The first year of the COVID-19 pandemic and health among cancer survivors in the United States.

BACKGROUND: Cancer survivors represent a population with high health care needs. If and how cancer survivors were affected by the first year of the coronavirus disease 2019 (COVID-19) pandemic are largely unknown.
METHODS: Using data from the nationwide, population-based Behavioral Risk Factor Surveillance System (2017-2020), the authors investigated changes in health-related measures during the COVID-19 pandemic among cancer survivors and compared them with changes among adults without a cancer history in the United States. Sociodemographic and health-related measures such as insurance coverage, employment status, health behaviors, and health status were self-reported. Adjusted prevalence ratios of health-related measures in 2020 versus 2017-2019 were calculated with multivariable logistic regressions and stratified by age group (18-64 vs. ≥65 years).
RESULTS: Among adults aged 18-64 years, the uninsured rate did not change significantly in 2020 despite increases in unemployment. The prevalence of unhealthy behaviors, such as insufficient sleep and smoking, decreased in 2020, and self-rated health improved, regardless of cancer history. Notably, declines in smoking were larger among cancer survivors than nonelderly adults without a cancer history. Few changes were observed for adults aged ≥65 years.
CONCLUSIONS: Further research is needed to confirm the observed positive health behavior and health changes and to investigate the role of potential mechanisms, such as the national and regional policy responses to the pandemic regarding insurance coverage, unemployment benefits, and financial assistance. As polices related to the public health emergency expire, ongoing monitoring of longer term effects of the pandemic on cancer survivorship is warranted.

INTRODUCTION

The economic and health care disruptions caused by the coronavirus disease 2019 (COVID‐19) pandemic have been widespread in the United States. Cancer survivors, a population with high health care needs, are among the most vulnerable. , If and how cancer survivors were affected by the pandemic are largely unknown. Using data from the nationwide, population‐based Behavioral Risk Factor Surveillance System (BRFSS), we examined changes in multiple health‐related measures in 2020, the year when the COVID‐19 pandemic was declared, among cancer survivors and compared them with adults without a cancer history.

MATERIALS AND METHODS

BRFSS is an annual household telephone survey that collects data about noninstitutionalized adults' health behaviors, chronic health conditions, and health care access. We used 2017–2020 BRFSS data from all 50 states and the District of Columbia. The response rates ranged from 45.9% to 49.9% in 2017–2020. Cancer history was based on the self‐reported diagnosis of cancer other than skin cancer. Changes in demographic characteristics and the following self‐reported health‐related measures before (2017–2019) and during (2020) the COVID‐19 pandemic were compared between cancer survivors and adults without a cancer history (see Table S1 for details of the measures): access to care (including noninsurance and no usual source of care), unemployment, health behaviors (including insufficient sleep, obesity, physical inactivity, current cigarette smoking, binge drinking, and heavy drinking), and unfavorable health status (including other than “excellent” self‐rated health and frequent mental distress ). The timeframe for all measures referred to either the current situation or the past 30 days. Adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) for health‐related measures in 2020 versus 2017–2019 were calculated with multivariable logistic regressions controlling for sociodemographic factors and the state COVID‐19 mortality rate in 2020. State unemployment benefit generosity and state‐level per capita gross domestic product in 2019 were added to multivariable models for unemployment outcomes. Analyses were stratified by age group (18–64 vs. ≥65 years) because of differences in health insurance coverage and employment distribution. Because Medicare provides nearly universal insurance coverage for persons aged ≥65 years after retirement in the United States, only health behaviors and health status were examined among individuals aged ≥65 years. A sensitivity analysis was conducted by further inclusion of the BRFSS interview month in the models. All analyses used sample weights to account for the complex survey design and nonresponses, and they were conducted with SAS9.4 and SAS‐callable SUDAAN (SAS Institute, Inc, Cary, North Carolina). All tests were two‐sided with a significance level of .05. The analysis of de‐identified, publicly available data do not constitute human subjects research thus IRB review was not required.

RESULTS

A total of 57,132 adult cancer survivors and 1,044,585 adults without a cancer history were included. Regardless of cancer history, participants in 2020 reported slightly higher household incomes and were less likely to report disabilities in comparison with participants in 2017–2019 (Table 1). For individuals aged 18–64 years (Table 2), the percentage unemployed increased by 43% (95% CI for PR, 1.22–2.68) among cancer survivors and by 57% (95% CI for PR, 1.51–1.62) among adults without a cancer history in 2020 versus 2017–2019. Further analysis by unemployment duration showed that the increase in unemployment was driven by short‐term unemployment for <1 year. The percentage uninsured and the percentage without a usual source of care did not show significant changes in 2020.

TABLE 1

Sample characteristics by cancer history, Behavioral Risk Factor Surveillance System, 2017–2020

Characteristic	Cancer survivors				Individuals without a cancer history
	Total (N = 57,132)	2017–2019 (N = 45,025 [53.0%])	2020 (N = 12,107 [47.0%])	p	Total (N = 1,044,585)	2017–2019 (N = 794,565 [49.7%])	2020 (N = 250,020 [50.3%])	p
18–64 years
Sex				.46				.68
Male	17,640 (33.1)	13,800 (32.7)	3840 (33.5)		503,517 (50.5)	382,166 (50.6)	121,351 (50.5)
Female	39,492 (66.9)	31,225 (67.3)	8267 (66.5)		541,068 (49.5)	412,399 (49.4)	128,669 (49.5)
Age, years				.006				.29
18–44	9905 (24.4)	7797 (25.2)	2108 (23.5)		481,467 (59.8)	361,570 (59.6)	119,897 (59.9)
45–54	14,452 (26.5)	11,306 (27.4)	3146 (25.4)		246,502 (20.3)	187,615 (20.4)	58,887 (20.1)
55–64	32,775 (49.1)	25,922 (47.4)	6853 (51.1)		316,616 (19.9)	245,380 (19.9)	71,236 (19.9)
Race/ethnicity				.62				<.001
Non‐Hispanic White	44,562 (69.6)	35,129 (69.5)	9433 (69.7)		719,431 (56.1)	549,188 (56.8)	170,243 (55.3)
Non‐Hispanic Black	4080 (10.1)	3265 (10.5)	815 (9.7)		91,413 (12.4)	70,709 (12.4)	20,704 (12.3)
Hispanic	3369 (12.3)	2645 (12.2)	724 (12.4)		121,258 (19.9)	91,100 (19.5)	30,158 (20.3)
Other and unknown	5121 (8.1)	3986 (7.9)	1135 (8.3)		112,483 (11.6)	83,568 (11.2)	28,915 (12.0)
Household income				.001				<.001
<$25,000	14,842 (25.1)	12,051 (26.7)	2791 (23.2)		205,533 (20.1)	161,054 (21.3)	44,479 (18.9)
$25,000–$74,999	16,978 (28.3)	13,402 (28.2)	3576 (28.5)		325,513 (29.5)	250,910 (30.2)	74,603 (28.8)
≥$75,000	16,774 (30.7)	13,007 (30.0)	3767 (31.4)		348,605 (32.4)	261,675 (31.7)	86,930 (33.1)
Unknown	8538 (15.9)	6565 (15.1)	1973 (16.9)		164,934 (18.0)	120,926 (16.8)	44,008 (19.2)
Educational attainmenta				.17				<.001
≤High school graduate	18,923 (39.6)	15,119 (39.9)	3804 (39.3)		348,258 (39.9)	266,465 (40.4)	81,793 (39.4)
Some college	17,109 (32.3)	13,492 (32.9)	3617 (31.6)		290,882 (30.7)	221,956 (30.9)	68,926 (30.4)
≥College graduate	20,904 (27.6)	16,268 (26.8)	4636 (28.5)		401,001 (29.0)	302,949 (28.3)	98,052 (29.7)
Marital status				.95				.030
Married	30,779 (55.3)	24,174 (55.4)	6605 (55.3)		542,993 (48.3)	413,951 (48.6)	129,042 (48.0)
Unmarriedb	26,353 (44.7)	20,851 (44.6)	5502 (44.7)		501,592 (51.7)	380,614 (51.5)	120,978 (52.0)
No. of health conditionsc				.11				<.001
0	16,743 (30.5)	13,006 (29.5)	3737 (31.7)		549,254 (57.0)	414,142 (56.5)	135,112 (57.5)
1	15,760 (28.4)	12,443 (28.5)	3317 (28.2)		285,508 (26.5)	217,712 (26.5)	67,796 (26.4)
2+	24,629 (41.1)	19,576 (42.0)	5053 (40.1)		209,823 (16.6)	162,711 (17.0)	47,112 (16.1)
With disabilitiesd				.009				<.001
No	33,975 (59.6)	26,370 (58.1)	7605 (61.2)		814,449 (79.4)	615,336 (78.8)	199,113 (80.1)
Yes	23,157 (40.4)	18,655 (41.9)	4502 (38.8)		230,136 (20.6)	179,229 (21.2)	50,907 (19.9)
65+ years
Sex				.06				.62
Male	45,491 (46.0)	34,970 (45.2)	10,521 (46.8)		204,961 (44.2)	156,731 (44.3)	48,230 (44.1)
Female	62,424 (54.0)	48,629 (54.9)	13,795 (53.2)		293,711 (55.8)	226,426 (55.7)	67,285 (55.9)
Age, years				.57				.32
65–74	54,284 (51.6)	42,057 (51.6)	12,227 (51.6)		299,924 (60.8)	230,399 (61.0)	69,525 (60.7)
75–79	23,603 (22.0)	18,302 (22.3)	5301 (21.7)		90,797 (18.6)	69,478 (18.3)	21,319 (18.8)
80+	30,028 (26.4)	23,240 (26.1)	6788 (26.7)		107,951 (20.6)	83,280 (20.7)	24,671 (20.5)
Race/ethnicity				.024				.008
Non‐Hispanic White	93,719 (81.3)	72,593 (81.1)	21,126 (81.5)		411,081 (73.7)	315,983 (74.1)	95,098 (73.2)
Non‐Hispanic Black	5965 (8.3)	4654 (7.8)	1311 (8.8)		32,142 (9.3)	24,842 (9.0)	7300 (9.7)
Hispanic	2055 (4.4)	1586 (5.1)	469 (3.8)		21,105 (9.7)	16,134 (9.4)	4971 (10.1)
Other and unknown	6176 (6.0)	4766 (6.1)	1410 (5.8)		34,344 (7.3)	26,198 (7.5)	8146 (7.1)
Annual household income				<.001				<.001
<$25,000	22,571 (20.1)	17,966 (21.2)	4605 (19.0)		110,448 (23.0)	86,948 (24.0)	23,500 (22.0)
$25,000–$74,999	40,108 (35.2)	31,232 (36.2)	8876 (34.3)		178,647 (33.2)	137,955 (33.8)	40,692 (32.6)
≥$75,000	21,524 (21.0)	16,500 (20.1)	5024 (21.8)		95,632 (19.1)	72,574 (18.9)	23,058 (19.4)
Unknown	23,712 (23.7)	17,901 (22.5)	5811 (25.0)		113,945 (24.7)	85,680 (23.3)	28,265 (26.0)
Educational attainmenta				.020				.37
≤High school graduate	36,355 (39.6)	28,487 (40.8)	7868 (38.4)		178,806 (43.6)	138,927 (43.9)	39,879 (43.3)
Some college	29,630 (31.7)	22,814 (31.2)	6816 (32.2)		135,120 (29.8)	103,092 (29.8)	32,028 (29.8)
≥College graduate	41,630 (28.3)	32,078 (27.7)	9552 (29.0)		182,633 (26.1)	139,533 (25.8)	43,100 (26.4)
Marital status				.22				.13
Married	53,494 (55.3)	41,087 (54.8)	12,407 (55.8)		249,908 (54.7)	190,660 (54.4)	59,248 (55.1)
Unmarriedb	54,421 (44.7)	42,512 (45.2)	11,909 (44.2)		248,764 (45.3)	192,497 (45.6)	56,267 (45.0)
No. of health conditionsc				.94				.48
0	23,649 (21.2)	18,302 (21.4)	5347 (21.1)		139,217 (27.7)	106,000 (27.5)	33,217 (27.9)
1	34,603 (31.8)	26,839 (31.7)	7764 (31.8)		165,585 (32.8)	127,243 (32.8)	38,342 (32.8)
2+	49,663 (47.0)	38,458 (46.9)	11,205 (47.1)		193,870 (39.5)	149,914 (39.7)	43,956 (39.3)
With disabilitiesd				.31				<.001
No	58,438 (54.1)	45,038 (53.7)	13,400 (54.6)		303,418 (60.7)	231,510 (59.6)	71,908 (61.8)
Yes	49,477 (45.9)	38,561 (46.3)	10,916 (45.4)		195,254 (39.3)	151,647 (40.4)	43,607 (38.2)

Note: The data are presented as sample N (weighted %). 

The education categories do not add up to 100% because of a small number of missing values (<1%).

Unmarried includes divorced, widowed, separated, never married, a member of an unmarried couple, refused, and missing.

Health conditions include a history of heart attack (also known as myocardial infarction), angina (also known as coronary heart disease), stroke, asthma, chronic obstructive pulmonary disease (emphysema or chronic bronchitis), arthritis, depression disorder, kidney disease, and diabetes.

Disabilities include six questions on whether the participant is deaf or has serious difficulty with hearing; is blind or has serious difficulty with seeing even when wearing glasses; has serious difficulty with concentrating, remembering, or making decisions; has serious difficulty with walking or climbing stairs; has difficulty with dressing or bathing; and has difficulty with doing errands such as visiting a doctor's office or shopping alone.

TABLE 2

Association of the COVID‐19 pandemic with health‐related measures by cancer history, Behavioral Risk Factor Surveillance System, 2017–2020

	Cancer survivors			Individuals without a cancer history			p for interactiona in adjusted model
	Crude prevalence, %		Adjusted prevalence ratio (95% CI)	Crude prevalence, %		Adjusted prevalence ratio (95% CI)
	2017–2019	2020		2017–2019	2020
18–64 years
Access to care
Uninsured	8.8	8.0	0.92 (0.79–1.06)	15.2	15.6	1.02 (0.998–1.05)	.14
No usual source of care	11.8	11.5	0.98 (0.86–1.10)	27.8	28.2	1.01 (0.997–1.03)	.54
Unemployment
Unemployed	6.5	9.3	1.43 (1.22–1.68)	6.0	9.3	1.57 (1.51–1.62)	.49
Unemployed for ≥1 year	3.8	3.4	0.89 (0.71–1.12)	2.7	2.7	0.99 (0.93–1.05)	.45
Unemployed for <1 year	2.7	5.9	2.18 (1.75–2.72)	3.3	6.7	2.04 (1.96–2.13)	.51
Health behaviors
Insufficient sleepb	43.1	39.2	0.91 (0.86–0.97)	37.1	34.3	0.92 (0.91–0.94)	.39
Obesityc	36.5	40.2	1.10 (1.04–1.17)	30.8	32.7	1.06 (1.04–1.07)	.12
Physical inactivityd	29.2	30.5	1.04 (0.97–1.12)	22.0	21.3	0.97 (0.95–0.99)	.08
Currently smokinge	21.9	19.2	0.88 (0.82–0.94)	16.0	14.9	0.93 (0.91–0.95)	.049
Binge drinkingf	12.4	11.2	0.90 (0.81–1.01)	18.4	17.0	0.93 (0.91–0.95)	.73
Heavy drinkingg	7.3	6.9	0.95 (0.83–1.10)	7.4	7.6	1.02 (0.99–1.06)	.45
Health outcomes
Self‐rated health: not excellent	91.7	88.4	0.96 (0.95–0.98)	80.0	74.8	0.94 (0.93–0.94)	.32
Frequent mental distressh	22.0	22.3	1.01 (0.94–1.10)	13.3	14.7	1.10 (1.08–1.13)	.09
65+ years
Health behaviors
Insufficient sleepb	27.3	26.0	0.96 (0.89–1.02)	26.5	25.6	0.96 (0.93–0.999)	.82
Obesityc	29.2	29.1	1.00 (0.95–1.05)	28.8	29.4	1.02 (0.99–1.05)	.35
Physical inactivityd	32.1	32.2	1.00 (0.96–1.05)	29.4	30.5	1.04 (1.01–1.06)	.22
Currently smokinge	7.5	8.0	1.06 (0.95–1.18)	8.6	8.5	0.99 (0.95–1.04)	.31
Binge drinkingf	4.3	4.4	1.02 (0.88–1.19)	4.9	4.7	0.97 (0.9–1.04)	.51
Heavy drinkingg	4.7	4.9	1.05 (0.92–1.21)	4.7	4.7	0.99 (0.92–1.06)	.37
Health outcomes
Self‐rated health: not excellent	92.1	91.5	0.99 (0.98–1.003)	86.5	85.9	0.99 (0.99–0.999)	.58
Frequent mental distressh	8.9	9.4	1.06 (0.96–1.17)	7.3	7.7	1.06 (0.99–1.12)	.89

Abbreviations: CI, confidence interval; COVID‐19, coronavirus disease 2019.

Note: Models have been adjusted for the following: sex, age group, race/ethnicity, marital status, annual household income, number of comorbidities (for cancer survivors) or number of chronic conditions (for individuals without a cancer history), disability status, and state COVID‐19 mortality rate in 2020. For unemployment outcomes, state unemployment benefit generosity and state‐level per capita gross domestic product in 2019 have been further adjusted.

p for interaction is the p value for the interaction term of period (2020 vs. 2017–2019) by cancer history in the model.

Insufficient sleep is defined as less than 7 hours per night on average. Data are available only for 2018 and 2020.

Obesity is defined as a body mass index ≥30 kg/m2.

Physical inactivity is defined as no participation in any physical activities or exercise during the past month.

Currently smoking is defined as smoking cigarettes every day or some days.

Binge drinking is defined as having ≥5 drinks for males or having ≥4 drinks for females on ≥1 occasion in the past month.

Heavy drinking is defined as having >14 drinks per week for males or having >7 drinks per week for females.

Frequent mental distress is defined as ≥14 self‐reported mentally unhealthy days in the past 30 days.

For individuals aged 18–64 years (Table 2), in terms of health behaviors, the prevalence of insufficient sleep and smoking decreased in 2020 in adults with and without a cancer history. Moreover, smoking prevalence decreased to a larger extent among cancer survivors (PR, 0.88 vs. 0.93; p for interaction = .049). The prevalence of physical inactivity and binge drinking also decreased among adults without a cancer history. Following the recent trend (Fig. 1), the prevalence of obesity continued to increase, regardless of cancer history. Self‐rated health improved among both cancer survivors and adults without a cancer history. More adults without a cancer history reported frequent mental distress in 2020 than 2017–2019. Among participants aged ≥65 years, few changes in health‐related measures were observed.

FIGURE 1

Trends of health‐related measures among cancer survivors and individuals without a cancer history (Behavioral Risk Factor Surveillance System, 2017–2020): (A) individuals aged 18–64 years and (B) individuals aged ≥65 years. Insufficient sleep is defined as less than 7 hours per night on average (data are available only for 2018 and 2020). Obesity is defined as a body mass index ≥30 kg/m2. Physical inactivity is defined as no participation in any physical activities or exercise during the past month. Currently smoking is defined as smoking cigarettes every day or some days. Binge drinking is defined as having ≥5 drinks for males or having ≥4 drinks for females on ≥1 occasion in the past month. Heavy drinking is defined as having >14 drinks per week for males or having >7 drinks per week for females. Frequent mental distress is defined as ≥14 self‐reported mentally unhealthy days in the past 30 days.

Results from the sensitivity analysis further including the interview month in the multivariable models are shown in Table S2. The findings were virtually the same as those from the main analysis.

DISCUSSION

To the best of our knowledge, our study provides the first nationally representative estimation of the effects of the first year of the COVID‐19 pandemic on cancer survivors in the United States. In agreement with previous studies conducted in the general population, we found that the uninsured rate did not change significantly among working‐age cancer survivors in 2020 despite increased unemployment amidst the COVID‐19 pandemic. This trend is potentially explained in part by increased enrollment in the Affordable Care Act Marketplace, especially in states that relaxed enrollment criteria in 2020, and by the Families First Coronavirus Response Act, which increased the federal government's share of Medicaid costs, prohibited states from implementing new Medicaid eligibility restrictions, and prevented states from terminating Medicaid coverage during the public health emergency. These provisions likely compensated for the loss in employer‐sponsored insurance. The Families First Coronavirus Response Act is expected to expire in 2022; ongoing monitoring of health insurance coverage and access to care will be important, especially as new COVID‐19 variants emerge.

Among adults aged 18–64 years, decreased unhealthy behaviors such as insufficient sleep and smoking were observed, regardless of cancer history, and decreased physical inactivity and binge drinking were observed for individuals without a cancer history; this suggests that the pandemic may have motivated people to adopt certain healthier lifestyles. Decreased commute times and converting to active transportation might also provide some workers opportunities to increase physical activity during the pandemic. An exception is that obesity rates increased in adults with and without a cancer history, which may reflect a continuation of the prepandemic obesity epidemic trend and difficulty in changing one's weight status over a short time. Self‐rated health improved in 2020 overall, and this potentially reflects decreases in unhealthy behaviors and positive health effects from national policy responses to the pandemic, including financial assistance. Adults without a cancer history were more likely to report ≥2 weeks of mental distress during the past month in 2020, and this confirms the increased mental health problems reported in studies using smaller convenience samples. ,

There are several limitations to the study. First, the survey provides population‐based weights for annual estimation; thus, we were not able to examine the changes by month, although further controlling for the interview month in the models did not change the estimates (Table S2). The World Health Organization declared COVID‐19 a pandemic in March 2020; therefore, our results may underestimate the effects of the pandemic. Second, although the response rates were similar across the 4 years of study, some states paused interviews during shutdowns, and income was slightly higher for 2020 participants than those in earlier years. Other surveys, including the census, have noted this pattern as well. Although BRFSS weights account for nonresponse bias, residual bias may be present. Third, although we selected a wide range of health‐related measures, we were unable to examine some important outcomes because they were not assessed in BRFSS nationwide (e.g., insurance type), were not assessed in 2020 (e.g., vegetable and fruit intake), or were not assessed within the current or near‐current timeframe (e.g., care affordability assessed for the past 12 months, which could include months in 2019); these merit further investigation. For example, with the sharp decline in employment, many working‐age adults changed their employment‐sponsored insurance to public insurance or self‐purchased private insurance from the Marketplace during the pandemic, with variations in cost‐sharing and provider networks. The effects of these changes in coverage type on out‐of‐pocket costs, access to care, and care utilization across the cancer continuum are important areas for future evaluation as data become available. Lastly, the COVID‐19 status of individuals is not available in BRFSS 2020, and neither is the essential worker status.

In conclusion, using a nationwide, population‐based survey dataset, we found that the uninsured rate did not change significantly in 2020 among working‐age individuals in the United States despite increases in unemployment. Moreover, the prevalence of some unhealthy behaviors, such as insufficient sleep and smoking, decreased in 2020, and self‐rated health improved, regardless of cancer history, among individuals aged 18–64 years. Future research is needed to confirm the observed positive health behavior and health changes and to investigate the role of potential mechanisms, such as the national and regional policy responses to the pandemic regarding insurance coverage, unemployment benefits, and financial assistance. As polices related to the public health emergency expire, ongoing monitoring of longer term effects of the pandemic on cancer survivorship is warranted. Future studies are also needed to evaluate the impact of health polices, including Medicaid expansion and other provisions of the Affordable Care Act, on health equity as the nation transitions into a COVID‐19 endemic.

AUTHOR CONTRIBUTIONS

Xuesong Han: Conceptualization, formal analysis, data curation, investigation, methodology, project administration, supervision, writing–original draft, and writing–review and editing. Sylvia Kewei Shi: Conceptualization, formal analysis, data curation, investigation, methodology, and writing–review and editing. Jingxuan Zhao: Conceptualization, data curation, investigation, methodology, and writing–review and editing. Leticia M. Nogueira: Conceptualization, data curation, investigation, methodology, and writing–review and editing. Priti Bandi: Conceptualization, data curation, investigation, methodology, and writing–review and editing. Stacey A. Fedewa: Conceptualization, data curation, investigation, methodology, and writing–review and editing. Ahmedin Jemal: Conceptualization, data curation, investigation, methodology, supervision, and writing–review and editing. K. Robin Yabroff: Conceptualization, data curation, investigation, methodology, supervision, and writing–review and editing.

CONFLICTS OF INTEREST

Xuesong Han and Jingxuan Zhao have received a grant from AstraZeneca for research outside the current study. K. Robin Yabroff serves on the Flatiron Health Equity Advisory Board. All authors are employed by the American Cancer Society, Inc, a not‐for‐profit public health organization that receives support from the public through fundraising and direct contributions. The society also receives a small portion of its support from corporations and industry to support its mission programs and services.

Appendix

Click here for additional data file.