León‑Salas et al. BMC Res Notes (2020) 13:376 https://doi.org/10.1186/s13104-020-05218-8 BMC Research Notes RESEARCH NOTE Open Access Health status, lifestyle habits, and perceived social support in long‑term cancer survivors: a cross‑sectional study Beatriz León‑Salas1,2,3, Edurne Zabaleta‑del‑Olmo2,4,5,6,7, Joan Llobera2,8,9, Bonaventura Bolíbar‑Ribas2,4,7, Tomás López‑Jiménez2,4,7, Marc Casajuana‑Closas2,4,7 and Magdalena Esteva2,8,9* Abstract Objective: To compare the presence of comorbidities and self-perceived health and social support between long- term cancer survivors and people without a history of cancer from a clinical trial examining the effects of a multiple risk behavior intervention. Results: Of the 4259 people studied, 190 (4.46%) were cancer survivors. They had a mean ± SD age of 62.8 ± 7 years vs. 58.7 ± 8 years (P < 0.01) for non-cancer people and were more likely to be on long-term sick leave (11.9 vs. 3.5%, P < 0.001). No differences were observed for smoking, adherence to the Mediterranean diet, physical activity, obesity, or social support. Cancer survivors were more likely to have worse self-perceived health (OR 1.82; 95% CI 1.02–2.75), more comorbidities (OR 1.68; 95% CI 1.18–2.39), COPD (OR 2.17; 95% CI 1.25–3.78), and depression (OR 1.65; 95% CI 1.06–2.57). Older age and worse self-perceived health were independent predictors of survivorship in the adjusted analysis. Keywords: Primary care, Cancer, Survivorship, Lifestyle, Comorbidity, Quality of life, Health promotion Introduction of transition: Issues related to diagnosis and treatment More and more people are surviving cancer thanks to diminishes in importance, and concerns related to long- advances in early detection and diagnostic techniques term follow-up care, management of late effects, rehabili- and treatment. Survival rates are increasing worldwide, tation, and health promotion dominate.” even for the most aggressive forms of cancer [1]. In Spain, Cancer survivors may develop other conditions as a over 50% of adults are still alive 5 years after diagnosis [2] result of their cancer treatment. Some of these are tran- and the estimated number of prevalent cases at 5 years sient, but others can become chronic and significantly exceeds 500,000 [3]. These trends call for greater atten- affect quality of life [4]. Cancer survivors may also be at tion to be paid to long-term cancer survivorship. increased risk of a second cancer if the risk factors asso- As explained by Grunfel and Earle [3], “the period after ciated with the original cancer persist. There is increasing completing primary and adjuvant cancer treatment until evidence that interventions aimed at promoting healthy recurrence or death is now recognized as a unique phase eating, regular exercise, and maintenance of a healthy in the cancer control continuum. Survivorship is a time weight can offset some of the adverse effects of cancer and cancer treatment [5–10]. Alongside smoking cessa- tion, these behaviors reduce not only the risk of cancer *Correspondence: mesteva@ibsalut.caib.es recurrence but also the risk of other health conditions, 8 Unit of Research Majorca Department of Primary Care, Balearic Health Service, Escola Graduada 3, 07002 Palma, Majorca, Spain such as cardiovascular disease, diabetes, and other can- Full list of author information is available at the end of the article cers [11–13]. Cancer also has social impacts in the form © The Author(s) 2020. 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The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdo‑ main/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. León‑Salas et al. BMC Res Notes (2020) 13:376 Page 2 of 7 of job loss or change and difficulties with social and per- patients without a history of cancer). Cancer survivor- sonal relationships [14]. Although the health and qual- ship was defined as the period from completion of pri- ity of life of cancer survivors are important public health mary or adjuvant cancer treatment to recurrence, death, issues, knowledge in this area is still lacking, particularly or cure. ClinicalTrials.gov, NCT03136211. in Spain [15]. Other baseline variables were (1) sociodemographic The aim of this study was to compare the presence variables, namely age, sex, level of education, civil sta- of comorbid conditions and self-perceptions of health tus, and employment status, classified as working/not and social support between long-term cancer survivors working (homemaker, retiree, student) unemployed and and people without a history of cancer from a clinical long-term sick leave; (2) perceived social support meas- trial examining the effects of a multiple risk behavior ured using the Duke-UNC questionnaire [18, 19], (< 32 intervention. points indicating low support); (3) self-perceived health status; (4) comorbidity measured using the non-cancer Main text Charlson Comorbidity Index (CCI) [20]; (5) lifestyle hab- Methods its, namely smoking (yes/no); adherence to the Medi- We performed a cross-sectional multicenter study nested terranean diet measured using the 14-item PREDIMED within phases II and III of the ERIA trial, a parallel clus- scale [21], where 0–8 points indicates low adherence) [5]; ter randomized clinical trial designed to analyze the and physical activity, assessed using the Brief Physical effects of a complex individual and group multiple risk Activity Assessment tool for primary care [22, 23], where intervention on the uptake of healthy behaviors (smoking patients are classified as sufficiently active if they perform cessation, adherence to the Mediterranean diet, and suf- three or more 20-min vigorous activity sessions, five or ficient levels of physical activity). The trial was conducted more 30-min moderate activity sessions, or five or more in accordance with the Medical Research Council guid- sessions of any combination of moderate and vigorous ance on complex interventions [16]. The definitive (phase sessions. If they do not meet these criteria, they are clas- III) trial was launched after the exploratory phase II trial. sified as insufficiently active. It was conducted between 2014–2015 and 2016–2018 by We performed a bivariate analysis to investigate asso- the Primary Care Prevention and Health Promotion Net- ciations between independent variables and being in work (RedIAPP) in 38 primary care centers in 11 Spanish the cancer survivor group or the non-cancer group; the provinces. The trial protocol has been published [17]. χ2 test was used for categorical variables and the t test The participants were recruited by their general practi- for continuous variables. Statistical significance was tioners (GPs). Inclusion criteria were: (1) be aged between established as P < 0.05. Odds ratios with 95% confidence 45 and 75 years, (2) be registered with a GP participating intervals (CIs) were calculated to assess strength of asso- in the study and have had arranged an appointment with ciation. Finally, we performed multiple logistic regression their GP or nurse, and (3) have two of the following risk analysis of variables with a P value < 0.20 in the bivariate behaviors: smoking, low adherence to the Mediterranean analysis using backward elimination. Whenever a vari- diet, and insufficient physical activity. Cardiovascular able was eliminated from the model, changes to the B risk and depression had been used as inclusion criteria in coefficients were checked to assess confounding. Statis- the exploratory phase II trial, but were eliminated in the tical analyses were performed in SPSS, version 23. The phase III trial due to feasibility issues. Exclusion criteria study was approved by the ethics committees at each of were cognitive impairment, dependency in activities of the participating centers. daily living, severe mental disease, long-term home care and active or palliative cancer treatment. The flow of par- Results ticipants through the study is shown in Additional file 1: In total, 4259 people were included in the study: 190 can- Figure S1. cer survivors (4.46%; 95% CI 3.82–5.09) and 4069 non- Based on the assumption that 50% of cancer survivors cancer patients. The median time since diagnosis was and 40% of non-cancer patients would rate their health as 6.5 years (interquartile range, 3–10 years). fair or poor, we estimated that the study would be pow- The sociodemographic variables are summarized in ered at 78% with a confidence level of 95%. Table 1. Patients who had survived cancer were on aver- For this sub-study, the variables analyzed were those age older than those without a history of cancer, but no measured at the baseline interview (i.e., before any significant differences were observed for sex or civil sta- intervention). The dependent variable was presence tus. In the cancer survival group, there were higher pro- or absence of a cancer diagnosis. The subjects were portions of patients not working, patients with long-term thus divided into cancer survivors (patients diagnosed sick leave, and patients with primary education or no with cancer who met the criteria for survivorship) and schooling. León‑Salas et al. BMC Res Notes (2020) 13:376 Page 3 of 7 Table 1 Sociodemographic characteristics of study participants Sociodemographic variables Cancer survivors Non-cancer patients P N = 190 N = 4069 N (%) N (%) Mean (SD) age, years 62.8 (7.5) 58.7 (8.1) < 0.001 Sex Male 85 (44.7) 1.762 (43.3) 0.70 Female 105 (55.3) 2.307 (56.7) Civil status Single 4 (2.1) 114 (2.9) < 0.001 Married/living with a partner 61 (32.1) 1.058 (26.8) Separated/divorced 102 (53.7) 2.104 (53.3) Widowed 16 (8.4) 478 (12.1) Employment status Not working 119 (72.6) 1.616 (40.9) < 0.001 Working 51 (26.8) 1.777 (45.0) Unemployed 7 (3.7) 413 (10.5) Long-term sick leave 13 (6.8) 14 (13.6) Level of education Higher/university education 28 (14.7) 583 (14.8) 0.004 Secondary education 54 (28.4) 1.523 (38.6) Primary education 85 (44.7) 1.573 (39.8) No schooling 23 (12.1) 270 (6.8) SD standard deviation The results for lifestyle habits, comorbidities, and than in the non-cancer group. Other authors have found social functioning are shown in Table 2. Almost four of that cancer survivors experience difficulties returning to every 10 patients in the overall group smoked, and while their normal lives, and to work in particular [24]. Islam the rate was somewhat lower among cancer survivors, et al. [25] reported that patients with cancer were 1.4 the difference with non-cancer patients was not signifi- times more likely to be unemployed than healthy patients cant. Adherence to the Mediterranean diet and physical due to disease- and treatment-related problems, high- activity levels were also low overall. Almost 80% of the lighting the importance of support programs to help members of both groups had low adherence to the Medi- them return to work when they are able to [26]. terranean diet, and almost 90% were insufficiently active. Our study shows similar behaviors among cancer Engagement in healthy behaviors was not more common survivors and non-cancer patients in terms of exercise, among patients who had survived cancer. diet, and smoking, with very high levels of unhealthy Cancer survivors had significantly worse self-perceived behaviors and overweight/obesity in both groups. This health, more comorbidities, and higher rates of depres- observation supports previous reports that modifiable sion, diabetes, and chronic obstructive pulmonary dis- cardiovascular risk factors such as hypertension, obe- ease (COPD). Both groups had similar perceptions of sity, smoking, and physical inactivity are more com- social support. Multivariate analysis confirmed that mon in cancer survivors than in the general population cancer survivors had worse self-perceived health than [27]. One would expect people who have survived can- patients who had never had cancer (Table 3). cer to be more motivated to lead a healthy lifestyle and one would also expert them to receive guidance from Discussion their health care providers on how to make suitable In this study cancer survivors were on average older than changes, particularly in terms of diet and exercise, to non-cancer patients, perhaps because two-thirds of can- prevent recurrent and new cancers, reduce cardiovas- cer cases occur in patients aged over 60 years. Older age cular risk factors, and improve quality of life [12, 28]. would also explain why cancer survivors were more likely Nevertheless, healthy lifestyle choices among cancer not to be working and to be on long-term sick leave, survivors and support from health care providers in although the unemployment rate was lower in this group making these choices would appear to be suboptimal. León‑Salas et al. BMC Res Notes (2020) 13:376 Page 4 of 7 Table 2 Distribution of lifestyle behaviors, comorbidities, and social function Variables Cancer survivors Non-cancer patients OR (95% CI) P N (%) N (%) Lifestyle Smoking   No 120 (63.2) 2.428 (59.7) 1   Yes 70 (36.8) 1.641 (40.3) 0.86 (0.63–1.16) 0.33 Adherence to Mediterranean diet   Good (score ≥ 9) 35 (18.4) 646 (16.3) 1   Low (score 0–8) 155 (81.6) 3.325 (83.7) 0.86 (0.59–1.25) 0.43 Physical activity   Insufficiently active 168 (89.4) 3.590 (88.8) 1   Sufficiently active 20 (10.6) 453 (11.2) 1.06 (0.66–1.70) 0.81 Health status and social function Self-perceived health   Excellent/very good/good 42 (44.2) 1.187 (59.1) 1   Fair/poor 53 (55.8) 823 (40.9) 1.82 (1.02–2.75) 0.005 Weight   Normal 34 (17.9) 750 (19.0) 1   Overweight 62 (32.6) 1.442 (36.6) 0.94 (0.61–1.45) 0.80   Obese 94 (49.5) 1.753 (44.4) 1.18 (0.79–1.76) 0.41 No. of health problems   0 67 (35.3) 1741 (42.8) 1   1 58 (30.5) 1.325 (32.6) 1.13 (0.79–1.62) 0.48   ≥ 2 65 (34.2) 1.003 (24.6) 1.68 (1.18–2.39) 0.004 Depression   No 166 (87.4) 3.742 (92.0) 1   Yes 24 (12.6) 327 (8.0) 1.65 (1.06–2.57) 0.02 Hypertension   No 107 (56.3) 2.506 (61.6) 1   Yes 83 (43.7) 1.563 (38.4) 1.24 (0.92–1.66) 0.14 Chronic obstructive pulmonary disease   No 175 (92.1) 3.915 (96.2) 1   Yes 15 (7.9) 154 (3.8) 2.17 (1.25–3.78) 0.006 Diabetes mellitus not affecting target organs   No 149 (78.4) 3.405 (83.7) 1   Yes 41 (21.6) 664 (16.3) 1.41 (0.98–2.01) 0.057 Self-perceived social support   Standard (score ≥ 32) 180 (95.2) 3.609 (95.4) 1   Low (score < 32) 9 (4.8) 296 (7.6) 0.61 (0.30–1.20) 0.15 OR odds ratio, CI confidence interval Weaver et al. [27] found that just one in three cancer Cancer survivors had worse self-perceived health than survivors reported having had a health promotion dis- non-cancer patients. Depression, COPD, and chronic cussion with their health care provider. It has also been non-malignant conditions were all more common in this found that some survivors are unsure about how to group, supporting previous findings showing a higher make changes and perceive a lack of support from their prevalence of chronic lifestyle- or treatment-related dis- health care team [29]. Lifestyle interventions are known eases in cancer survivors compared with members of to bring about positive lifestyle changes that result the general population [6, 30]. No significant differences in improved health and functioning [30], and these were observed for obesity, but this may be because both changes should be a primary goal for cancer survivors. groups had similar obesity-related risk factors. León‑Salas et al. BMC Res Notes (2020) 13:376 Page 5 of 7 Table 3 Multiple logistic regression analysis Limitations Variables Adjusted OR (95% CI) P • The clinical trial participants had to have at least Age 1.04 (1.001–1.081) 0.014 two modifiable risk behaviors and this means that Self-perceived health unhealthy behaviors will have been overrepresented Excellent/very good/good 1 in our sample, preventing us from making popula- Fair/poor 1.81 (1.18–2.78) 0.006 tion-based estimates of differences between cancer Employment status survivors and non-cancer patients. Not working 1 • Worse health status and higher permanent disability Working 0.56 (0.29–1.06) 0.07 rates among cancer survivors could have been influ- Unemployment 0.43 (0.15–1.16) 0.09 enced by their older age, although it should be noted Long-term sick leave 1.49 (0.67–3.32) 0.32 that poor self-perceived health remained a significant OR odds ratio, CI confidence interval predictor of cancer survivorship after adjusting for confounders. • We were unable to gain a broader perspective of health problems that may affect cancer survivors because our sample was small, on some of the more uncommon diseases in the CCI. The cancer survivors perceived a similar level of social support to non-cancer patients. For some authors, social Supplementary information functioning may be affected in the early years of diagnosis Supplementary information accompanies this paper at https​://doi. org/10.1186/s1310​4-020-05218​-8. and beyond [31–34] but others have found no differences in perceptions of family support or satisfaction with part- Additional file 1: Figure S1. Flow chart of subjects. Phase II and III study ners between cancer survivors and non-cancer patients EIRA. [35]. It may be that adults who survive a cancer become more resilient to adverse situations and learn mechanisms Abbreviations to maintain their self-esteem and continue to enjoy good RedIAPP: Primary Care Prevention and Health Promotion Network; GPs: Gen‑ social and personal relationships. eral Practitioners; CCI: Charlson Comorbidity Index; COPD: Chronic obstructive The results of this study indicate a need to encourage pulmonary disease; SD: Standard deviation; OR: Odds ratio. cancer survivors to make positive lifestyle changes that Acknowledgements will bring them better general health and protect against The authors are grateful to all the researchers within the EIRA trial for their recurrent and new cancers and other chronic diseases. work in coordinating the study and collecting the data. We would also like to thank the primary care physicians and nurses for their efforts during the Primary care providers should systematically evaluate patient recruitment stage. lifestyle behaviors of patients with cancer, advise them on associated health risks and benefits, and encourage them Authors’ contributions BLS and ME conceptualized the sub-study, collected and analyzed the data, to cultivate healthy habits. Further research is needed to and wrote the original draft of the manuscript. EZdO, JL, B BR, TL, MCC concep‑ investigate why more cancer survivors do not engage in tualized phases II and III of the EIRA trial, coordinated the data collection, and healthy lifestyle behaviors. reviewed and edited the draft manuscript. All authors read and approved the final manuscript. Conclusions Funding In this series, we observed that cancer survivors had more This study was funded by a research grant from the Instituto de Salud Carlos III Institute of Health at the Spanish Ministry of Economy and Competitiveness. chronic diseases and were more likely to be on long-term In Catalonia: PI15/00114, PI15/00565, PI15/0519; Castilla y León: PI15/00762; sick and have worse self-perceived health than people with Aragón: PI15/00896; Mallorca: PI15/01412; Andalusia: PI15/01151; Euskadi: similar characteristics without a history of cancer. The two PI15/01072; Galicia: PI15/01133.This funding was applicable only to data collection and fees for conference attendance and publication. The project groups, however, had similar perceptions of social sup- also received partial funds from the RedIAPP Preventive Activities and Health port. A large proportion of cancer survivors engaged in Promotion Network (RD12/0005; RD16/0007) for data collection by the unhealthy lifestyle practices that could negatively affect coordinating researcher, from the Spanish Cancer League, Balearic Association (2012) for the translation of the manuscript, and from the Catalan Department both their health and quality of life. Health care providers of Health (SLT002/16/00/00112) for a data manager contract. must take an active role in assessing their patients’ lifestyle habits after a diagnosis of cancer and discuss the beneficial Availability of data and materials The datasets used and analyzed during the current study are available from effects that leading a healthy lifestyle can have on quality of the corresponding author on reasonable request. life and prognosis. León‑Salas et al. BMC Res Notes (2020) 13:376 Page 6 of 7 Ethics approval and consent to participate 8. 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