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
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Table 2 Health condition s and health behaviors of cancer survivors and noncancer controls: Behavioral Risk Factor Surveillance System, 2009
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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
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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
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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.