Diet and physical activity behaviors: how are they related to illness perceptions, coping, and health-related quality of life in young people with hereditary cancer syndromes?

Individuals with inherited cancer syndromes, such as Li-Fraumeni syndrome (LFS), may be motivated to adopt health-protective behaviors, such as eating more fruits and vegetables and increasing physical activity. Examining these health behaviors among young people with high lifetime genetic cancer risk may provide important insights to guide future behavioral interventions that aim to improve health-related quality of life (HRQOL). We used a self-regulatory framework to investigate relationships among diet and physical activity behaviors and psychosocial constructs (e.g., illness perceptions, coping, HRQOL) in adolescents and young adults (AYAs; aged 15-39 years) with LFS. This longitudinal mixed-methods study included 57 AYAs aged 16-39 years at enrollment), 32 (56%) of whom had a history of one or more cancers. Participants completed one or two telephone interviews and/or an online survey. We thematically analyzed interview data and conducted regression analyses to evaluate relationships among variables. AYAs described adopting healthy diet and physical activity behaviors to assert some control over health and to protect HRQOL. More frequent use of active coping strategies was associated with greater reported daily fruit and vegetable intake. Greater reported physical activity was associated with better quality of psychological health. Healthy diet and physical activity behaviors may function as LFS coping strategies that confer mental health benefits. Clinicians might emphasize these potential benefits and support AYAs in adopting health behaviors that protect multiple domains of health. Future research could use these findings to develop behavioral interventions tailored to AYAs with high genetic cancer risk.

Trajectories and risk factors of fatigue following colorectal cancer diagnosis.

AIM: This study sought to identify groups of colorectal cancer patients based upon trajectories of fatigue and examine how demographic, clinical and behavioural risk factors differentiate these groups. METHOD: Patients were from six cancer centres in the United States and Germany. Fatigue was measured using the fatigue subscale of the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) at five time points (baseline/enrolment and 3, 6, 12 and 24 months after diagnosis). Piecewise growth mixture models identified latent trajectories of fatigue. Logistic regression models examined differences in demographic, clinical and behavioural characteristics between fatigue trajectory groups. RESULTS: Among 1615 participants (57% men, 86% non-Hispanic White, mean age 61 ± 13 years at diagnosis), three distinct groups were identified. In the high fatigue group (36%), fatigue significantly increased in the first 6 months after diagnosis and then showed statistically and clinically significant improvement from 6 to 24 months (P values < 0.01). Throughout the study period, average fatigue met or exceeded cutoffs for clinical significance. In the moderate (34%) and low (30%) fatigue groups, fatigue levels remained below or near population norms across the study period. Patients who were diagnosed with Stage II-IV disease and/or current smokers were more likely to be in the high fatigue than in the moderate fatigue group (P values < 0.05). CONCLUSION: A large proportion of colorectal cancer patients experienced sustained fatigue after initiation of cancer treatment. Patients with high fatigue at the time of diagnosis may benefit from early supportive care.

Reporting Rigor of Cancer Rehabilitation Interventions: Application of the CReDECI-2 Guidelines.

ABSTRACT: Clear reporting of cancer rehabilitation interventions is critical for interpreting and translating research into clinical practice. This study sought to examine the completeness of intervention reporting of cancer rehabilitation interventions addressing disability and to identify which elements are most frequently missing. This was a secondary analysis of randomized controlled trials included in two systematic reviews examining effectiveness of cancer rehabilitation interventions that address cancer-related disability, including functional outcomes. Eligible trials were reviewed for intervention reporting rigor using the Criteria for Reporting the Development and Evaluation of Complex Interventions in Healthcare 2 checklist. Intervention descriptions for cancer rehabilitation interventions were generally incomplete. Approximately 85% ( n = 157) of trials described ≤50% of Criteria for Reporting the Development and Evaluation of Complex Interventions in Healthcare 2 checklist items. Commonly underreported items included description of the intervention's underlying theoretical basis, fidelity, description of process evaluation or external conditions influencing intervention delivery, and costs or required resources for intervention delivery. The findings reveal that cancer rehabilitation intervention descriptions lacked necessary detail in this body of literature. Poor descriptions limit the translation of research to clinical practice. To ensure higher-quality study design and reporting, future intervention research should incorporate an intervention reporting checklist to ensure more complete descriptions for research and practice.

Fatigue as an Understudied Barrier to Participation in Life Roles.

Fatigue is one of the most burdensome and disabling symptoms in numerous acute and chronic conditions and is associated with reduced participation in all aspects of daily life, for example, parenting, employment, and socialization. Historically, occupational practitioners played key roles in fatigue management by creating and implementing interventions. The American Occupational Therapy Foundation convened a Planning Grant Collective workshop with the goal to develop collaborative research ideas and proposals to advance the understanding and management of fatigue. Participants from occupational therapy and other disciplines, with expertise with fatigue or who were conducting research on fatigue, participated in a 3-day virtual workshop. Four main topics emerged: implementation science, treatment taxonomy, trial design and comparative effectiveness, and phenotyping. This white paper describes the proceedings, summarizes the discussions, and outlines recommendations from the PGC workshop on fatigue.

Telehealth Utilization Among Occupational Therapists in Oncology: Results From a National Survey.

While the COVID-19 pandemic introduced wide expansion of telehealth access in health care, evidence concerning telehealth use in occupational therapy (OT) for cancer survivors remains limited. The objective of this study was to identify the prevalence and perceptions of telehealth services among occupational therapy practitioners (OTPs) in oncology. Descriptive statistics and qualitative content analysis were used to analyze data from a pre-pandemic national survey of OTPs (n = 126) focusing on telehealth. Most OTPs in oncology settings support telehealth use, despite a dearth of access prior to the pandemic. The highest levels of telehealth endorsement among OTPs related to ease of accessibility (48%). Treatments rated as best suited for OT oncology telehealth sessions included education (41%), quality of life/well-being/lifestyle (21%), and psychosocial interventions (19%). These data suggest widespread benefits of telehealth-delivered OT treatment in oncology. Advocacy is needed to ensure the continuation of legislation allowing expanded telehealth access and reimbursement for OT.

How do young people with a hereditary cancer predisposition syndrome understand and experience cancer survivorship? "With Li-Fraumeni syndrome, it's just an intermission".

OBJECTIVES: Adolescents and young adult (AYA) cancer survivors face unique medical and psychosocial sequalae, including chronic health conditions, late effects of treatment and fear of recurrence. The meaning of cancer survivorship may be further complicated for AYAs with hereditary cancer predisposition syndromes. This study used a patient-centered framework to investigate how AYAs with Li-Fraumeni syndrome (LFS) consider cancer survivorship. METHODS: An interprofessional team conducted 30 semi-structured interviews with AYAs (aged 18-41, mean 31 years) enrolled in the National Cancer Institute's LFS Study (NCT01443468). Twenty had experienced at least one cancer diagnosis. Interview data were thematically analyzed by an inter-professional team using interpretive description and grounded theory methods. FINDINGS: Participants viewed "survivorship" as a period marked by no evidence of formerly diagnosed disease. By contrast, participants felt the label "survivor" was tenuous since LFS is characterized by multiple primary malignancies and uncertainty about intervals between one diagnosis and the next. Many AYAs viewed survivorship as requiring a high degree of suffering. Though many personally rejected "survivor" identities, almost all articulated its various functions including positive, negative, and more complicated connotations. Instead, they chose language to represent a range of beliefs about survival, longevity, prognosis, and activism. CONCLUSIONS: AYAs with LFS struggle with the term "survivor" due to their multi-organ cancer risk, short intervals between malignancies, and evolving identities. Loved ones' cancer-related suffering informed perspectives on survivorship. Survivorship care for AYAs with cancer risk syndromes requires interprofessional interventions that address their unique biomedical and psychosocial needs.

Loneliness as a risk factor for cancer-related cognitive impairment: a secondary data analysis from the Haze study.

PURPOSE: The purpose of this study was to investigate the association between loneliness and cancer-related cognitive impairment (CRCI) in a cohort of breast cancer survivors. METHODS: Female breast cancer survivors (stage I-III) reporting cognitive impairments 2 months to 5 years after chemotherapy (n = 61) participated in a prospective, nonblinded, waitlist-controlled pilot study. The intervention was a tailored cognitive rehabilitation program. Data were collected pre-/post-intervention. Loneliness was measured using the UCLA Loneliness Scale. Perceived cognitive function was measured using two subscales of the FACT-Cog and two PROMIS - Applied Cognition short forms. Spearman correlation coefficients were calculated to determine the relationship between loneliness and perceived cognitive function (PCF). RESULTS: Participants' loneliness severity was correlated with diminished PCF across all cognitive measures (Spearman r= -0.63 FACT-Cog Perceived Cognitive Impairment, p < 0.0001; r= -0.6 FACT-Cog Perceived Cognitive Abilities, p < 0.0001; r= -0.49 PROMIS Cognitive Ability, p = 0.0002; r = 0.50 PROMIS General Concerns, p = 0.0002). Loneliness scores significantly decreased following participation in the cognitive rehabilitation program in intervention participants as compared to wait-list controls [-5.0 ± 7.24, 95% CI (-8.06, -1.94), p = 0.0025]. CONCLUSIONS: Perceived loneliness was significantly and consistently correlated with PCF. The intervention may have served a dual purpose in both addressing cognitive deficits and loneliness. Additional research dedicated to understanding the association between loneliness and cognitive function, as well as screening for and addressing loneliness in clinical oncology settings, may be warranted. IMPLICATIONS FOR REHABILITATIONScreening for and addressing loneliness in oncology rehabilitation settings is warranted.Rehabilitation professionals are well-positioned to screen for and address loneliness during clinic visits as part of routine cancer rehabilitation care.Group settings may be appropriate for addressing cancer-related cognitive impairment in rehabilitation, as these groups may serve the dual purpose of addressing cognitive impairment and loneliness simultaneously.

Family communication challenges of adolescents and young adults with Li-Fraumeni syndrome: Implications for psychosocial care.

OBJECTIVES: This qualitative-descriptive study explored adolescent and young adult (AYA) perspectives, experiences, and challenges with openness and closedness in family communication about Li-Fraumeni syndrome (LFS). METHODS: We conducted interviews with AYAs (aged 15-39 years) with LFS enrolled in the National Cancer Institute's LFS study (NCT01443468). An interprofessional clinician-researcher team analyzed transcribed data using the constant comparative method and interpretive description. RESULTS: AYAs (N = 38; 26 females, 12 males, mean age=29 years) reported navigating openness and closedness about LFS in their families, which varied by LFS topic, relationship, disease trajectory, and developmental phase. AYAs described communication challenges, including broaching difficult topics (e.g., reproductive decision-making, end-of-life), balancing information-sharing with emotionally protecting family and self, and struggling with interactions that cause relational tensions. CONCLUSIONS: AYAs reported experiencing LFS family communication challenges that disrupted their psychosocial well-being. LFS-related stressors and life transitions complicated and were complicated by these challenging family interactions. PRACTICE IMPLICATIONS: Clinicians may support AYAs with LFS by inquiring about family communication, responding empathically to communication concerns, providing resources to support difficult conversations, and engaging mental health providers as needed. Researchers could partner with AYAs to develop tailored communication skills training and social support tools.

A New Approach to Understanding Cancer-Related Fatigue: Leveraging the 3P Model to Facilitate Risk Prediction and Clinical Care.

A major gap impeding development of new treatments for cancer-related fatigue is an inadequate understanding of the complex biological, clinical, demographic, and lifestyle mechanisms underlying fatigue. In this paper, we describe a new application of a comprehensive model for cancer-related fatigue: the predisposing, precipitating, and perpetuating (3P) factors model. This model framework outlined herein, which incorporates the emerging field of metabolomics, may help to frame a more in-depth analysis of the etiology of cancer-related fatigue as well as a broader and more personalized set of approaches to the clinical treatment of fatigue in oncology care. Included within this review paper is an in-depth description of the proposed biological mechanisms of cancer-related fatigue, as well as a presentation of the 3P model's application to this phenomenon. We conclude that a clinical focus on organization risk stratification and treatment around the 3P model may be warranted, and future research may benefit from expanding the 3P model to understand fatigue not only in oncology, but also across a variety of chronic conditions.

A Molecular Approach to Understanding the Role of Diet in Cancer-Related Fatigue: Challenges and Future Opportunities.

Cancer-related fatigue (CRF) is considered one of the most frequent and distressing symptoms for cancer survivors. Despite its high prevalence, factors that predispose, precipitate, and perpetuate CRF are poorly understood. Emerging research focuses on cancer and treatment-related nutritional complications, changes in body composition, and nutritional deficiencies that can compound CRF. Nutritional metabolomics, the novel study of diet-related metabolites in cells, tissues, and biofluids, offers a promising tool to further address these research gaps. In this position paper, we examine CRF risk factors, summarize metabolomics studies of CRF, outline dietary recommendations for the prevention and management of CRF in cancer survivorship, and identify knowledge gaps and challenges in applying nutritional metabolomics to understand dietary contributions to CRF over the cancer survivorship trajectory.

A qualitative study of online information-seeking preferences among cancer survivors.

PURPOSE: As the cancer survivor population increases, diminished health care provider capacity will place more responsibility on survivors to obtain health information. Many survivors search for cancer information online, yet there is a dearth of research on how survivors obtain and engage with this information. This study examined cancer survivors' information-seeking behaviors and perceptions during a self-guided online search task. METHODS: Ten adult cancer survivors (largely breast and thyroid) completed a task in which they searched for online cancer-related information of their choice. Participants were asked to verbally narrate the procedural aspects of the task and provide real-time responses to the search results and experiences related to the task. Transcripts were analyzed using a qualitative descriptive approach, and codes and themes were examined and interpreted. RESULTS: Participants searched primarily for information specific to their cancer type and stage, seeking personalized information about risk factors, prognosis, and treatments. Additionally, participants reported having to engage in excessive navigation to find relevant cancer information, citing aesthetic, usability, and credibility features of the websites that they considered barriers to obtaining this information. CONCLUSIONS: Survivors' online health information needs require streamlined cancer information resources that are disaggregated by cancer type, stage, and treatment course and located on websites with aesthetic and usability features that facilitate expedient searches for personally relevant cancer information. IMPLICATIONS FOR CANCER SURVIVORS: This study provides useful perspectives of cancer survivors that may inform the development of online cancer resources to better serve this population.

Neuroticism, cancer mortality salience, and physician avoidance in cancer survivors: Proximity of treatment matters.

OBJECTIVE: To examine if the relationship between neuroticism and physician avoidance/physician visit concerns are mediated by perceptions that cancer is associated with death ("cancer mortality salience"; CMS) for cancer survivors to inform public health interventions and tailored health communications. METHODS: Cancer survivors comprised 42.3% of the total sample (n = 525). Participants completed a 4-item neuroticism scale, 4-item cancer perceptions scale, and 4-item physician avoidance and concerns scale. Multiple linear regression models were used to assess relationships among variables for cancer survivors and separately for those without a history of cancer. RESULTS: Neuroticism was positively associated with CMS for cancer survivors, b = 0.26, (p < 0.001), and those without cancer, b = 0.22, (p < 0.001). There was an association between neuroticism and physician avoidance among cancer survivors with temporally distant treatment courses after controlling for CMS, b = 0.56 (p = 0.006), but not for those currently or recently having had undergone treatment (p = 0.949). There was also an indirect relationship between neuroticism and physician visit concerns that was mediated by CMS for cancer survivors, b = 0.07, CI = [0.03, 0.13], but this relationship was again driven by cancer survivors with more distal treatment courses. CONCLUSIONS: High neuroticism in cancer survivors is associated with physician avoidance and physician visit concerns when treatment is temporally distant. Interventions aimed at decoupling the association between cancer and death can help increase the willingness of cancer survivors to attain cancer care follow-ups and healthcare more generally.

Spiritual peace and life meaning may buffer the effect of anxiety on physical well-being in newly diagnosed cancer survivors.

OBJECTIVE: To assess the extent to which spiritual well-being moderates the relationship between anxiety and physical well-being in a diverse, community-based cohort of newly diagnosed cancer survivors. METHODS: Data originated from the Measuring Your Health (MY-Health) study cohort (n = 5506), comprising people assessed within 6-13 months of cancer diagnosis. Life meaning/peace was assessed using the 8-item subscale of the Spiritual Well-Being Scale (FACIT-Sp-12). Anxiety was measured with an 11-item PROMIS Anxiety short form, and physical well-being was assessed using the 7-item FACT-G subscale. Multiple linear regression models were used to assess relationships among variables. RESULTS: Life meaning and peace was negatively associated with anxiety, b = -0.56 (P < .001) and positively associated with physical well-being, b = 0.43 (P = <.001) after adjusting for race, education, income, and age. A significant interaction between life meaning/peace and anxiety emerged (P < .001) indicating that spiritual well-being moderates the relationship between anxiety and physical well-being. Specifically, for cancer survivors high in anxiety, physical well-being was dependent on levels of life meaning/peace, b = 0.19, P < .001. For those low in anxiety, physical well-being was not associated with levels of life meaning/peace, b = 0.01, P = .541. Differences in cancer clinical factors (cancer stage at diagnosis, cancer type) did not significantly impact results. CONCLUSIONS: Further research is needed to assess how spiritual well-being may buffer the negative effect of anxiety on physical well-being. A clinical focus on spiritual well-being topics such as peace and life meaning may help cancer survivors of all types as they transition into follow-up care.

Consensus-Building efforts to identify best tools for screening and assessment for supportive services in oncology.

Purpose: To build consensus around an optimal patient-reported outcome measure of cancer symptoms and patient needs to facilitate patient-provider communication and trigger referrals to supportive services.Methods and materials: The Grid-Enabled Measures platform was used to crowdsource and facilitate collaboration to achieve consensus. Respondents were invited to nominate and independently rate the usefulness of measures that: (1) have been actively used at a healthcare institution, (2) have a multiple choice or yes/no type format, (3) are applicable to adults with cancer, (4) are patient-reported, and 5) have psychometric data if possible. Discussion boards within the GEM workspace allowed respondents to identify barriers to implementing patient assessment and referral systems.Results: 166 individuals from various disciplines from 25 organizations participated. Six instruments were nominated, and 553 rating surveys were submitted. The three most highly-rated overall instruments were the Distress Thermometer, the James Supportive Case Screening, and the Functional Assessment of Cancer Therapy-General. Participants noted that wide-scale implementation of this process requires both identifying problems and providing clinicians with algorithms to facilitate appropriate referrals.Conclusions: Consensus reported three most highly-related measures as optimal for comprehensive screening and identification for referral by assessing multiple domains of functioning and quality of life.Implications for RehabilitationGaining consensus on the best patient reported outcome measures is an important step towards improving access to cancer rehabilitation services.A consensus agreed on several measures to use for cancer rehabilitation screening. Functional Assessment of Cancer Therapy-General, National Comprehensive Cancer. Network Distress Thermometer and the James Instrument.The selected measures do not put undue burden on clinicians and patients.

A qualitative analysis of pressure injury development among medically underserved adults with spinal cord injury.

Purpose: Medically underserved adults with spinal cord injury (SCI) remain at high risk of incurring medically serious pressure injuries even after receiving education in prevention techniques. The purpose of this research is to identify circumstances leading to medically serious pressure injury development in medically underserved adults with SCI during a lifestyle-based pressure injury prevention program, and provide recommendations for future rehabilitation approaches and intervention design.Methods: This study entailed a qualitative secondary case analysis of treatment notes from a randomized controlled trial. Participants were 25 community-dwelling, medically underserved adults with SCI who developed medically serious pressure injuries during the course of the intervention of the RCT.Results and conclusions: Among the 25 participants, 40 unique medically serious pressure injuries were detected. The six themes related to medically serious pressure injury development were: (1) lack of rudimentary knowledge pertaining to wound care; (2) equipment and supply issues; (3) comorbidities; (4) non-adherence to prescribed bed rest; (5) inactivity; and (6) circumstances beyond the intervention's reach. Together, these factors may have undermined the effectiveness of the intervention program. Modifications, such as assessing health literacy levels of patients prior to providing care, providing tailored wound care education, and focusing on equipment needs, have potential for altering future rehabilitation programs and improving health outcomes.Implications for rehabilitationTo provide patients with spinal cord injury with the necessary information to prevent medically serious pressure injury development, health care providers need to understand their patient's unique personal contexts, including socio-economic status, language skills, and mental/cognitive functioning.When providing wound care information to patients with spinal cord injury who have developed a medically serious pressure injury, practitioners should take into account the level of health literacy of their patient in order to provide education that is appropriate and understandable.Practitioners should be aware of how to help their patient advocate for outside services and care that address their equipment needs, such as finding funding or grants to pay for expensive medical equipment.

Embracing the complexity: Older adults with cancer-related cognitive decline-A Young International Society of Geriatric Oncology position paper.

Cancer-related cognitive decline (CRCD) may have particularly significant consequences for older adults, impacting their functional and physical abilities, level of independence, ability to make decisions, treatment adherence, overall quality of life, and ultimately survival. In honor of Dr. Hurria's work we explore and examine multiple types of screening, assessment and non-pharmacologic treatments for CRCD. We then suggest future research and clinical practice questions to holistically appreciate the complexity of older adults with cancer's experiences and fully integrate the team-based approach to best serve this population.

Catalyzing Research to Optimize Cancer Survivors' Participation in Work and Life Roles.

Participation refers to a state of health in which a person is able to fully engage in roles and life situations. Adults living with and beyond cancer often report persistent participation restrictions that affect their productivity and quality of life. The American Occupational Therapy Foundation convened a group of scientists from seven different disciplines in a Planning Grant Collective (PGC) to stimulate research to identify scalable ways to preserve and optimize participation among cancer survivors. Participants identified challenges, prioritized solutions, and generated novel research questions that move beyond symptom and impairment mitigation as outcomes to identify interventions that improve participation in roles and life situations. This article summarizes the PGC discussion and recommendations regarding three challenges: (a) the dynamic and multi-faceted nature of participation, (b) a need to integrate the concept of participation within the culture of oncology, and (c) identification of priority areas in which new lines of research regarding participation would be most impactful.

Factors Protecting Against Pressure Injuries in Medically Underserved Adults With Spinal Cord Injury: A Qualitative Study.

Background: Pressure injuries negatively impact quality of life and participation for individuals with spinal cord injury (SCI). Objective: To examine the factors that may protect against the development of medically serious pressure injuries in adults with SCI. Methods: A qualitative analysis was conducted using treatment notes regarding 50 socioeconomically disadvantaged individuals who did not develop medically serious pressure injuries during a 12-month pressure injury prevention intervention program. Results: Eight types of potentially protective factors were identified: meaningful activity, motivation to prevent negative health outcomes, stability/resources, equipment, communication and self-advocacy skills, personal traits, physical factors, and behaviors/activities. Conclusions: Some protective factors (eg, personal traits) may be inherent to certain individuals and nonmodifiable. However, future interventions for this population may benefit from a focus on acquisition of medical equipment and facilitation of sustainable, health-promoting habits and routines. Substantive policy changes may be necessary to facilitate access to adequate resources, particularly housing and equipment, for socioeconomically disadvantaged individuals with SCI. Further research is needed to understand the complex interplay of risk and protective factors for pressure injuries in adults with SCI, particularly in underserved groups.

The association of health-related quality of life with unmet supportive care needs and sociodemographic factors in low-income Latina breast cancer survivors: a single-centre pilot study.

Purpose: Determine correlations between health-related quality of life (HRQOL), supportive care need, and sociodemographic factors in low-income Latina breast cancer survivors.Methods: A descriptive, survey-based, cross-sectional study was completed with 102 low-income Latina breast cancer survivors at a major public safety net hospital. Correlation coefficients were calculated between number of unmet supportive care needs (per Supportive Care Needs Survey), HRQOL (per SF-36), and sociodemographic variables.Results: Unmet supportive care needs were correlated with lower HRQOL in all domains (r > -0.40; p < 0.0001). Lower income was significantly associated with lower HRQOL (r > 0.21; p < 0.05) and more supportive care needs (r = -0.22; p < 0.05). Multimorbidity was significantly associated with decreased HRQOL (r > -0.23; p < 0.05) and greater supportive care need (r = 0.19; p < 0.05).Conclusions: Identifying and addressing unmet supportive care needs may improve HRQOL in low-income Latina breast cancer survivors. Rehabilitation interventions that address barriers to accessing supportive care related to low SES and multimorbidity may also improve health outcomes in this population. The dual effect of multimorbidity on both quality of life and level of supportive care need in this population warrants further investigation.Implications for rehabilitationScreening for unmet supportive care needs may be an important step in improving health-related quality of life during cancer rehabilitation.Challenges accompanying multimorbidity and lower socioeconomic status may prevent low-income cancer patients from accessing adequate supportive care.Rehabilitation interventions for socioeconomically disadvantaged cancer survivors should compensate for both socioeconomic status and the presence of comorbidities in order to reduce disparities in quality of life during survivorship.