Evaluation of disparities in maintaining healthy lifestyle behaviors among female cancer survivors by race/ethnicity and US nativity

1Introduction

There are approximately 8.7 million female cancer survivors living today with an estimated 289,150 new cases to be diagnosed in 2021 [1] . US females comprised 48.8 % of all new cancers in 2020 according to the National Cancer Institute (NCI) [2] , with breast (30 %), lung/bronchus (13 %), and colorectal (8 %) being the most common, accounting for an estimated 50 % of incident cancers. Updated probability statistics in 2020 determined that cancer survival among US females continues to vary but remains directly dependent on stage at diagnosis, tumor grade, modifiable risk factors (e.g., smoking, body weight, diet, physical inactivity, etc.), and the prevalence and severity of comorbid conditions [3] . Women are also more likely to be long-term survivors of cancer and in the US, constitute for the majority of survivors [3] . Surviving cancer does not necessitate successful survivorship, as there remain sociodemographic, clinical, and modifiable risk factors that may negatively affect overall betterment of health post-cancer treatment [45] .

Successful cancer survivorship, as defined by the National Cancer Institute [6] , is the physical and psychosocial health of an individual once cancer treatment is completed. Despite innovations in cancer care, associated survivorship continues to be disparate, especially among racial/ethnic minority groups and immigrant populations. There are subgroups of women who face worse survivorship outcomes (e.g., recurrence, higher mortality rates, etc.) such as African American (AA)/Black and Hispanic/Latina survivors [37] . Hispanic and AA/Black survivors, for example, are at increased risk for cardiovascular disease (CVD), lymphedema, hypertension, depression, osteoporosis, and chronic pain when compared with non-Hispanic white (NHW) survivors [89] , which can in turn, increase risk of recurrence and therefore mortality [810] . We recently found that among a US-based nationally-representative sample of female cancer survivors, racial/ethnic minority groups, impoverished women, and those with low educational attainment are significantly more likely to report worse health status and healthcare barriers than NHW, those living above the poverty line and those with a college degree, respectively [11] . Uniquely, health behavior disparities also exist within immigrant populations [1213] . The heightened immigration enforcement in the US more recently has been associated with negative impacts on health and wellbeing among this population. From a population perspective, research is just beginning to focus on the health behaviors of immigrant cancer survivors given their time in the US 141516 . The US healthcare system serves many immigrant individuals (citizens who were born elsewhere, qualified legal immigrants, and others), so understanding whether and how their behaviors are unique to that group can assist in informing cancer survivorship and future preventive care.