Lifestyle habits predict long-term health better than cancer treatment history

By Dr. Priyom Bose, Ph.D.Reviewed by Lauren HardakerJun 2 2026

Maintaining a healthy weight and staying physically active may do more to protect childhood cancer survivors from diabetes, heart disease, depression, and poor quality of life than the cancer treatments they received decades earlier. 

Study: Lifestyle habits predict long-term health better than cancer treatment history. Image credit: Pixel-Shot/Shutterstock.com

A recent Nature Communications study assessed the impact of modifiable lifestyle factors on childhood cancer survivors and compared these risks to those associated with chemotherapy and radiotherapy.

Survivors face decades of treatment-related illness

Childhood cancer survival rates in the United States now exceed 85%, resulting in over half a million survivors nationally and up to half a million in Europe. Survivors face elevated risks for treatment-related chronic health conditions (CHCs) such as metabolic syndrome, cardiovascular disease, musculoskeletal disorders, subsequent malignant neoplasms (SMNs), and emotional distress. These complications reduce health-related quality of life (QoL) and increase the risk of premature mortality.

In the general population, adherence to a healthy lifestyle: non-smoking, moderate alcohol intake, maintaining a healthy weight, and regular physical activity, reduces the risk of CHCs, particularly cardiovascular disease. Among childhood cancer survivors, higher physical activity and healthy lifestyle scores are associated with lower mortality. However, the size of lifestyle’s protective effect against treatment-associated CHCs and how this benefit compares with that of non-survivor controls remains unclear.

Assessing lifestyle factors and health outcomes in childhood cancer survivors

The current longitudinal study used data from the Childhood Cancer Survivor Study (CCSS), including survivors diagnosed before age 21 (1970–1999) from 31 North American institutions. Eligible participants were alive five years post-diagnosis, at least 18 years old at follow-up, and had completed at least two questionnaires; sibling controls were included for comparison. Participants were followed longitudinally for a median of 13 years, with lifestyle behaviors assessed repeatedly over time.

Questionnaires collected self-reported data on smoking, alcohol use, body mass index (BMI), and physical activity. Behaviors were scored, where never smoking, low-risk drinking, normal BMI, and sufficient physical activity each received 1 point, and overweight and low activity each earned 0.5. Combined scores (0–4) were classified as unhealthy (0–2), moderately healthy (2.5–3), or healthy (3.5–4).

Each CHC was identified using questionnaires and confirmed with standard grading criteria. Emotional distress was evaluated by a validated protocol. Treatment data (diagnosis, chemotherapy, radiotherapy) from the first five years post-diagnosis were extracted from medical records for analysis.

Associations between lifestyle scores and CHCs were assessed using piecewise exponential models with lifestyle as a time-varying covariate. Emotional distress and QoL were analyzed with repeated-measures logistic regression.

Healthy habits may matter more than treatment

The study included 18,664 survivors, nearly half of whom were women, with a median age of 25 at enrollment and a median follow-up of 13 years. All lifestyle groups were similar in basic demographics and cancer history. However, an unhealthy lifestyle correlated with lower education, income, and insurance rates, and a higher likelihood of being married. Several adverse health outcomes were more common among survivors with less healthy lifestyle scores.

An unhealthy lifestyle was linked to substantially worse long-term health outcomes. Compared with survivors who maintained healthy habits, those with unhealthy lifestyles were 50% more likely to develop high blood pressure and nearly three times as likely to develop diabetes. They also faced a 30% to 80% higher risk of conditions such as abnormal cholesterol levels, heart attack, heart failure, heart valve disease, and joint replacement, while anxiety and depression were up to 80% more common.

The effects extended beyond physical health. Survivors with unhealthy lifestyles were about twice as likely to report poor physical quality of life and 80% more likely to experience poor mental quality of life.

The researchers did not find significant links between the overall lifestyle score and stroke, osteoporosis, subsequent cancers, heart rhythm disorders, or respiratory disease. The association with high blood pressure was strongest among survivors in their 30s, while a potential age-specific pattern for subsequent cancers appeared only among survivors in their 20s, despite no overall association between lifestyle and cancer risk.

Overweight, obesity, and physical inactivity emerged as the strongest drivers of many long-term health problems. Excess body weight was particularly influential, accounting for a substantial share of diabetes cases and contributing to conditions such as high blood pressure, abnormal cholesterol levels, heart disease, heart rhythm disorders, and joint replacement. Meanwhile, low physical activity was most strongly linked to heart failure, respiratory disease, poorer quality of life, and a smaller proportion of subsequent cancers.

Other lifestyle factors played more targeted roles. Smoking was most strongly associated with stroke, osteoporosis, anxiety, and depression, while heavy or risky alcohol consumption was primarily linked to higher risks of stroke and anxiety.

Perhaps most notably, the researchers found that unhealthy lifestyle habits accounted for a larger share of several chronic health conditions, including diabetes, high blood pressure, joint replacement, anxiety, depression, and reduced quality of life, than previous chemotherapy or radiotherapy exposures. Lifestyle-related factors were also linked to a meaningful proportion of heart disease outcomes, highlighting the significant role that modifiable behaviors may play in shaping long-term health after childhood cancer.

Absolute excess risks for diabetes, heart failure, valvular heart disease, arrhythmia, anxiety, depression, and impaired QoL were all higher for survivors with unhealthy or moderately healthy lifestyles compared to siblings. For several outcomes, including diabetes, heart failure, valvular heart disease, anxiety, depression, and impaired quality of life, the potential benefit of a healthy lifestyle appeared greater among childhood cancer survivors than among their siblings, suggesting survivors may have more to gain from lifestyle improvements.

The authors also note that chronic health conditions in childhood cancer survivors are often viewed as a manifestation of accelerated aging, raising the possibility that healthy lifestyle behaviors could help mitigate some of these effects.

Lifestyle changes offer a major prevention opportunity

The current study findings indicate that addressing modifiable lifestyle factors offers a promising opportunity to potentially help reduce chronic health conditions and improve the long-term well-being of childhood cancer survivors. By prioritizing healthy behaviors and supporting survivors with targeted interventions, healthcare providers and communities can help this population achieve better health outcomes and an enhanced QoL. Continued research and collaboration will be essential to ensure that these efforts are effective and sustainable.

The authors note several important limitations. Because lifestyle factors and many health outcomes were self-reported, some conditions may have been underreported. The study was observational and cannot establish cause-and-effect relationships. In addition, population-attributable fractions may differ in populations with different rates of obesity or other lifestyle factors. The findings should therefore be viewed as evidence of the potential benefits of healthy lifestyle behaviors rather than proof that lifestyle changes directly prevent these conditions.

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