Adherence to multiple health behaviours in cancer survivors: a systematic review and meta-analysis

  • Daniel N TollosaEmail author
  • Meredith Tavener
  • Alexis Hure
  • Erica L James



Multiple health behaviours (not smoking, minimal alcohol consumption, and maintaining a healthy weight by having a healthy diet and regular physical activity) improve quality of life and longevity of cancer survivors. Despite international guidelines, there are no existing reviews that synthesise cancer survivors’ adherence to healthy lifestyle recommendations.


Five databases (Embase, MEDLINE, PsycINFO, Web of Science, and Google Scholar) were searched for relevant articles published from 2007 until January 2018. Studies reporting adult cancer survivors’ adherence to at least two lifestyle behaviours (body mass index, physical activity, smoking, fruit and vegetable intake, fiber intake, red meat intake, caloric intake, sodium intake, and alcohol consumption) based on the World Cancer Research Fund/American Institute for Cancer Research (WCRF/AICR) recommendations were included in the review. The pooled prevalence of adherence to single and multiple behaviours was calculated using a random-effects model. Subgroup analysis (mean years of survival and publication year) was undertaken.


A total of 3322 articles were identified. Of these, 51 studies matched the inclusion criteria, presenting data from 2,620,586 adult cancer survivors. Adherence to single behaviours, which was estimated from studies that assessed at least two health behaviours, was highest for not smoking (PE 87%; 95% CI, 85%, 88%) and low or no alcohol intake (PE 83%; 95% CI, 81%, 86%), and lowest for fiber intake (PE 31%; 95% CI, 21%, 40%). Adherence to multiple healthy behaviours (13 studies), ranged from 7 to 40% (pooled estimate (PE) 23%; 95% CI, 17%, 30%). Recent survivors (< 5-year survival time) had relatively better adherence to multiple behaviours (PE 31%; 95% CI, 27%, 35%) than long-term (> 5 years) survivors (PE 25%; 95% CI, 14%, 36%). Adherence to multiple behaviours improved over time since 2007.


Adherence to physical activity, dietary, and multiple lifestyle behaviours recommendations was low amongst cancer survivors. Recent cancer survivors were relatively more adherent to WCRF/AICR recommendations compared to long-term survivors.

Implications for Cancer Survivors

Health promotion programs help support healthy lifestyle behaviours of cancer survivors.

PROSPERO registration number: CRD42018091663


Adherence Cancer survivors Diet Physical activity BMI Multiple health behaviours WCRF/AICR 



American Institute for Cancer Research


body mass index


confidence interval


health-related quality of life


metabolic equivalent task


National Heart, Lung, and Blood Institute


pooled estimate


Preferred Reporting Items for Systematic Reviews and Meta-Analyses


World Cancer Research Fund



DNT was supported by a University of Newcastle PhD scholarship. The author thanks Ms. Debbie Booth for her support during the development of search strategies and Dr. Tanmay Bagade, Mr. Tenwa Yimer, and Mr. Girmay Kiross for their support during the screening of the articles.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Ethical approval is not required because of the review nature of the research. This article does not contain any studies with animals performed by any of the authors.

Supplementary material

11764_2019_754_MOESM1_ESM.docx (55 kb)
ESM 1 (DOCX 54 kb)


  1. 1.
    American cancer society (ACS). Cancer treatment & survivorship facts & figures 2016–2017. Atlanta: American Cancer Society; 2016.Google Scholar
  2. 2.
    WCRF/AICR. Food, nutrition, physical activity, and the prevention of cancer: a global perspective. In.: World Cancer Research Fund/American Institute for Cancer Research. 2007.Google Scholar
  3. 3.
    National Institute of Health (NIH). Cancer trends progress report. In.: National Cancer Institute. 2018.Google Scholar
  4. 4.
    Schmitz KH, Neuhouser ML, Agurs-Collins T, Zanetti KA, Cadmus-Bertram L, Dean LT, et al. Impact of obesity on cancer survivorship and the potential relevance of race and ethnicity. J Natl Cancer Inst. 2013;105(18):1344–54.Google Scholar
  5. 5.
    Travis LB, Ng AK, Allan JM, Pui C-H, Kennedy AR, Xu XG, et al. Second malignant neoplasms and cardiovascular disease following radiotherapy. J Natl Cancer Inst. 2012;104(5):357–70.Google Scholar
  6. 6.
    Demark-Wahnefried W, Rogers LQ, Alfano CM, Thomson CA, Courneya KS, Meyerhardt JA, et al. Practical clinical interventions for diet, physical activity, and weight control in cancer survivors. CA Cancer J Clin. 2015;65(3):167–89.Google Scholar
  7. 7.
    Rock CL, Doyle C, Demark-Wahnefried W, Meyerhardt J, Courneya KS, Schwartz AL, et al. Nutrition and physical activity guidelines for cancer survivors. CA Cancer J Clin. 2012;62(4):243–74.Google Scholar
  8. 8.
    Lahart IM, Metsios GS, Nevill AM, Carmichael AR. Physical activity, risk of death and recurrence in breast cancer survivors: a systematic review and meta-analysis of epidemiological studies. Acta Oncol (Stockh). 2015;54(5):635–54.Google Scholar
  9. 9.
    Gold EB, Pierce JP, Natarajan L, Stefanick ML, Laughlin GA, Caan BJ, et al. Dietary pattern influences breast cancer prognosis in women without hot flashes: the women’s healthy eating and living trial. J Clin Oncol. 2009;27(3):352–9.Google Scholar
  10. 10.
    Rutledge L, Demark-Wahnefried W. Weight management and exercise for cancer survivors. Clin J Oncol Nurs. 2016;20(2):129–32.Google Scholar
  11. 11.
    Bishop JD, Killelea BK, Chagpar AB, Horowitz NR, Lannin DR. Smoking and breast cancer recurrence after breast conservation therapy. Int J Breast Cancer. 2014: 327081.Google Scholar
  12. 12.
    Kwan M, Kushi LH, Weltzien E, Tam EK, Castillo A, Sweeney C, et al. Alcohol consumption and breast cancer recurrence and survival among women with early-stage breast cancer: the life after cancer epidemiology study. J Clin Oncol. 2010;28(29):4410–6.Google Scholar
  13. 13.
    Prochaska JJ, Spring B, Nigg CR. Multiple health behavior change research: an introduction and overview. Prev Med. 2008;46(3):181–8.Google Scholar
  14. 14.
    Demark-Wahnefried W, Jones LW. Promoting a healthy lifestyle among cancer survivors. Hematol Oncol Clin North Am. 2008;22(2):319–42 viii.Google Scholar
  15. 15.
    Blanchard CM, Courneya KS, Stein K, American Cancer Society’s SCS, II. Cancer survivors’ adherence to lifestyle behavior recommendations and associations with health-related quality of life: results from the American Cancer Society's SCS-II. J Clin Oncol Off J Am Soc Clin Oncol. 2008;26(13):2198–204.Google Scholar
  16. 16.
    Bruno E, Gargano G, Villarini A, Traina A, Johansson H, Mano MP, et al. Adherence to WCRF/AICR cancer prevention recommendations and metabolic syndrome in breast cancer patients. Int J Cancer. 2016;138(1):237–44.Google Scholar
  17. 17.
    Greenlee H, Molmenti CL, Crew KD, Awad D, Kalinsky K, Brafman L, et al. Survivorship care plans and adherence to lifestyle recommendations among breast cancer survivors. J Cancer Surviv. 2016;10(6):956–63.Google Scholar
  18. 18.
    Inoue-Choi M, Robien K, Lazovich D. Adherence to the WCRF/AICR guidelines for cancer prevention is associated with lower mortality among older female cancer survivors. Cancer Epidemiol Biomarkers Prev. 2013; 22(5):792–802.Google Scholar
  19. 19.
    Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097.Google Scholar
  20. 20.
    National Heart Lung Blood Institute (NHLBI). Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies [].
  21. 21.
    Andrykowski MA. Physical and mental health status and health behaviors in male breast cancer survivors: a national, population-based, case-control study. Psycho-Oncology. 2012;21(9):927–34.Google Scholar
  22. 22.
    Beesley VL, Eakin EG, Janda M, Battistutta D. Gynecological cancer survivors' health behaviors and their associations with quality of life. Cancer Causes Control. 2008;19(7):775–82.Google Scholar
  23. 23.
    Berdan CA, Tangney CC, Scala C, Stolley M. Childhood cancer survivors and adherence to the American Cancer Society Guidelines on Nutrition and Physical Activity. J Cancer Surviv. 2014;8(4):671–9.Google Scholar
  24. 24.
    Bluethmann SM, Basen-Engquist K, Vernon SW, Cox M, Gabriel KP, Stansberry SA, et al. Grasping the ‘teachable moment’: time since diagnosis, symptom burden and health behaviors in breast, colorectal and prostate cancer survivors. Psycho-Oncology. 2015;24(10):1250–7.Google Scholar
  25. 25.
    Dennis Parker EA, Sheppard VB, Adams-Campbell L. Compliance with national nutrition recommendations among breast cancer survivors in “stepping stone”. Integr Cancer Ther. 2014;13(2):114–20.Google Scholar
  26. 26.
    Eakin EG, Youlden DR, Baade PD, Lawler SP, Reeves MM, Heyworth JS, et al. Health behaviors of cancer survivors: data from an Australian population-based survey. Cancer Causes Control. 2007;18(8):881–94.Google Scholar
  27. 27.
    Fisher A, Beeken RJ, Heinrich M, Williams K, Wardle J. Health behaviours and fear of cancer recurrence in 10 969 colorectal cancer (CRC) patients. Psycho-Oncology. 2016;25(12):1434–40.Google Scholar
  28. 28.
    Forsythe LP, Alfano CM, George SM, McTiernan A, Baumgartner KB, Bernstein L, et al. Pain in long-term breast cancer survivors: the role of body mass index, physical activity, and sedentary behavior. Breast Cancer Res Treat. 2013;137(2):617–30.Google Scholar
  29. 29.
    Gjerset GM, Loge JH, Gudbergsson SB, Bye A, Fosså SD, Oldervoll LM, et al. Lifestyles of cancer survivors attending an inpatient educational program—a cross-sectional study. Support Care Cancer. 2016;24(4):1527–36.Google Scholar
  30. 30.
    Grimmett C, Bridgewater J, Steptoe A, Wardle J. Lifestyle and quality of life in colorectal cancer survivors. Qual Life Res Int J Qual Life Asp Treat Care Rehab. 2011;20(8):1237–45.Google Scholar
  31. 31.
    Grimmett C, Wardle J, Steptoe A. Health behaviours in older cancer survivors in the English Longitudinal Study of Ageing. Eur J Cancer. 2009;45(12):2180–6.Google Scholar
  32. 32.
    Harding M. Health-promotion behaviors and psychological distress in cancer survivors. Oncol Nurs Forum. 2012;39(2):E132–40.Google Scholar
  33. 33.
    Hawkes AL, Lynch BM, Owen N, Aitken JF. Lifestyle factors associated concurrently and prospectively with co-morbid cardiovascular disease in a population-based cohort of colorectal cancer survivors. Eur J Cancer. 2011;47(2):267–76.Google Scholar
  34. 34.
    Hawkes AL, Lynch BM, Youlden DR, Owen N, Aitken JF. Health behaviors of Australian colorectal cancer survivors, compared with noncancer population controls. Support Care Cancer. 2008;16(10):1097–104.Google Scholar
  35. 35.
    Hong S, Bardwell WA, Natarajan L, Flatt SW, Rock CL, Newman VA, et al. Correlates of physical activity level in breast cancer survivors participating in the Women’s Healthy Eating and Living (WHEL) Study. Breast Cancer Res Treat. 2007;101(2):225–32.Google Scholar
  36. 36.
    Kanera IM, Bolman CA, Mesters I, Willems RA, Beaulen AA, Lechner L. Prevalence and correlates of healthy lifestyle behaviors among early cancer survivors. BMC Cancer. 2016;16:4.Google Scholar
  37. 37.
    Krebs P, Coups EJ, Feinstein MB, Burkhalter JE, Steingart RM, Logue A, et al. Health behaviors of early-stage non-small cell lung cancer survivors. J Cancer Surviv. 2012;6(1):37–44.Google Scholar
  38. 38.
    LeMasters TJ, Madhavan SS, Sambamoorthi U, Kurian S. Health behaviors among breast, prostate, and colorectal cancer survivors: a US population-based case-control study, with comparisons by cancer type and gender. J Cancer Surviv. 2014;8(3):336–48.Google Scholar
  39. 39.
    Lin LL, Brown JC, Segal S, Schmitz KH. Quality of life, body mass index, and physical activity among uterine cancer patients. Int J Gynecol Cancer. 2014;24(6):1027–32.Google Scholar
  40. 40.
    Lynch BM, Mihala G, Beesley VL, Wiseman AJ, Gordon LG. Associations of health behaviours with return to work outcomes after colorectal cancer. Support Care Cancer. 2016;24(2):865–70.Google Scholar
  41. 41.
    Mayer DK, Terrin NC, Menon U, Kreps GL, McCance K, Parsons SK, et al. Health behaviors in cancer survivors. Oncol Nurs Forum. 2007;34(3):643–51.Google Scholar
  42. 42.
    Mosher CE, Lipkus IM, Sloane R, Kraus WE, Snyder DC, Peterson B, et al. Cancer survivors’ health worries and associations with lifestyle practices. J Health Psychol. 2008;13(8):1105–12.Google Scholar
  43. 43.
    Mowls DS, Brame LS, Martinez SA, Beebe LA. Lifestyle behaviors among US cancer survivors. J Cancer Surviv. 2016;10(4):692–8.Google Scholar
  44. 44.
    Nayak P, Paxton RJ, Holmes H, Nguyen HT, Elting LS. Racial and ethnic differences in health behaviors among cancer survivors. Am J Prev Med. 2015;48(6):729–36.Google Scholar
  45. 45.
    Ollberding NJ, Maskarinec G, Wilkens LR, Henderson BE, Kolonel LN. Comparison of modifiable health behaviours between persons with and without cancer: the multiethnic cohort. Public Health Nutr. 2011;14(10):1796–804.Google Scholar
  46. 46.
    O'Neill SC, DeFrank JT, Vegella P, Richman AR, Henry LR, Carey LA, et al. Engaging in health behaviors to lower risk for breast cancer recurrence. PLoS ONE. 2013;8(1):e53607.Google Scholar
  47. 47.
    Pacheco-Figueiredo L, Antunes L, Bento MJ, Lunet N. Health-related behaviours in the EpiPorto study: cancer survivors versus participants with no cancer history. Eur J Cancer Prev. 2011;20(4):348–54.Google Scholar
  48. 48.
    Park B, Kim SI, Seo SS, Kang S, Park SY, Lim MC. Health behaviors and associated sociodemographic factors in cervical cancer survivors compared with matched non-cancer controls. PLoS One. 2016;11(8):e0160682.Google Scholar
  49. 49.
    Park B, Kong SY, Kim J, Kim Y, Park IH, Jung SY, et al. Health behaviors of cancer survivors in nationwide cross-sectional survey in Korea: higher alcohol drinking, lower smoking, and physical inactivity pattern in survivors with higher household income. Medicine (Baltimore). 2015;94(31):e1214.Google Scholar
  50. 50.
    Pierce JP, Stefanick ML, Flatt SW, Natarajan L, Sternfeld B, Madlensky L, et al. Greater survival after breast cancer in physically active women with high vegetable-fruit intake regardless of obesity. J Clin Oncol. 2007;25(17):2345–51.Google Scholar
  51. 51.
    Rabin C, Politi M. Need for health behavior interventions for young adult cancer survivors. Am J Health Behav. 2010;34(1):70–6.Google Scholar
  52. 52.
    Shinn EH, Basen-Engquist K, Thornton B, Spiess PE, Pisters L. Health behaviors and depressive symptoms in testicular cancer survivors. Urology. 2007;69(4):748–53.Google Scholar
  53. 53.
    Smith WA, Li C, Nottage KA, Mulrooney DA, Armstrong GT, Lanctot JQ, et al. Lifestyle and metabolic syndrome in adult survivors of childhood cancer: a report from the St. Jude Lifetime Cohort Study. Cancer. 2014;120(17):2742–50.Google Scholar
  54. 54.
    Song S, Hwang E, Moon HG, Noh DY, Lee JE. Adherence to guidelines for cancer survivors and health-related quality of life among Korean breast cancer survivors. Nutrients. 2015;7(12):10307–19.Google Scholar
  55. 55.
    Spector DJ, Noonan D, Mayer DK, Benecha H, Zimmerman S, Smith SK. Are lifestyle behavioral factors associated with health-related quality of life in long-term survivors of non-Hodgkin lymphoma? Cancer. 2015;121(18):3343–51.Google Scholar
  56. 56.
    Stephenson LE, Gwyn DG, Reimer RA, Nicole SN: Physical activity and diet behaviour in colorectal cancer patients receiving chemotherapy: associations with quality of life. BMC Gastroenterol. 2009;9(60).
  57. 57.
    Stolley MR, Sharp LK, Tangney CC, Schiffer LA, Arroyo C, Kim Y, et al. Health behaviors of minority childhood cancer survivors. Cancer. 2015;121(10):1671–80.Google Scholar
  58. 58.
    Virtue SM, Manne SL, Kashy D, Heckman CJ, Zaider T, Kissane DW, et al. Correspondence of physical activity and fruit/vegetable consumption among prostate cancer survivors and their spouses. Eur J Cancer Care (Engl). 2015;24(6):827–39.Google Scholar
  59. 59.
    Von Gruenigen VE, Waggoner SE, Frasure HE, Kavanagh MB, Janata JW, Rose PG, et al. Lifestyle challenges in endometrial cancer survivorship. Obstet Gynecol. 2011;117(1):93–100.Google Scholar
  60. 60.
    Wang Z, McLoone P, Morrison DS. Diet, exercise, obesity, smoking and alcohol consumption in cancer survivors and the general population: a comparative study of 16282 individuals. Br J Cancer. 2015;112(3):572–5.Google Scholar
  61. 61.
    Warner EL, Nam GE, Zhang YY, McFadden M, Wright J, Spraker-Perlman H, et al. Health behaviors, quality of life, and psychosocial health among survivors of adolescent and young adult cancers. J Cancer Surviv. 2016;10(2):280–90.Google Scholar
  62. 62.
    Weaver KE, Palmer N, Lu L, Case LD, Geiger AM. Rural-urban differences in health behaviors and implications for health status among US cancer survivors. Cancer Causes Control. 2013;24(8):1481–90.Google Scholar
  63. 63.
    White A, Pollack LA, Smith JL, Thompson T, Underwood JM, Fairley T. Racial and ethnic differences in health status and health behavior among breast cancer survivors--Behavioral Risk Factor Surveillance System, 2009. J Cancer Surviv. 2013;7(1):93–103.Google Scholar
  64. 64.
    Wijndaele K, Lynch BM, Owen N, Dunstan DW, Sharp S, Aitken JF. Television viewing time and weight gain in colorectal cancer survivors: a prospective population-based study. Cancer Causes Control. 2009;20(8):1355–62.Google Scholar
  65. 65.
    Winkels RM, van Lee L, Beijer S, Bours MJ, van Duijnhoven FJB, Geelen A, et al. Adherence to the World Cancer Research Fund/American Institute for Cancer Research lifestyle recommendations in colorectal cancer survivors: results of the PROFILES registry. Cancer Med. 2016;5(9):2587–95.Google Scholar
  66. 66.
    Yaghjyan L, Wolin K, Chang SH, Colditz G. Racial disparities in healthy behaviors and cancer screening among breast cancer survivors and women without cancer: National Health Interview Survey 2005. Cancer Causes Control. 2014;25(5):605–14.Google Scholar
  67. 67.
    Zhang FF, Ojha RP, Krull KR, Gibson TM, Lu L, Lanctot J, et al. Adult survivors of childhood cancer have poor adherence to dietary guidelines. J Nutr. 2016;146(12):2497–505.Google Scholar
  68. 68.
    Zhao GX, Li CY, Okoro CA, Li J, Wen XJ, White A, et al. Trends in modifiable lifestyle-related risk factors following diagnosis in breast cancer survivors. J Cancer Surviv. 2013;7(4):563–9.Google Scholar
  69. 69.
    Hawkes AL, Chambers SK, Pakenham KI, Patrao TA, Baade PD, Lynch BM, et al. Effects of a telephone-delivered multiple health behavior change intervention (CanChange) on health and behavioral outcomes in survivors of colorectal cancer: a randomized controlled trial. J Clin Oncol. 2013;31(18):2313–21.Google Scholar
  70. 70.
    Spring B, Moller AC, Coons MJ. Multiple health behaviours: overview and implications. J Public Health (Oxf). 2012;34(Suppl 1):i3–10.Google Scholar
  71. 71.
    Dalla Via J, Daly RM, Fraser SF. The effect of exercise on bone mineral density in adult cancer survivors: a systematic review and meta-analysis. Osteoporos Int. 2017;28(2):287–303.Google Scholar
  72. 72.
    Drake BF, Quintiliani LM, Sapp AL, Li Y, Harley AE, Emmons KM, et al. Comparing strategies to assess multiple behavior change in behavioral intervention studies. Transl Behav Med. 2013;3(1):114–21.Google Scholar
  73. 73.
    Goodman MS, Li Y, Bennett GG, Stoddard AM, Emmons KM. An evaluation of multiple behavioral risk factors for cancer in a working class, multi-ethnic population. Journal of data science. 2006;4(3):291–306.Google Scholar
  74. 74.
    Kippen R, James E, Ward B, Buykx P, Shamsullah A, Watson W, et al. Identification of cancer risk and associated behaviour: implications for social marketing campaigns for cancer prevention. BMC Cancer. 2017;17(1):550.Google Scholar
  75. 75.
    Rabin C. Review of health behaviors and their correlates among young adult cancer survivors. J Behav Med. 2011;34(1):41–52.Google Scholar
  76. 76.
    Arteaga CL, Adamson PC, Engelman JA, Foti M, Gaynor RB, Hilsenbeck SG, et al. AACR cancer progress report 2014. Clin Cancer Res. 2014;20(19 Supplement):S1–S112.Google Scholar
  77. 77.
    Yaw YH, Shariff ZM, Kandiah M, Mun CY, Yusof RM, Othman Z, et al. Weight changes and lifestyle behaviors in women after breast cancer diagnosis: a cross-sectional study. BMC Public Health. 2011;11:309.Google Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Daniel N Tollosa
    • 1
    • 2
    • 3
    Email author
  • Meredith Tavener
    • 1
    • 2
  • Alexis Hure
    • 1
    • 2
  • Erica L James
    • 1
    • 2
  1. 1.School of Medicine and Public HealthUniversity of NewcastleNewcastleAustralia
  2. 2.Hunter Medical Research InstituteNewcastleAustralia
  3. 3.College of Health Sciences, Public Health DepartmentMekelle UniversityMekelleEthiopia

Personalised recommendations