Financial Hardship and Nonadherence to Lifestyle and Surveillance in Childhood Cancer Survivors

The association between medical financial hardship and nonadherence to healthy lifestyle and late-effects surveillance recommendations in long-term survivors of childhood cancer is unknown.

To study the associations between medical financial hardship and nonadherence to healthy lifestyle and late-effects surveillance recommendations.

This retrospective cohort study was performed among participants in the multiinstitutional Childhood Cancer Survivor Study. Participants were 5-year cancer survivors diagnosed at age 21 years or younger between January 1, 1970, and December 31, 1999, and who completed both a medical financial hardship survey between 2017 and 2019 and a follow-up survey assessing lifestyle behaviors and adherence to risk-based surveillance between 2020 and 2022. Data were analyzed between September 29, 2023, and September 2, 2025.

Self-reported medical financial hardship determined by an affirmative response to at least 1 item in the material, behavioral, or psychological domains.

Associations of non-guideline-concordant physical activity, problematic drinking, smoking, and abnormal body mass index with domains of medical hardship were examined using separate multivariable logistic regression models. Associations between a composite lifestyle score (unhealthy, moderately healthy, and healthy) and nonadherence to surveillance for cardiomyopathy or breast, colorectal, cervical, and/or skin cancer were examined using polytomous logistic regression models.

Among 3322 survivors who completed both surveys (median [range] age, 41 [20-69] years; 1751 female [52.7%]), the presence of material, behavioral, and psychological hardship was reported by 1401 (42.2%), 1003 (30.2%), and 1243 (37.4%), respectively. Material hardship was associated with a greater odds of non-guideline-concordant physical activity (odds ratio [OR], 1.67 [95% CI, 1.29-2.18]) and abnormal body mass index (OR, 1.47 [95% CI, 1.15-1.88]). Behavioral and psychological hardships were associated with a higher odds of smoking (OR, 2.29 [95% CI, 1.13-4.62] and 3.95 [95% CI, 2.42-6.44], respectively). Material and psychological hardship were associated with a composite unhealthy lifestyle score (OR, 1.52 [95% CI, 1.11-2.07] and 1.96 [95% CI, 1.31-2.93], respectively), and a higher risk was noted among survivors reporting hardship in at least 2 domains. Psychological hardship was associated with greater nonadherence to skin cancer surveillance (OR, 1.78 [95% CI, 1.05-3.02]) among survivors at high risk due to treatment exposures. Material hardship was associated with greater nonadherence to breast cancer screening (OR, 2.85 [95% CI, 1.27-6.38]) among survivors at average risk. Associations between multiple medical hardship domains and nonadherence to cervical cancer screening were also observed (material and behavioral hardship: OR, 3.20 [95% CI, 1.44-7.14]; material and psychological hardship: OR, 2.18 [95% CI, 1.10-4.35]; behavioral and psychological hardship: OR, 3.25 [95% CI, 1.50-7.04]).

This cohort study of adult survivors of childhood cancer found that medical financial hardship was associated with nonadherence to healthy lifestyle behaviors and certain recommended surveillance tests for subsequent malignant neoplasms. These findings underscore the need to identify and address medical financial hardship as a potential risk factor of nonadherence to healthy lifestyle and guideline-concordant survivorship care.