As of 2007, nearly 2.6 million individuals were living with a previous diagnosis of breast cancer [1]. Because of advances in early detection and treatment of breast cancer, most women can expect to live many years after a breast cancer diagnosis [2]; approximately 90 % of breast cancer survivors are alive 5 years post-diagnosis [3]. However, breast cancer survivors remain at an increased risk for recurrence, second primary cancers and late effects of treatment, which may have a significant adverse impact on their physical health and quality of life [2]. Healthy behaviors (e.g., physical activity, avoiding alcohol) and maintaining a healthy weight may play significant roles in decreasing the risk for recurrence, mitigating negative impacts of cancer and its treatment for breast cancer survivors [4-10]. In addition, a trial found that physically active breast cancer survivors with high vegetable–fruit intake had an approximate 50 % reduction in risk of mortality [11]. A healthy lifestyle is also important for preventing and/or managing comorbid chronic diseases, such as heart disease or diabetes [12], which are associated with low quality of life and poor survival among breast cancer survivors [13, 14].

Population-based studies of the prevalence of behavioral risk factors in the US (e.g., smoking, physical activity, diet, body mass index, alcohol use, sun protection behaviors) reveal few differences between cancer survivors and non-cancer controls [15, 16]. It is unclear whether this holds true among breast cancer survivors. Previous studies have shown that many breast cancer survivors have physical activity levels below recommendations and low fruit and vegetable consumption [17-19]. Furthermore, after a breast cancer diagnosis, many women reduce their levels of physical activity [18] and experience increased weight and percent body fat [20]. Significant racial and ethnic disparities in diet and physical activity have also been documented among breast cancer survivors [17, 21, 22]. Nevertheless, none of these studies compared breast cancer survivors to non-cancer controls. Further, there are no national prevalence estimates of these risk factors among breast cancer survivors by race/ethnicity, despite evidence of racial and ethnic disparities in early detection, treatment, survival, and quality of life [23, 24]. Differences in health status and health behaviors may explain some of these racial and ethnic disparities.

To address these gaps in the literature, we used data from the Behavioral Risk Factor Surveillance System (BRFSS) to identify racial and ethnic differences in health status and health behavior among female breast cancer survivors. To our knowledge, no population-based studies have specifically focused on these differences among female breast cancer survivors—a group that represents the largest segment of the survivor population. Identifying differences in these factors will help to focus, tailor and prioritize public health interventions for the health and well-being of female breast cancer survivors.

Breast cancer survivors were older (median age, 68 years, range 24–99 years) than females without a history of breast cancer (median age, 55 years, range 18–99 years) at the time of interview. However, the median age at diagnosis for breast cancer survivors was 56 years. Statistically significant differences were observed for most demographic characteristics and health care access indicators by race/ethnicity for breast cancer survivors and females without a history of breast cancer (Table 1).

At the time of interview, the median ages of Hispanic (62.7 years), “other” race (63.8) and black (64.2) female breast cancer survivors were younger than white (68.0) survivors; a smaller proportion of black females were married or in a relationship; and white and “other” race respondents were more likely to have more than a high school education. Compared to all other racial/ethnic groups, Hispanics were more likely to report unemployment (11.1 %) and “other” races were more likely to report being employed (39.3 %). Black and Hispanic breast cancer survivors were more likely to reside in the center city of a metropolitan statistical area (61.1 and 54.4 %, respectively). Fewer Hispanics had their last checkup less than a year prior to interview (75.5 %) (Table 1).

Similar racial and ethnic differences were observed among females without a history of breast cancer, except Hispanics were less likely to have health insurance coverage (67.1 %) or a usual healthcare provider (69.2 %) (Table 1) compared to all other racial/ethnic groups.

In this study, significant racial/ethnic differences in health behaviors and health status were identified among females with a history of breast cancer. Specifically, these differences were observed for obesity, heavy alcohol consumption and smoking. Black long-term breast cancer survivors (diagnosed five or more years before interview) were more likely than any other racial/ethnic group to be obese. Furthermore, more black and “other” race long-term survivors were obese compared to survivors diagnosed less than 5 years before interview. Finally, regardless of whether they had a previous breast cancer diagnosis, white females were more likely to heavily consume alcohol and be former smokers than any other racial/ethnic group. These findings may better inform our understanding of breast cancer disparities, especially for black breast cancer survivors who often experience lower quality of life [33] and poorer survival despite having a lower incidence of disease compared to white women [24].

Racial and ethnic differences in health behaviors and health status among cancer survivors have been documented previously [34]. However, to our knowledge, this is the first population-based study to examine racial/ethnic differences across a broad range of health behaviors and health status among female breast cancer survivors. Our findings are consistent with some results from a population-based study that examined racial/ethnic differences among long-term cancer survivors. Similar to our results, Schootman et al. found fewer black survivors reported heavy alcohol consumption and more black survivors reported a height and weight consistent with being overweight or obese compared to white breast cancer survivors [34]. However, their study found racial/ethnic differences in self-rated health and physical activity, whereas ours did not. These discrepancies in findings are likely due to differences between their study population and ours.

Health behaviors, such as engaging in physical activity, maintaining a healthy weight, not consuming large amounts of alcohol and abstaining from smoking, can aid in reducing the risk for cancer recurrence, secondary primary cancers, and may lead to improved physical health, health status and quality of life [4, 5, 7]. Despite the racial and ethnic differences observed, overall, breast cancer survivors were more likely than females without breast cancer to report positive health behaviors such as not currently smoking, less heavy alcohol consumption, more physical activity and eating five or more servings of fruits and vegetables per day. These findings are encouraging; although, it is unclear how much of the findings are due to a “healthy survivors” bias, whereby the healthiest females are more likely to live after a diagnosis of breast cancer. Furthermore, healthier survivors may be more likely to participate in the telephone survey, while survivors who are less healthy may be unwilling or unable to be interviewed. Therefore, our sample may be more representative of healthy survivors.

Healthy behaviors are also important in preventing or attenuating the effect of many other chronic diseases [35]. In this study, blacks, regardless of having a history of breast cancer, were more likely to report the presence of comorbidities, most commonly hypertension and diabetes, and had the greatest mean number of comorbidities overall. The high prevalence of obesity coupled with the large number of comorbidities among blacks especially highlights the need to target this group for intervention, regardless of breast cancer history. Furthermore, among short-term breast cancer survivors, obesity among blacks is similar to whites, but is increased compared to whites among long-term survivors. These differences in obesity and comorbidities may explain the lower quality life and poor survival following a breast cancer diagnosis observed among blacks compared to whites [12, 14, 33]. Additional research is needed to identify when to and who should counsel breast cancer survivors who may not be practicing healthy habits. Oncologists may provide the initial consultation about healthy behaviors, but longer term survivors may benefit from a coordinated effort with primary care physicians to encourage healthy behaviors [36, 37]. Further research is also needed to identify the factors associated with the racial differences observed in this study in order to develop effective, culturally appropriate interventions to promote health among all females, especially those with a previous breast cancer diagnosis and existing comorbidities.

There were several strengths that support the validity of these findings. First, this dataset included a large population-based sample of breast cancer survivors from all 50 states. Next, guideline-based standards for health behaviors were used allowing comparability with previous studies. Finally, regression analysis was used to explore racial and ethnic differences, thus we were able to adjust for covariates and also present prevalence estimates (predicted marginals) of each outcome for all racial/ethnic groups.

These findings are subject to some limitations. First, due to the low overall median response rates (~35 %), the results may not be generalizable to people who chose not to participate if they substantially differed from those who did participate. Furthermore, due to small numbers, we were unable to report racial sub-categories for “other” race. In addition, this analysis relied on self-reported previous breast cancer diagnoses; as a result, findings may be subject to recall bias and some respondents may have misreported breast cancer history [38]. However, studies have generally found that most BRFSS measures related to health behavior [39], health status [40], physical activity and healthcare access are reliable and valid [41, 42]. Additionally, respondents were asked about their most recent cancer diagnosis and it is possible that some breast cancer survivors were not included. Finally, the BRFSS does not collect any information on tumor characteristics (e.g., stage at diagnosis, grade, and hormone receptor status), phase of care, treatment patterns, recurrence and acculturation, all of which may play a role in health behaviors, health status and quality of life.

In conclusion, racial/ethnic differences in health behaviors were identified and differences varied by time since diagnosis. These findings suggest opportunities for interventions to increase health behaviors and reduce racial disparities among breast cancer survivors [37]. These interventions should be comprised of system, physician and patient components in order to reach patients at different points in the survivorship trajectory, especially those who are most at risk for poor health behaviors, and include other health professionals (e.g., community health workers) and lay health methods that can help patients adopt healthier behaviors following disease diagnosis and treatment.