The overall goals of the current study were to determine the prevalence of cancer screening practices and risky health behaviors in HCT survivors in comparison to a healthy sibling group, and identify populations with poor adherence to screening and health promotion recommendations.15,17–20
We found that compared to siblings, survivors were less likely to report risky health behaviors such as smoking or excessive alcohol intake, and had similar or better cancer screening practices. However, despite the potential for long-term sequelae, younger survivors, those without health insurance, and with lower education continued to engage in high risk behaviors, thus informing education and targeted interventions in the future.
The Institute of Medicine (IOM) recommends that all cancer survivors have regular medical care that is adapted to specific risks due to their previous cancer therapy, lifestyle, or any comorbid health conditions.25
Investigators from the Childhood Cancer Survivors Study (CCSS) have found that despite having similar cancer screening rates as the general population, the frequency and extent of these screenings remains suboptimal for many adult survivors of childhood cancer.10,26,27
On the other hand, studies in survivors of adult onset cancer have reported better than expected cancer screening practices in survivors when compared to age-matched controls.28,29
To date, few studies have examined the cancer screening practices of long-term HCT survivors, a population at risk for developing chronic health conditions, including subsequent malignant neoplasms.9
We found that the vast majority of female survivors reported having had a recent clinical breast examination (88%) or pap smear (85%), and this was better than or comparable to U.S. population-based data from the time of questionnaire administration (breast examination, 60–76%; pap smear, 85–87%) 30,31
. The reported low rates of regular BSE (survivors, 29%; siblings, 27%) or TSE (survivors, 18%; siblings 20%) in the current study were similar to those reported in adult survivors of childhood cancer (27% for regular BSE, 17% regular TSE),27
and may reflect ongoing controversies regarding the utility and yield of such screenings.32–35
After adjusting for sociodemographics and level of concern regarding future health, female HCT survivors were nearly three times as likely to report having had at least one mammogram compared to sibling controls. There were no differences in cervical cancer or testicular cancer screening practices between the two groups.
It is now well-recognized that female cancer survivors previously treated with chest or mantle radiation are at increased risk of developing breast cancer years following completion of therapy;26
as a result it is recommended that these women undergo screening at a younger age than general population..21,22,26
In the current study, nearly all women (96%) treated with chest radiation who were 30 years of age or older at the time of questionnaire reported having had at least one screening mammogram, and all had a recent clinical breast examination. As expected, the difference in screening rates between radiation-treated, non-radiation treated, and sibling participants was greatest for the 30–39 year old age group. While none of the consensus guidelines were available at the time of questionnaire administration, it is encouraging that a sizeable number of survivors treated with radiation had undergone regular breast cancer screening, a finding that is likely to continue to improve with increased awareness and greater dissemination of survivorship screening guidelines.
Guidelines of the USPSTF recommend that healthcare providers screen all adults for tobacco use and other high risk behavior, and that cessation interventions be provided for those engaged in such behavior.36
Adverse health related outcomes attributed to excess alcohol or tobacco use have been well-described in the non-oncology community, and there is a growing body of literature describing their modifying effect on adverse outcomes in long-term cancer survivors.10
For patients engaging in high risk behaviors, a diagnosis of cancer or HCT may serve as a catalyst for life change. However, studies have found that most survivors report relatively few changes in their overall health behaviors, and that the lifestyle practices largely remain unchanged in the long-term by the cancer experience.13,37
In the current study, despite having a similar past smoking history, survivors were significantly less likely to report current smoking, and had a higher quit rate when compared to sibling controls. Overall, after adjusting for baseline demographic differences, HCT survivors were 50% less likely to report high risk behavior when compared to sibling controls.
Despite the encouraging health practices of HCT survivors, there were a sizeable number of survivors who continued to engage in risky health behaviors long after undergoing HCT. Consistent with previous research,10,38
we found that younger age, lack of health insurance, and lower education were significant predictors of adverse health behavior. The reasons why cancer survivors chose to engage in these behaviors are not known, but a perception of invulnerability or denial have been proposed as possible factors.39
Survivors who initiated smoking after HCT were younger at HCT, had a longer period of follow-up post-HCT and were less likely to report regular cancer/HCT-related visits when compared to those who quit smoking after HCT, suggesting that the level of engagement in health-related issues may be an important modifier of risk for adverse health behaviors in this population. This highlights the importance of ongoing multi-disciplinary long term follow-up care that places equal emphasis on primary as well as secondary disease prevention.
The results of this study must be interpreted in the context of potential limitations. Approximately one third of the eligible patients did not participate in the current study. Although participants and non-participants were similar in many respects, it is possible that those who participated were more likely to be engaged in health screenings, less likely to have high risk behaviors. If this were to be true, the prevalence rates presented here are more conservative than what would be expected with complete participation. In addition, similar to previous studies, 13,28,29,38,39
information regarding cancer screening and health risk behaviors were ascertained using self-report, potentially contributing to an overestimation of cancer screening practices and underestimation of adverse health behaviors in both survivors and siblings. However, the reported cancer screening rates for siblings were similar to those in the general population at the time of survey, suggesting that despite these limitations, information presented in the current study adequately represented the health behaviors of long-term survivors of HCT.
In summary, HCT survivors had comparable cervical and testicular cancer screening practices, were more likely to have had breast cancer screening by mammography, and were less likely to be engaged in high risk behaviors when compared to healthy sibling controls. We found that despite potential long-term risks, certain subsets of survivors continue to engage in high-risk behaviors such as smoking and excessive alcohol intake, indicating the need for targeted interventions for these high risk populations. Continued vigilance in encouraging appropriate cancer screening and healthy behaviors for HCT survivors will be critical to building on the positive behavioral outcomes described in the current study.