Long-term comparative trajectories of health, behavioral, and economic outcomes: From pre-diagnosis to survivorship.

Abstract

Although cancer survivorship involves interconnected changes in health, health behaviors, and economic well-being, few studies have comprehensively examined how these outcomes evolve before and after a cancer diagnosis within the same population over time. Using population-based longitudinal data, we characterized trajectories before and after incident cancer diagnosis and compared them with those of matched individuals without cancer. Using 15 waves (1992-2022) of the Health and Retirement Study, we identified 5,423 incident cancer cases and matched them to up to four controls (n = 17,530) using exact matching on sex and race/ethnicity and propensity score matching on age and entry wave (caliper = 0.1). Outcomes included health (self-rated health, functional limitations, depressive symptoms, cognition), lifestyle (BMI, smoking, drinking, physical activity), and economic measures (employment, out-of-pocket medical spending). Using a time-centered design, all measures were aligned to the wave of incident cancer diagnosis (t₀), and outcome trajectories were estimated from up to 24 years before to 24 years after diagnosis. Differences in post-diagnosis changes between cancer cases and matched controls were assessed using fixed-effects difference-in-differences models. Cancer diagnosis was associated with immediate declines in self-rated health (-19%) and increased functional limitations (+44%) at t₀, followed by partial recovery but persistent deficits. Depressive symptoms spiked and remained elevated for four years. Smoking declined at diagnosis and remained lower, while changes in BMI and alcohol use were more transient. Physical activity declined and remained suppressed for six years. Employment dropped sharply, and out-of-pocket spending rose by $2,382 (95% CI: $1,705 to $3,061), with disparities persisting for six years. Mortality risk remained elevated and widened through year six. Notably, cancer survivors exhibited higher post-diagnosis cognitive functioning. Cancer diagnosis is associated with profound, multidimensional disruptions, many of which persist for years. These findings underscore the need for comprehensive survivorship care, including mental health services, rehabilitation, lifestyle counseling, and financial support, to address the long-term burden.