Research Article: Healthy lifestyle is inversely associated with mortality in cancer survivors: Results from the Third National Health and Nutrition Examination Survey (NHANES III)

Date Published: June 26, 2019

Publisher: Public Library of Science

Author(s): Nena Karavasiloglou, Giulia Pestoni, Miriam Wanner, David Faeh, Sabine Rohrmann, Xianwu Cheng.


Individual lifestyle behaviors have been associated with prolonged survival in cancer survivors, but little information is available on the association between combined lifestyle behaviors and mortality in this population. Data from 522 cancer survivors participating in the Third National Health and Nutrition Examination Survey (NHANES III) were analyzed. Behaviors pertaining to lifetime healthy body weight maintenance, physical activity, smoking, diet quality (assessed by the Healthy Eating Index) and moderate alcohol consumption were combined in a lifestyle score (range 0–5). Cox proportional hazards regression models were used to calculate multivariable-adjusted hazard ratios (HR) and 95% confidence intervals (CI). Both in continuous and categorical models, the lifestyle score was statistically significantly associated with lower mortality in the total study population (HRcontinuous = 0.81, 95% CI: 072, 0.90, per 1 unit increase; HR1-2 vs. 0 total = 0.71, 95% CI: 0.56, 0.92; HR3-5 vs. 0 total = 0.57, 95% CI: 0.38, 0.85, in the fully adjusted model) and in sex-specific analyses.

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Cancer is the second leading cause of death in the United States [1]. Screening programs, early detection, and medical advancements have led to a decrease in cancer death rates [1] and an increase in survival among cancer patients [2]. However, little is known about survivors’ lifestyle behaviors and how they influence survival [3, 4]. A recent report highlighted that while there is not sufficient evidence in order to form recommendations for cancer survivors, there are indications that healthy body weight, physical activity, and dietary factors post-diagnosis may be associated with longer survival [5].

Description of the study population and baseline characteristics are shown in Table 1. Mean time between cancer diagnosis and entry in the NHANES III was 9.7 years (SEM: 0.6; for the total study population). The most frequent cancer site was breast, followed by colorectal and prostate cancers. Participants who adhered to none of the healthy lifestyle behaviors entered the study at a slightly younger age and were more likely to be current or former smokers compared to participants who adhered to some or most of the healthy lifestyle behaviors.

In our study of cancer survivors, lifetime healthy body weight maintenance, never smoking, regular participation in physical activity, consumption of a high-quality diet and moderate consumption of alcohol, as expressed by a lifestyle score, was associated with lower mortality. Lower mortality was also observed for cancer survivors who only adhered to some of these healthy lifestyle behaviors and the results did not vary significantly by sex.