Associations Among Health Behaviors and Psychosocial Outcomes in Adolescent and Young Adult Cancer Survivors

Abstract

Purpose:

Adolescents and young adults (AYA) experience challenges both during and after their cancer treatment. Health behaviors are important contributors to health, yet little research examines health behaviors in AYA cancer survivors. We examined frequencies of health behaviors and associations between health behaviors, psychosocial, and clinical factors in AYA cancer survivors.

Methods:

Participants were survivors of AYA cancer (n = 60; 38.3% male; mean age = 25.3 years [standard deviation, SD = 4.6]; mean years since therapy completion = 9.0 [SD = 4.2]) from the Alberta Children's Hospital (ACH). Survivors were 13–21 years old at the time of diagnosis. Measures included demographic and clinical data, and the ACH Long-Term Survivor's Questionnaire. Health behaviors were compared with a control group (n = 600) using data from the 2017 Canadian Community Health Survey. Frequencies, conditional logistic regression, and logistic regression analyses were conducted.

Results:

Compared with controls, survivors reported engaging in physical activity (91.5% vs. 87.5%; odds ratio [OR] = 0.87, 95% confidence interval [CI] = 0.34–2.24; p = 0.77), smoking tobacco (15.3% vs. 19.7%; OR = 1.85, 95% CI = 0.89–3.85; p = 0.10), and street drug use (27.6% vs. 36.5%; OR = 1.60, 95% CI = 0.88–2.91; p = 0.12) at the same rate. Survivors reported binge drinking significantly less (61.0% vs. 76.6%; OR = 0.53, 95% CI = 0.30–0.92; p = 0.024) than controls. Logistic regression analyses revealed a significant model predicting binge drinking [χ²(5, 58) = 23.17, p < 0.001] with greater time off treatment, fear of another health condition, and higher mean body mass index emerging as significant predictors.

Conclusion:

AYA cancer survivors engage in risky health behaviors at rates similar to their peers. Further research is needed to understand factors mediating survivors' decision to participate in risky health behaviors.

Introduction

Over the past few decades, the incidence of cancer among adolescents and young adults (AYAs) 15–39 years of age has increased >38%.¹ Since the early 1990s, survival rates for AYAs have improved, with >80% of patients surviving for many years postdiagnosis.² Many cancer survivors have undergone treatments including chemotherapy, radiation, and surgery that lead to long-term health complications. These late effects place survivors at higher risk for chronic medical conditions later in life.^2,3 In addition, the experience of late effects may influence survivors' health behaviors and psychosocial well-being in a bidirectional manner.

Health behaviors refer to a suite of behaviors that are affected by one's social, cultural, and physical environments, and can be positive or negative in nature.⁴ Although there are many studies examining health behaviors among older adult and childhood cancer survivors, there is a paucity of research regarding health behaviors among AYA cancer survivors. Indeed, a systematic review examining health behaviors focusing on health promotion interventions among AYA cancer survivors found that, of the 17 eligible studies, 15 focused on young adult survivors of childhood cancer, whereas only 2 focused specifically on survivors diagnosed as AYAs.⁵ AYAs are a unique population already engaged in risk-taking behavior at higher rates than older adults or children⁶ and especially vulnerable to the development of mental health disorders.⁷ Thus, there is a critical need for AYA-specific research.

Of the studies examining health behaviors in AYA cancer survivors, evidence suggests that survivors may be particularly at risk for engaging in negative health behaviors. For example, numerous studies have demonstrated that AYA cancer survivors do not participate in adequate physical activity,^8–11 and that healthy dietary practices among this population are lacking.^8,12 Warner et al. examined health behaviors (i.e., smoking, binge drinking, physical inactivity, and fruit and vegetable consumption) among AYA cancer survivors relative to same-aged peers with no history of cancer. Compared with controls, female AYA survivors were more likely to be current smokers, which was associated with poor emotional and social support, and being 10 or more years postdiagnosis. Furthermore, for both male and female survivors, poor social and emotional support was associated with poorer dietary choices, such as low fruit and vegetable consumption.¹³ These findings are consistent with those of other studies, which found higher rates of smoking among AYA survivors of childhood or AYA cancer.^14–16 Finally, a study completed by Salloum et al. found that survivors of AYA cancer report the highest rate of tobacco use and current engagement in cigarette smoking at 27%, compared with all other age groups of cancer survivors.¹⁷

Current knowledge regarding factors related to engaging in health behaviors among AYA cancer survivors is lacking. Such information would provide crucial insight into understanding the decision-making process of AYA survivors who choose to engage in risky health behaviors. Thus, the specific aims for this study were to: (1) examine the frequencies of health behaviors (i.e., physical activity, binge drinking, street drug use, and tobacco smoking) in a cohort of AYA cancer survivors; (2) compare these rates to an age- and sex-matched healthy control population across the whole sample and by sex; and (3) examine associations between clinical and psychosocial factors and health behaviors (i.e., physical activity, drug use, tobacco smoking, and binge drinking) in AYA cancer survivors. We hypothesized that AYA cancer survivors would engage in more negative health behaviors and would be less active than their peers. In addition, we hypothesized that poorer psychosocial outcomes (i.e., fatigue, depressive symptomatology, fear of cancer recurrence [FoCR], fear of another chronic health condition or a secondary cancer [FoACH]) would be associated with increased incidence of engaging in negative health behaviors and lower engagement in physical activity.

Methods

Participants

Participants were patients enrolled in the Long-Term Survivor's Clinic at the Alberta Children's Hospital (ACH) in Calgary, Alberta, Canada. All outpatients enrolled in this clinic had completed cancer treatment (i.e., surgery, chemotherapy, and radiation therapy) and were at least 2 years off therapy. Participants typically attended this clinic at least once annually for a follow-up appointment. Inclusion criteria for this study included: patients diagnosed between 13 and 21 years of age (consistent with the definition of AYA cancer in places such as the United Kingdom¹⁸).

Control group

The Canadian Community Health Survey (CCHS) is a national cross-sectional survey of the Canadian population that collects information related to health status, health care utilization, and health determinants from Canadians 12 years and over who live in private dwellings in all 10 provinces and 3 territories. An area frame and multistage stratified cluster-sampling procedure was used to survey 63,522 households across Canada.¹⁹ Excluded from the target population are persons living on reserves, full-time members of the Canadian Forces, institutionalized populations, children in foster care and certain remote regions. Such exclusions account for <3% of the total Canadian population. CCHS data are available for public use. Data from the 2017 CCHS cycle were used for analyses.

Procedure

As part of their routine clinic appointment, all survivors completed a questionnaire related to their current health status. The ACH Long-Term Survivor's Questionnaire was mailed to all survivors before their clinic appointment. Those survivors who did not complete the ACH Long-Term Survivor's Questionnaire before attending clinic were asked to complete the questionnaire in the waiting room before their appointment. Thus, 100% of survivors completed the Long-Term Questionnaire. Ethics approval was obtained from the Heath Research Ethics Board of Alberta—Cancer Committee (HREBA.CC-16-0972). Data from these questionnaires were collected retrospectively from the period of August 2011 to August 2017; therefore, patient consent was not applicable for this study.

Measures

Demographic and clinical information

Demographic (i.e., gender and age) and clinical information (i.e., diagnosis, treatment, age at diagnosis, and time off treatment) were obtained from each survivor's chart. In addition, weight and height were gathered to calculate body mass index (BMI). BMI was calculated according to the Centers for Disease Control and Prevention (CDC) guidelines²⁰ and compared with corresponding BMI category (underweight <18.5; healthy weight 18.5–24.9; overweight 25.0–29.9; obese >30.0).¹⁸

ACH Long-Term Survivor's Questionnaire

The ACH Long-Term Survivor Questionnaire is designed to facilitate communication between the Long-Term Survivor's Clinic team and the survivor and family (see Supplementary Table S1). The questionnaire was mailed to survivors and their families before their regularly scheduled clinic visit or is completed in the waiting room on the day of the appointment. The questionnaire is a critical component of the clinic visit and it is used as a guide for health care providers during each survivor appointment. The Long-Term Survivor's Questionnaire assesses current health status including current health problems, reproductive health, sexual health, and patient's health behaviors such as participation in physical activity, binge drinking, tobacco use, and street drug use. Street drug use is defined as a drug that is taken for nonmedical reasons and may include cannabis or cocaine. Patients responding “yes” to the use of street drugs were subsequently asked what type of drug(s) they used and how often it was used. If a survivor reported engaging in an aforementioned behavior during any questionnaire, they were coded as “yes” for that behavior. If the survivor did not report engaging in a behavior during any of their completed questionnaires, they were coded as “no” for that behavior. We used this to create a binary data set that captured if a survivor ever reported the behavior or psychosocial outcome. Within the Long-Term Survivor Questionnaire, psychosocial outcomes assessed included fatigue (i.e., tiredness), “yes” or “no”; FoCR, “yes” or “no”; and fear of other health conditions, “yes” or “no.”

In addition, survivors were asked about the following symptoms of depression consistent with the Diagnostic and Statistical Manual-V criteria for clinical depression: “Have you had any of these problems during the last month”: (a) loss of interest in daily activities; (b) disturbed sleep patterns; (c) changes in appetite or weight; (d) feelings of sadness, hopelessness, despair; and (e) crying easily for no reason. Survivors who endorsed two or more of these symptoms concurrently were categorized as experiencing depressive symptomatology. As this was a tool originally developed to help guide the clinic visits, the questionnaire measure has not been validated.

Data analysis

To address Aim 1 of our study, examining health behavior frequencies in the AYA survivor cohort, we ran descriptive statistics to determine the frequency of survivors who engaged in binge drinking, street drug use, tobacco smoking, and physical activity. For Aim 2, to compare these values with healthy controls, age- and sex-matched data were randomly selected for extraction from the CCHS database at a ratio of 10:1 for each survivor who completed the Long-Term Survivor Questionnaire. CCHS data were filtered to ensure that individuals who had a previous or current cancer diagnosis were excluded. Conditional logistic regression analyses were used to compare engagement in health behaviors between matched survivors and controls. In addition, health behaviors among survivors and controls were compared by sex.

To address Aim 3 of the study, which examined associations between clinical and psychosocial factors and health behaviors for physical activity, drug use, tobacco smoking, and binge drinking in AYA cancer survivors, we began by running zero-order correlations between all clinical, demographic, psychosocial, and health behavior variables collected. We then considered four logistic regression models where engagement in the following health behaviors were the criterion variables: physical activity, binge drinking, street drug use, and tobacco smoking.

To maintain sufficient power for each analysis, the number of predictor variables selected for each logistic regression was determined by a guide of one predictor for every 10 events, as indicated by the size of the smallest outcome category.²¹ Variables that bore the greatest statistical relationship (i.e., rho >0.20)²² to the criterion variable in preliminary correlational analyses, or were theoretically supported in the literature (e.g., sex, age), were used as predictor variables in the analyses.

Multicollinearity was assessed using variance inflation factors to ensure appropriate ranges of <10. Subsequently, linear and binary logistic regression analyses were conducted to examine the relationships between psychosocial outcomes and health behaviors. For each model presented, predictor variables, partial regression coefficients, the Wald test, odds ratio (OR), and 95% confidence intervals (CIs) are presented. Data were analyzed using IBM SPSS (26.0), with alpha set at 0.05.

Results

Patient characteristics

Patient characteristics are detailed in Table 1. Participants consisted of 60 survivors of AYA cancer (38.3% male) with a mean age of 25.3 years (standard deviation [SD] = 4.6; range = 18.09–36.66) at their most recent clinic visit and an average of 9.0 (SD = 4.2) years since therapy completion. Survivors were between the ages of 13–21 years at diagnosis, with a mean age of diagnosis of 15.6 years (SD = 1.6). The primary diagnoses for these survivors were lymphoma (41.7%) and solid tumors (36.7%). Over half of survivors were overweight or obese (55.9%).

Table 1.

Survivors of Adolescents and Young Adults Cancer Demographic Information

Characteristic	Survivors		Comparison sample
Characteristic	n (%)	M (SD)	n (%)
Sex			230 (38.3)
Male	23 (38.3)		370 (61.7)
Female	37 (61.7)
Age at diagnosis		15.6 (1.6)
Time off therapy		9.0 (4.2)
Current age		25.3 (4.6)
18–19 Years old	6 (10)		60 (10)
20–24 Years old	23 (38.3)		230 (38.3)
25–29 Years old	19 (31.7)		190 (31.7)
30–34 Years old	11 (18.3)		110 (18.3)
35–39 Years old	1 (1.7)		10 (1.7)
Treatment type
Chemotherapy	58 (96.7)
Surgery	38 (63.3)
Radiation	30 (50)
Diagnosis
Lymphoma	25 (41.7)
Solid tumor	22 (36.7)
Leukemia	30 (50)
Central nervous system tumors	3 (5)
Psychosocial outcomes
Fatigue	27 (45)
Depression	18 (30)
FoCR	26 (43.3)
FoACH	35 (58.3)
BMI
Underweight	2 (3.4)
Healthy weight	24 (40.7)
Overweight	20 (33.9)
Obese	13 (22.0)
Long-term survivor clinic appointments attended		4.1 (1.8)

BMI, body mass index; FoACH, fear of another health condition or a secondary cancer; FoCR, fear of cancer recurrence; SD, standard deviation.

Aim 1 and 2: frequency of engaging in health behaviors compared with the general population

Across all potential clinic visits, survivors reported significantly lower rates of binge drinking compared with controls (61.0% vs. 76.6%; OR = 0.53, 95% CI = 0.30–0.92; p = 0.024). There was no significant difference in street drug use among survivors compared with controls (27.6% vs. 36.5%; OR = 1.60, 95% CI = 0.88–2.91; p = 0.12). In addition, rates of tobacco smoking did not significantly differ between survivors and controls (15.3% vs. 19.7%; OR = 1.85, 95% CI = 0.89–3.85; p = 0.10), nor did physical activity (91.5% vs. 87.5%; OR = 0.87, 95% CI 0.34–2.24; p = 0.77). When each health behavior was examined by sex across survivor and control populations, no differences were found across any of the groups. Frequency data for health behaviors are given in Figure 1.

FIG. 1.

Health behavior frequencies of survivors and matched healthy controls. **p < 0.01.

Aim 3: clinical and psychosocial associated with health behaviors

Zero-order correlations to identify significant associations between variables are given in Table 2. Binary logistic multiple regression analyses are given in Table 3. Findings from the models are described hereunder. Given that only 15.3% of survivors reported smoking tobacco, sufficient power could not be obtained for a regression model with >1 predictor, therefore we did not complete this analysis.

Table 2.

Bivariate Correlations of the Variables in the Analysis (N = 60)

Variable	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)	(9)	(10)	(11)	(12)
(1) Survivor sex	—	0.14	0.25	0.12	−0.29^a	−0.21	−0.062	−0.17	−0.030	0.15	−0.035	0.109
(2) Mean BMI		—	0.31^a	0.28^a	−0.084	−0.026	0.093	−0.021	0.15	0.25	−0.10	−0.281^a
(3) Time off treatment			—	0.022	−0.19	0.15	0.11	−0.19	−0.39^b	0.19	−0.007	−0.35^b
(4) Age at diagnosis				—	0.079	0.20	0.026	−0.11	0.19	0.090	−0.13	0.19
(5) Fatigue					—	0.50^b	0.062	0.050	0.18	0.043	0.27^a	0.16
(6) Depression						—	0.15	0.087	0.077	0.17	0.23	0.069
(7) Fear of cancer reoccurrence							—	0.59^b	0.20	0.13	0.092	0.030
(8) Fear of additional health concerns								—	0.38^b	0.094	0.15	0.13
(9) Binge drinking									—	0.32^a	0.24	0.13
(10) Smoking tobacco										—	0.27^a	−0.14
(11) Street drug use											—	−0.040
(12) Physical activity												—

p < 0.05, ^bp < 0.01.

Table 3.

Binary Logistic Regression Analyses for Associations Between Health Behaviors and Psychosocial Outcomes

	B	SE	Wald χ²	df	p	Exp(B)	95% CI
Criterion variable: physical activity
Overall model^a			18.08	4	0.001
Time off therapy	−1.66	0.98	2.87	1	0.090	0.19	0.028–1.30
Sex	1.43	1.40	1.05	1	0.306	4.19	0.27–64.82
FoACH	−0.68	1.54	0.20	1	0.657	0.51	0.025–10.30
Depression	1.65	1.52	1.17	1	0.280	5.18	0.26–102.32
Criterion variable: binge drinking
Overall model^a			16.65	4	0.002
Time off therapy^a	−0.23	0.092	6.44	1	0.011	0.79	0.66–0.95
Sex	0.66	0.70	0.87	1	0.351	1.93	0.49–7.64
FoACH^a	1.56	0.65	5.82	1	0.016	4.78	1.34–16.82
Depression	0.73	0.72	1.01	1	316	2.06	0.50–8.51
Criterion variable: street drug use
Overall model			1.87	2	0.392
Sex	0.85	0.64	1.74	1	0.187	2.33	0.66–8.18
Fatigue	0.46	0.64	0.52	1	0.470	1.59	0.45–5.54

Significant models and predictors were p < 0.05.

CI, confidence interval; SE, standard error.

Physical activity

In the model for physical activity, a positive health behavior, the variables of time off treatment, sex, depression, and fear of another health concern or secondary cancer were used as predictors. The overall regression model was significant, [χ²(4, 58) = 18.08, p = 0.001]. No predictors in this model significantly predicted engagement in physical activity.

Binge drinking

For the model exploring engagement in binge drinking, predictor variables included time off treatment, sex, FoACH, depression, and mean BMI. The overall regression model was significant [χ²(4, 58) = 16.65, p = 0.002]. Survivors who were a shorter time off treatment were less likely to engage in binge drinking (OR = 0.79, 95% CI = 0.66–0.95). In addition, survivors who reported FoACH were 4.78 times more likely (OR = 4.78, 95% CI = 1.34–16.82) to engage in binge drinking.

Street drug use

For the health behavior outcome of using street drugs, predictor variables included sex and fatigue. The overall regression model was not found to be significant [χ²(2, 58) = 1.87, p = 0.392].

Discussion

This study examined frequencies of health behaviors in a population of young adult survivors of cancer diagnosed between the ages of 13 and 21 years, and explored associations among health behaviors and clinical and psychosocial outcomes. We hypothesized that AYA cancer survivors would engage in negative health behaviors more often than their peers, less physical activity, and that engagement in risky health behaviors (i.e., binge drinking, tobacco smoking, and drug use) would be associated with more psychosocial difficulties. We found that most (91.5%) survivors reported engaging in some type of physical activity, a positive health behavior despite the fact that ∼56% of these survivors were overweight or obese, a finding that is higher than rates for this age group within the general Canadian population. However, nearly two-thirds of survivors (61%) reported binge drinking, whereas nearly one-third (27.6%) reported using street drugs. Yet, survivors did not engage in these behaviors at a significantly different rate than their peers with the exception of binge drinking. In the case of binge drinking, survivors of AYA cancer report engaging in binge drinking at a significantly lower rate than controls. Although these findings are not concerning in and of themselves, it still warrants attention given the previous cancer diagnosis and the subsequent risk for additional medical comorbidities.

With respect to the clinical and psychosocial factors related to engaging in health behaviors, time off treatment was significantly related to engagement in binge drinking such that less time off treatment was associated with less binge drinking. Given that our sample reported significantly lower rates of binge drinking compared with same-aged controls, perhaps the more distant the cancer experience, the more likely survivors are to return to levels comparable with the population.

In addition, survivors who reported FoACH were more likely to engage in binge drinking. Of interest, one may have expected FoACH to be associated with reduced engagement in potentially risky health behaviors. In our sample, however, binge drinking may represent a maladaptive coping strategy to manage survivors' anxiety related to FoACH. Binge drinking has been identified as a strategy to “numb” the fear, stress, and emotional pain of a traumatic health experience.^23,24 Although the direction of the relationship between FoACH and binge drinking warrants further attention in the context of our research, the results of this study highlight a need to further explore binge drinking and fear of another health condition among this vulnerable group of survivors.

That our regression models for other health behaviors were not significant was disappointing. However, this speaks to the complexity of the factors that may be related to the decision to engage in health behaviors. For example, the decision to engage in positive or negative health behaviors in AYA cancer survivors may be mediated by distinct psychosocial profiles. For example, Lowe et al.²⁵ examined health behavior profiles among 106 young adult cancer survivors and found that three distinct health behavior profiles emerged. High-risk (n = 25) survivors displayed significantly more engagement in negative health behaviors relative to moderate (n = 39) and low (n = 40) risk survivors. Specifically, high-risk survivors had the highest current rates of alcohol, tobacco, and marijuana use.²⁵ However, high-risk survivors also engaged in greater physical activity, compared with moderate and low-risk survivors who engaged in the least and moderate amounts of physical activity, respectively.²⁵ These results may suggest that certain personality traits may predispose AYAs to certain levels of risk-taking behaviors. Accordingly, certain interventions may be better suited for AYA survivors who fall into a particular risk profile. Clearly, further research is needed to elucidate the factors that mediate survivors' decisions to engage in negative or positive health behaviors.

This study was not without limitations. In particular, as retrospective data were used, some of the data for specific questions were missing or incomplete across time points if the survivor missed their clinic appointment. Another limitation of this study was the use of a nonvalidated measure that uses yes/no questions, which does not allow for a more comprehensive examination of survivors' responses. In addition, as this is a self-reported measure, some bias is expected from patients. For example, “physical activity” was not clearly defined, thus some patients may consider going for a 5-minute walk to be adequate physical activity, whereas others may have only answered “yes” to this question if they participate in moderate to vigorous physical activity, such as playing basketball. Of importance, we did not capture survivors' race/ethnicity that would have been an important variable to consider, especially in the context of health behaviors. Regarding risky behaviors, some participants may have felt obligated to answer the question consistent with socially acceptable norms, which may not be an actual reflection of the behaviors in which they are engaging. Alternatively, as survivors were often accompanied by their parents, they may have failed to answer some of these questions honestly. Finally, we did not explore longitudinal associations with health behaviors prohibiting any conclusions to be made about causation. Despite these shortcomings, the data provide valuable insight into potential associations between psychosocial outcomes and health behaviors, which warrant further investigation into possible mediating factors.

Conclusion

In this cohort of young adult survivors of adolescent cancer, survivors continue to engage in risky health behaviors such as binge drinking, which can compromise their health. Survivors also struggle with maintaining a healthy body weight, despite reporting to engage in physical activity. This holds significant implications related to chronic health problems and increased risk for secondary cancers. Further research is needed to understand the underlying factors mediating survivors' decision to participate in risky health behaviors.

Footnotes

Author Disclosure Statement

No competing financial interests exist

Funding Information

This work was supported by the Charbonneau Cancer Research Institute, the Alberta Children's Hospital Research Institute and the Daniel Family Chair in Psychosocial Oncology.

Supplementary Material

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Supplementary Material

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