Beyond Survival: The Hidden Impact of Depression on Life After Cancer

Beyond Survival: The Hidden Impact of Depression on Life After Cancer | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Beyond Survival: The Hidden Impact of Depression on Life After Cancer Valeriya Vasenina, Divya Sood, Adam Hanley, Julie Fritz, Erin P. Ward This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7964115/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 07 Jan, 2026 Read the published version in Journal of Cancer Survivorship → Version 1 posted 11 You are reading this latest preprint version Abstract Purpose Depression is common among patients with cancer and is known to worsen quality of life (QoL). However, less is known about how a prior history of depression affects QoL in long-term survivors. This study examined whether cancer survivors with a history of depression report poorer QoL compared to those without depression. Methods Data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative phone-based survey, were analyzed. Adults ≥ 18 years with a history of cancer were stratified by presence of depression. Demographics and QoL indicators—including emotional support, social isolation, cancer-related pain, memory concerns, and ability to complete daily activities—were compared using Chi-square analyses. Results Of 72,765 cancer survivors, 21% reported a history of depression. Compared to non-depressed survivors, those with depression were younger, less likely to be married, and more likely to have lower income, obesity, and smoking (p < 0.001). They reported poorer mental (35% vs. 6%) and physical (34% vs. 15%) health days, lower life satisfaction (15% vs. 3%), reduced emotional support (66% vs. 84%), and greater functional limitations (p < 0.001). Depression prevalence was highest among brain (38%) and gynecologic (36%) cancer survivors. Conclusions Comorbid depression among cancer survivors is strongly associated with poorer QoL across emotional, social, and functional domains. Implications for Cancer Survivors Integrating depression screening and psychosocial interventions into survivorship care is critical to improving long-term well-being and daily functioning. Cancer survivorship Depression Quality of life Psychosocial care Figures Figure 1 Introduction Quality of life (QoL) during and after a diagnosis of cancer is increasingly being recognized as an important metric for understanding the overall well-being and survivorship outcomes. 1 , 2 Depression is a common and impactful comorbidity, affecting an estimated 24% of cancer patients. 3 , 4 While its prevalence is well established, the extent to which depression influences QoL outcomes among cancer survivors remains less clearly defined. Most existing studies examining depression and QoL in cancer populations have been limited to small cohorts or clinical trial settings. 5 , 6 These studies have highlighted that depression can be a significant predictor of poorer QoL, particularly in patients with advanced cancer. 2,7 Importantly, even mild levels of depression have been shown to produce clinically meaningful reductions in health utility values, underscoring the importance of identifying and addressing psychological health needs in survivorship care. 2,8 Despite these findings, few large-scale datasets concurrently capture cancer history, depression history, and multiple domains of QoL. The Behavioral Risk Factor Surveillance System (BRFSS) provides a unique opportunity to bridge this gap. In 2022, the BRFSS introduced expanded items assessing cancer history, cancer type, and depression history, along with comprehensive QoL indicators. 9,10 Leveraging this nationally representative dataset, we aimed to examine whether a history of depression is associated with poorer QoL among cancer survivors, comparing outcomes between those with a history of cancer alone (CA) and those with both cancer and depression (C + D). Methods Study Design and Data Source We utilized data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS), an annual cross-sectional telephone survey conducted by the Centers for Disease Control and Prevention (CDC). The BRFSS collects information on health-related risk behaviors, chronic health conditions, and preventive service use among U.S. adults aged ≥ 18 years. A complex sampling design ensures representation across all 50 states, the District of Columbia, and U.S. territories. 11 Methodological enhancements, including the incorporation of cellular telephone respondents and iterative proportional fitting for weighting, have been implemented to improve the validity and representativeness of prevalence estimates. 9 The 2022 BRFSS included wellness and depression-related questions across all 50 states. Depression was assessed by two primary items: (1) lifetime diagnosis of a depressive disorder, and (2) number of days of poor mental health in the past 30 days. Six additional questions addressed health-related quality-of-life (QoL) and social support (Appendix Table 1). Study Population Eligible participants were adults (≥ 18 years) who provided definitive (“yes” or “no”) responses regarding cancer history and history of depression. Exclusion criteria included: respondents younger than 18 years (n = 165), those missing responses on cancer history (n = 3,628; 0.8%), and those missing responses on depression history (n = 2,405; 0.5%). Variables and Outcomes The primary objective was to compare self-reported QoL outcomes between cancer survivors (CA) and cancer survivors with depression (C + D). QoL indicators included: number of poor mental health days, number of poor physical health days, perceived emotional support, cancer-related pain, and ability to perform activities of daily living (Appendix Table 1). As not all participants completed each QoL item, sample sizes varied by question. Secondary objectives included comparing demographic and social history characteristics between CA and C + D groups. Additionally, we explored variation in depression prevalence across cancer types. Statistical Analysis Descriptive statistics were used to summarize demographic characteristics and QoL measures. Group comparisons of demographic factors and QoL measures were performed using Chi-square tests. A p-value of 0.05 was considered statistically significant and all analysis was completed in Stata SE v19.5 (College Station, Tx). Results Of the 441,339 adults completing the 2022 BRFSS survey, 72,765 (16%) reported a history of cancer and 90,489 (21%) reported a history of depression. Among cancer survivors, 72,443 (99.6%) responded to the depression history item and were included in the analysis. Of these, 14,987 (21%) reported a history of depression (C + D) and 57,456 (79%) reported no depression history (CA). Demographic and socioeconomic differences Significant demographic differences were observed between groups (Table 1 ). Compared to CA survivors, C + D survivors were younger (18–44 years: 10% vs. 4%; p < 0.001), less likely to be married (45% vs. 59%; p < 0.001), and less likely to have graduated college (41% vs. 48%; p < 0.001). Income disparities were also present, with C + D patients more often reporting annual income < $ 50,000 (44% vs. 30%; p < 0.001). Patient’s with C + D were four times more likely to report inability to see a doctor due to cost (12% vs. 3%, Lifestyle factors C + D survivors had higher rates of obesity (36% vs. 26%; p < 0.001) and were more likely to be current smokers (16% vs. 7%; p < 0.001). They were less likely to report recent alcohol use (44% vs. 51%; p < 0.001) and physical activity in the past 30 days (64% vs. 76%; p < 0.001). Overall Health and Life Satisfaction C + D survivors reported poorer general health, with only 58% rating their overall health as excellent, very good or good compared to 78% of CA survivors (p 14 poor mental health days (35% vs. 6%; p 14 poor physical health days (34% vs. 15%; p < 0.001) in the prior 30 days. Dissatisfaction with life was also more common among C + D survivors (15% vs. 3%; p < 0.001). Social and emotional support C + D survivors reported lower levels of consistent emotional support with only 66% reporting always or usually having emotional support vs. 84% of CA patients ( p < 0.001). C + D were five times more likely to report feeling socially isolated “always/usually” (17% vs. 5%; p < 0.001). Functional independence and symptom burden C + D survivors experienced higher rates of cancer-related pain (16% vs. 7%; p < 0.001), cognitive difficulties with memory and decision making (31% vs. 6%; p < 0.001), and limitations in daily functioning. They were more likely to report difficulty dressing/bathing (12% vs. 4%; p < 0.001) and running errands independently (21% vs. 7%; p < 0.001). Depression by cancer type Depression prevalence varied across cancer types (Fig. 1 ). The highest rates were observed among survivors of brain cancer (38%) and gynecologic cancers (36%), compared to lower rates across other cancer types. Discussion This study demonstrates that cancer survivors with a history of depression (C + D) report significantly poorer outcomes across multiple quality-of-life (QoL) domains compared to survivors without depression (CA). Specifically, C + D survivors experienced worse physical and mental health, more negative perceptions of general health, greater social isolation, reduced emotional support, and lower life satisfaction. Functionally, they faced more challenges with activities of daily living and reported higher rates of cancer-related pain. These findings align with prior research highlighting the pervasive impact of depression on cancer survivorship. 2 , 6 For example, Alwhaibi et al. reported that comorbid depression in cancer patients was associated with significantly lower physical and mental health scores on the SF-12, reinforcing its broad effect on well-being. Such vulnerabilities may compound the adverse impact of cancer, particularly for individuals with limited social or financial support. While we also found that rates of depression varied significantly across cancer types—with the highest prevalence among patients with gynecologic and neurologic cancers—the mechanisms driving these differences remain unclear. However, prior literature suggests that certain cancers may carry an elevated risk of new-onset depression. 12 , 13 Neurological involvement in brain tumors, for example, may directly impact emotional regulation. Hartung et al. and Young et al. have documented high levels of depressive symptoms and psychological distress in patients with gliomas, attributing these in part to neurological effects and the poor prognostic implications. 3 , 14 Similarly, gynecologic cancers, particularly ovarian cancer, have been linked to increased depression risk, likely due to hormonal disruptions and emotional burden. 15 , 16 It is plausible that patients with these cancer types could benefit from more intensive screening efforts, as depression may significantly influence cancer-specific outcomes. Major organizations, including the American College of Surgeons Commission on Cancer (CoC) and the American Society of Clinical Oncology (ASCO), recommend routine screening for depression and anxiety in survivorship care, with validated tools and referral pathways for timely intervention. 7 , 17 The National Comprehensive Cancer Network (NCCN) further emphasizes that untreated depression contributes to social isolation, treatment non-adherence, and worse long-term outcomes. 18 Our findings reinforce these recommendations, underscoring the urgent need for systematic psychosocial distress screening and interventions, especially for those with known depression or social vulnerabilities. Taken together, these results add to a growing body of evidence that depression in cancer survivors is not only common but also profoundly consequential, affecting health, social, and functional outcomes. Failure to address depression risks undermining survivorship care and long-term recovery. Several limitations warrant consideration. The cross-sectional nature of the BRFSS precludes causal inference. Cancer and depression diagnoses were self-reported, introducing potential recall bias and misclassification. Moreover, the dataset lacks detail on cancer stage, treatment status, time since diagnosis, and depression severity—all factors that likely influence QoL outcomes. Conclusions This nationally representative study demonstrates that depression among cancer survivors is associated with significantly poorer outcomes across physical, emotional, social, and functional domains. Survivors with comorbid depression reported higher rates of pain, cognitive impairment, social isolation, and barriers to care, alongside clustering of health risk behaviors such as smoking, obesity, and inactivity. These compounded vulnerabilities were especially pronounced among survivors of brain and gynecologic cancers, suggesting the need for targeted screening in high-risk groups. Although limited by its cross-sectional design and reliance on self-reported diagnoses, the large sample size enhances generalizability. Collectively, these findings underscore the urgency of integrating routine depression screening, psychosocial interventions, and lifestyle support into survivorship care to improve long-term outcomes and quality of life for cancer survivors. Declarations Funding None Competing Interests None Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Erin Ward and Valeriya Vasenina. The first draft of the manuscript was written by Erin Ward and Valeriya Vasenina and all authors commented on additional versions of the manuscript. All authors read and approved the final manuscript. Data Availability The datasets generated and analyzed during the current study are available in the Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) 2022 repository, https://www.cdc.gov/brfss/annual_data/annual_2022.html References Alwhaibi M, AlRuthia Y, Sales I. The Impact of Depression and Anxiety on Adult Cancer Patients' Health-Related Quality of Life. J Clin Med. Mar 12 2023;12(6)doi:10.3390/jcm12062196 Grotmol KS, Lie HC, Hjermstad MJ, et al. Depression-A Major Contributor to Poor Quality of Life in Patients With Advanced Cancer. J Pain Symptom Manage. Dec 2017;54(6):889-897. doi:10.1016/j.jpainsymman.2017.04.010 Hartung TJ, Brähler E, Faller H, et al. The risk of being depressed is significantly higher in cancer patients than in the general population: Prevalence and severity of depressive symptoms across major cancer types. Eur J Cancer. Feb 2017;72:46-53. doi:10.1016/j.ejca.2016.11.017 Parajuli J, Berish D, Valenti KG, Jao Y-L. Prevalence and predictors of depressive symptoms in older adults with cancer. Journal of Geriatric Oncology. 2021;12(4):618-622. doi:10.1016/j.jgo.2020.12.009 Ikhile D, Ford E, Glass D, Gremesty G, van Marwijk H. A systematic review of risk factors associated with depression and anxiety in cancer patients. PLoS One. 2024;19(3):e0296892. doi:10.1371/journal.pone.0296892 Lee A, Leong I, Lau G, et al. Depression and anxiety in older adults with cancer: Systematic review and meta-summary of risk, protective and exacerbating factors. Gen Hosp Psychiatry. Mar-Apr 2023;81:32-42. doi:10.1016/j.genhosppsych.2023.01.008 Andersen BL, Lacchetti C, Ashing K, et al. Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update. J Clin Oncol. Jun 20 2023;41(18):3426-3453. doi:10.1200/JCO.23.00293 Fujisawa D, Inoguchi H, Shimoda H, et al. Impact of depression on health utility value in cancer patients. Psychooncology. May 2016;25(5):491-5. doi:10.1002/pon.3945 Hsia J, Zhao G, Town M, et al. Comparisons of Estimates From the Behavioral Risk Factor Surveillance System and Other National Health Surveys, 2011-2016. Am J Prev Med. Jun 2020;58(6):e181-e190. doi:10.1016/j.amepre.2020.01.025 Prevention CfDCa. Methodologic Changes in the Behavioral Risk Factor Surveillance System in 2011 and Potential Effects on Prevalence Estimates. 2012. Hacker K, Thomas CW, Zhao G, Claxton JS, Eke P, Town M. Social Determinants of Health and Health-Related Social Needs Among Adults With Chronic Diseases in the United States, Behavioral Risk Factor Surveillance System, 2022. Prev Chronic Dis. Nov 27 2024;21:E94. doi:10.5888/pcd21.240362 Bach A, Knauer K, Graf J, Schaffeler N, Stengel A. Psychiatric comorbidities in cancer survivors across tumor subtypes: A systematic review. World J Psychiatry. Apr 19 2022;12(4):623-635. doi:10.5498/wjp.v12.i4.623 Linden W, Vodermaier A, Mackenzie R, Greig D. Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age. J Affect Disord. Dec 10 2012;141(2-3):343-51. doi:10.1016/j.jad.2012.03.025 Young JS, Al-Adli N, Sibih YE, et al. Recognizing the psychological impact of a glioma diagnosis on mental and behavioral health: a systematic review of what neurosurgeons need to know. J Neurosurg. Jul 1 2023;139(1):11-19. doi:10.3171/2022.9.Jns221139 Hu S, Baraghoshi D, Chang CP, et al. Mental health disorders among ovarian cancer survivors in a population-based cohort. Cancer Med. Jan 2023;12(2):1801-1812. doi:10.1002/cam4.4976 Horsboel TA, Kjaer SK, Johansen C, et al. Increased risk for depression persists for years among women treated for gynecological cancers - a register-based cohort study with up to 19 years of follow-up. Gynecol Oncol. Jun 2019;153(3):625-632. doi:10.1016/j.ygyno.2019.03.259 Lazenby M, Ercolano E, Grant M, Holland JC, Jacobsen PB, McCorkle R. Supporting commission on cancer-mandated psychosocial distress screening with implementation strategies. J Oncol Pract. May 2015;11(3):e413-20. doi:10.1200/jop.2014.002816 Riba MB, Donovan KA, Andersen B, et al. Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. Oct 1 2019;17(10):1229-1249. doi:10.6004/jnccn.2019.0048 Tables Tables 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files AppendixTable1.docx Tables.docx Cite Share Download PDF Status: Published Journal Publication published 07 Jan, 2026 Read the published version in Journal of Cancer Survivorship → Version 1 posted Editorial decision: Revision requested 02 Dec, 2025 Reviews received at journal 24 Nov, 2025 Reviews received at journal 11 Nov, 2025 Reviewers agreed at journal 10 Nov, 2025 Reviewers agreed at journal 06 Nov, 2025 Reviewers agreed at journal 05 Nov, 2025 Reviewers agreed at journal 03 Nov, 2025 Reviewers invited by journal 30 Oct, 2025 Editor assigned by journal 29 Oct, 2025 Submission checks completed at journal 29 Oct, 2025 First submitted to journal 27 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":92863,"visible":true,"origin":"","legend":"\u003cp\u003eRates of Depression by Cancer Type (N=14, 987)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7964115/v1/e55346fff11cc95690009f2e.png"},{"id":100069157,"identity":"9e25d01e-5930-4d8e-a48d-958c1ef74018","added_by":"auto","created_at":"2026-01-12 16:10:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":461673,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7964115/v1/83e49290-0794-4d90-a949-8399c906559d.pdf"},{"id":95663319,"identity":"4cf9f664-f728-4a70-84c6-c2d9d9333d10","added_by":"auto","created_at":"2025-11-11 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recognized as an important metric for understanding the overall well-being and survivorship outcomes.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Depression is a common and impactful comorbidity, affecting an estimated 24% of cancer patients.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e While its prevalence is well established, the extent to which depression influences QoL outcomes among cancer survivors remains less clearly defined.\u003c/p\u003e\u003cp\u003eMost existing studies examining depression and QoL in cancer populations have been limited to small cohorts or clinical trial settings.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e These studies have highlighted that depression can be a significant predictor of poorer QoL, particularly in patients with advanced cancer. \u003csup\u003e2,7\u003c/sup\u003e Importantly, even mild levels of depression have been shown to produce clinically meaningful reductions in health utility values, underscoring the importance of identifying and addressing psychological health needs in survivorship care. \u003csup\u003e2,8\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eDespite these findings, few large-scale datasets concurrently capture cancer history, depression history, and multiple domains of QoL. The Behavioral Risk Factor Surveillance System (BRFSS) provides a unique opportunity to bridge this gap. In 2022, the BRFSS introduced expanded items assessing cancer history, cancer type, and depression history, along with comprehensive QoL indicators. \u003csup\u003e9,10\u003c/sup\u003e Leveraging this nationally representative dataset, we aimed to examine whether a history of depression is associated with poorer QoL among cancer survivors, comparing outcomes between those with a history of cancer alone (CA) and those with both cancer and depression (C\u0026thinsp;+\u0026thinsp;D).\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy Design and Data Source\u003c/p\u003e\u003cp\u003eWe utilized data from the 2022 Behavioral Risk Factor Surveillance System (BRFSS), an annual cross-sectional telephone survey conducted by the Centers for Disease Control and Prevention (CDC). The BRFSS collects information on health-related risk behaviors, chronic health conditions, and preventive service use among U.S. adults aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years. A complex sampling design ensures representation across all 50 states, the District of Columbia, and U.S. territories. \u003csup\u003e11\u003c/sup\u003e Methodological enhancements, including the incorporation of cellular telephone respondents and iterative proportional fitting for weighting, have been implemented to improve the validity and representativeness of prevalence estimates.\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe 2022 BRFSS included wellness and depression-related questions across all 50 states. Depression was assessed by two primary items: (1) lifetime diagnosis of a depressive disorder, and (2) number of days of poor mental health in the past 30 days. Six additional questions addressed health-related quality-of-life (QoL) and social support (Appendix Table\u0026nbsp;1).\u003c/p\u003e\u003cp\u003eStudy Population\u003c/p\u003e\u003cp\u003eEligible participants were adults (\u0026ge;\u0026thinsp;18 years) who provided definitive (\u0026ldquo;yes\u0026rdquo; or \u0026ldquo;no\u0026rdquo;) responses regarding cancer history and history of depression. Exclusion criteria included: respondents younger than 18 years (n\u0026thinsp;=\u0026thinsp;165), those missing responses on cancer history (n\u0026thinsp;=\u0026thinsp;3,628; 0.8%), and those missing responses on depression history (n\u0026thinsp;=\u0026thinsp;2,405; 0.5%).\u003c/p\u003e\u003cp\u003eVariables and Outcomes\u003c/p\u003e\u003cp\u003eThe primary objective was to compare self-reported QoL outcomes between cancer survivors (CA) and cancer survivors with depression (C\u0026thinsp;+\u0026thinsp;D). QoL indicators included: number of poor mental health days, number of poor physical health days, perceived emotional support, cancer-related pain, and ability to perform activities of daily living (Appendix Table\u0026nbsp;1). As not all participants completed each QoL item, sample sizes varied by question.\u003c/p\u003e\u003cp\u003eSecondary objectives included comparing demographic and social history characteristics between CA and C\u0026thinsp;+\u0026thinsp;D groups. Additionally, we explored variation in depression prevalence across cancer types.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics were used to summarize demographic characteristics and QoL measures. Group comparisons of demographic factors and QoL measures were performed using Chi-square tests. A p-value of 0.05 was considered statistically significant and all analysis was completed in Stata SE v19.5 (College Station, Tx).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 441,339 adults completing the 2022 BRFSS survey, 72,765 (16%) reported a history of cancer and 90,489 (21%) reported a history of depression. Among cancer survivors, 72,443 (99.6%) responded to the depression history item and were included in the analysis. Of these, 14,987 (21%) reported a history of depression (C\u0026thinsp;+\u0026thinsp;D) and 57,456 (79%) reported no depression history (CA).\u003c/p\u003e\u003cp\u003eDemographic and socioeconomic differences\u003c/p\u003e\u003cp\u003eSignificant demographic differences were observed between groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Compared to CA survivors, C\u0026thinsp;+\u0026thinsp;D survivors were younger (18\u0026ndash;44 years: 10% vs. 4%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), less likely to be married (45% vs. 59%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and less likely to have graduated college (41% vs. 48%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Income disparities were also present, with C\u0026thinsp;+\u0026thinsp;D patients more often reporting annual income \u0026lt; \u003cspan\u003e$\u003c/span\u003e50,000 (44% vs. 30%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Patient\u0026rsquo;s with C\u0026thinsp;+\u0026thinsp;D were four times more likely to report inability to see a doctor due to cost (12% vs. 3%,\u003c/p\u003e\u003cp\u003eLifestyle factors\u003c/p\u003e\u003cp\u003eC\u0026thinsp;+\u0026thinsp;D survivors had higher rates of obesity (36% vs. 26%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and were more likely to be current smokers (16% vs. 7%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). They were less likely to report recent alcohol use (44% vs. 51%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and physical activity in the past 30 days (64% vs. 76%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eOverall Health and Life Satisfaction\u003c/p\u003e\u003cp\u003eC\u0026thinsp;+\u0026thinsp;D survivors reported poorer general health, with only 58% rating their overall health as excellent, very good or good compared to 78% of CA survivors (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). They were also more likely to report\u0026thinsp;\u0026gt;\u0026thinsp;14 poor mental health days (35% vs. 6%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and \u0026gt;\u0026thinsp;14 poor physical health days (34% vs. 15%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) in the prior 30 days. Dissatisfaction with life was also more common among C\u0026thinsp;+\u0026thinsp;D survivors (15% vs. 3%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eSocial and emotional support\u003c/p\u003e\u003cp\u003eC\u0026thinsp;+\u0026thinsp;D survivors reported lower levels of consistent emotional support with only 66% reporting always or usually having emotional support vs. 84% of CA patients ( p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). C\u0026thinsp;+\u0026thinsp;D were five times more likely to report feeling socially isolated \u0026ldquo;always/usually\u0026rdquo; (17% vs. 5%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eFunctional independence and symptom burden\u003c/p\u003e\u003cp\u003eC\u0026thinsp;+\u0026thinsp;D survivors experienced higher rates of cancer-related pain (16% vs. 7%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), cognitive difficulties with memory and decision making (31% vs. 6%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and limitations in daily functioning. They were more likely to report difficulty dressing/bathing (12% vs. 4%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and running errands independently (21% vs. 7%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003eDepression by cancer type\u003c/p\u003e\u003cp\u003eDepression prevalence varied across cancer types (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The highest rates were observed among survivors of brain cancer (38%) and gynecologic cancers (36%), compared to lower rates across other cancer types.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrates that cancer survivors with a history of depression (C\u0026thinsp;+\u0026thinsp;D) report significantly poorer outcomes across multiple quality-of-life (QoL) domains compared to survivors without depression (CA). Specifically, C\u0026thinsp;+\u0026thinsp;D survivors experienced worse physical and mental health, more negative perceptions of general health, greater social isolation, reduced emotional support, and lower life satisfaction. Functionally, they faced more challenges with activities of daily living and reported higher rates of cancer-related pain. These findings align with prior research highlighting the pervasive impact of depression on cancer survivorship.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e For example, Alwhaibi et al. reported that comorbid depression in cancer patients was associated with significantly lower physical and mental health scores on the SF-12, reinforcing its broad effect on well-being. Such vulnerabilities may compound the adverse impact of cancer, particularly for individuals with limited social or financial support.\u003c/p\u003e\u003cp\u003eWhile we also found that rates of depression varied significantly across cancer types\u0026mdash;with the highest prevalence among patients with gynecologic and neurologic cancers\u0026mdash;the mechanisms driving these differences remain unclear. However, prior literature suggests that certain cancers may carry an elevated risk of new-onset depression.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e Neurological involvement in brain tumors, for example, may directly impact emotional regulation. Hartung et al. and Young et al. have documented high levels of depressive symptoms and psychological distress in patients with gliomas, attributing these in part to neurological effects and the poor prognostic implications.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Similarly, gynecologic cancers, particularly ovarian cancer, have been linked to increased depression risk, likely due to hormonal disruptions and emotional burden.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e It is plausible that patients with these cancer types could benefit from more intensive screening efforts, as depression may significantly influence cancer-specific outcomes.\u003c/p\u003e\u003cp\u003eMajor organizations, including the American College of Surgeons Commission on Cancer (CoC) and the American Society of Clinical Oncology (ASCO), recommend routine screening for depression and anxiety in survivorship care, with validated tools and referral pathways for timely intervention.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e The National Comprehensive Cancer Network (NCCN) further emphasizes that untreated depression contributes to social isolation, treatment non-adherence, and worse long-term outcomes.\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e Our findings reinforce these recommendations, underscoring the urgent need for systematic psychosocial distress screening and interventions, especially for those with known depression or social vulnerabilities.\u003c/p\u003e\u003cp\u003eTaken together, these results add to a growing body of evidence that depression in cancer survivors is not only common but also profoundly consequential, affecting health, social, and functional outcomes. Failure to address depression risks undermining survivorship care and long-term recovery.\u003c/p\u003e\u003cp\u003eSeveral limitations warrant consideration. The cross-sectional nature of the BRFSS precludes causal inference. Cancer and depression diagnoses were self-reported, introducing potential recall bias and misclassification. Moreover, the dataset lacks detail on cancer stage, treatment status, time since diagnosis, and depression severity\u0026mdash;all factors that likely influence QoL outcomes.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThis nationally representative study demonstrates that depression among cancer survivors is associated with significantly poorer outcomes across physical, emotional, social, and functional domains. Survivors with comorbid depression reported higher rates of pain, cognitive impairment, social isolation, and barriers to care, alongside clustering of health risk behaviors such as smoking, obesity, and inactivity. These compounded vulnerabilities were especially pronounced among survivors of brain and gynecologic cancers, suggesting the need for targeted screening in high-risk groups. Although limited by its cross-sectional design and reliance on self-reported diagnoses, the large sample size enhances generalizability. Collectively, these findings underscore the urgency of integrating routine depression screening, psychosocial interventions, and lifestyle support into survivorship care to improve long-term outcomes and quality of life for cancer survivors.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eNone\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthor Contributions\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Erin Ward and Valeriya Vasenina. The first draft of the manuscript was written by Erin Ward and Valeriya Vasenina and all authors commented on additional versions of the manuscript. All authors read and approved the final manuscript.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eData Availability\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and analyzed during the current study are available in the \u003cstrong\u003eCenters for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) 2022\u003c/strong\u003e repository, https://www.cdc.gov/brfss/annual_data/annual_2022.html\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlwhaibi M, AlRuthia Y, Sales I. The Impact of Depression and Anxiety on Adult Cancer Patients\u0026apos; Health-Related Quality of Life. J Clin Med. Mar 12 2023;12(6)doi:10.3390/jcm12062196\u003c/li\u003e\n\u003cli\u003eGrotmol KS, Lie HC, Hjermstad MJ, et al. Depression-A Major Contributor to Poor Quality of Life in Patients With Advanced Cancer. J Pain Symptom Manage. Dec 2017;54(6):889-897. doi:10.1016/j.jpainsymman.2017.04.010\u003c/li\u003e\n\u003cli\u003eHartung TJ, Br\u0026auml;hler E, Faller H, et al. The risk of being depressed is significantly higher in cancer patients than in the general population: Prevalence and severity of depressive symptoms across major cancer types. Eur J Cancer. Feb 2017;72:46-53. doi:10.1016/j.ejca.2016.11.017\u003c/li\u003e\n\u003cli\u003eParajuli J, Berish D, Valenti KG, Jao Y-L. Prevalence and predictors of depressive symptoms in older adults with cancer. Journal of Geriatric Oncology. 2021;12(4):618-622. doi:10.1016/j.jgo.2020.12.009\u003c/li\u003e\n\u003cli\u003eIkhile D, Ford E, Glass D, Gremesty G, van Marwijk H. A systematic review of risk factors associated with depression and anxiety in cancer patients. PLoS One. 2024;19(3):e0296892. doi:10.1371/journal.pone.0296892\u003c/li\u003e\n\u003cli\u003eLee A, Leong I, Lau G, et al. Depression and anxiety in older adults with cancer: Systematic review and meta-summary of risk, protective and exacerbating factors. Gen Hosp Psychiatry. Mar-Apr 2023;81:32-42. doi:10.1016/j.genhosppsych.2023.01.008\u003c/li\u003e\n\u003cli\u003eAndersen BL, Lacchetti C, Ashing K, et al. Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update. J Clin Oncol. Jun 20 2023;41(18):3426-3453. doi:10.1200/JCO.23.00293\u003c/li\u003e\n\u003cli\u003eFujisawa D, Inoguchi H, Shimoda H, et al. Impact of depression on health utility value in cancer patients. Psychooncology. May 2016;25(5):491-5. doi:10.1002/pon.3945\u003c/li\u003e\n\u003cli\u003eHsia J, Zhao G, Town M, et al. Comparisons of Estimates From the Behavioral Risk Factor Surveillance System and Other National Health Surveys, 2011-2016. Am J Prev Med. Jun 2020;58(6):e181-e190. doi:10.1016/j.amepre.2020.01.025\u003c/li\u003e\n\u003cli\u003ePrevention CfDCa. Methodologic Changes in the Behavioral Risk Factor Surveillance System in 2011 and Potential Effects on Prevalence Estimates. 2012. \u003c/li\u003e\n\u003cli\u003eHacker K, Thomas CW, Zhao G, Claxton JS, Eke P, Town M. Social Determinants of Health and Health-Related Social Needs Among Adults With Chronic Diseases in the United States, Behavioral Risk Factor Surveillance System, 2022. Prev Chronic Dis. Nov 27 2024;21:E94. doi:10.5888/pcd21.240362\u003c/li\u003e\n\u003cli\u003eBach A, Knauer K, Graf J, Schaffeler N, Stengel A. Psychiatric comorbidities in cancer survivors across tumor subtypes: A systematic review. World J Psychiatry. Apr 19 2022;12(4):623-635. doi:10.5498/wjp.v12.i4.623\u003c/li\u003e\n\u003cli\u003eLinden W, Vodermaier A, Mackenzie R, Greig D. Anxiety and depression after cancer diagnosis: prevalence rates by cancer type, gender, and age. J Affect Disord. Dec 10 2012;141(2-3):343-51. doi:10.1016/j.jad.2012.03.025\u003c/li\u003e\n\u003cli\u003eYoung JS, Al-Adli N, Sibih YE, et al. Recognizing the psychological impact of a glioma diagnosis on mental and behavioral health: a systematic review of what neurosurgeons need to know. J Neurosurg. Jul 1 2023;139(1):11-19. doi:10.3171/2022.9.Jns221139\u003c/li\u003e\n\u003cli\u003eHu S, Baraghoshi D, Chang CP, et al. Mental health disorders among ovarian cancer survivors in a population-based cohort. Cancer Med. Jan 2023;12(2):1801-1812. doi:10.1002/cam4.4976\u003c/li\u003e\n\u003cli\u003eHorsboel TA, Kjaer SK, Johansen C, et al. Increased risk for depression persists for years among women treated for gynecological cancers - a register-based cohort study with up to 19 years of follow-up. Gynecol Oncol. Jun 2019;153(3):625-632. doi:10.1016/j.ygyno.2019.03.259\u003c/li\u003e\n\u003cli\u003eLazenby M, Ercolano E, Grant M, Holland JC, Jacobsen PB, McCorkle R. Supporting commission on cancer-mandated psychosocial distress screening with implementation strategies. J Oncol Pract. May 2015;11(3):e413-20. doi:10.1200/jop.2014.002816\u003c/li\u003e\n\u003cli\u003eRiba MB, Donovan KA, Andersen B, et al. Distress Management, Version 3.2019, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. Oct 1 2019;17(10):1229-1249. doi:10.6004/jnccn.2019.0048\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Cancer survivorship, Depression, Quality of life, Psychosocial care","lastPublishedDoi":"10.21203/rs.3.rs-7964115/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7964115/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eDepression is common among patients with cancer and is known to worsen quality of life (QoL). However, less is known about how a prior history of depression affects QoL in long-term survivors. This study examined whether cancer survivors with a history of depression report poorer QoL compared to those without depression.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eData from the 2022 Behavioral Risk Factor Surveillance System (BRFSS), a nationally representative phone-based survey, were analyzed. Adults\u0026thinsp;\u0026ge;\u0026thinsp;18 years with a history of cancer were stratified by presence of depression. Demographics and QoL indicators\u0026mdash;including emotional support, social isolation, cancer-related pain, memory concerns, and ability to complete daily activities\u0026mdash;were compared using Chi-square analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOf 72,765 cancer survivors, 21% reported a history of depression. Compared to non-depressed survivors, those with depression were younger, less likely to be married, and more likely to have lower income, obesity, and smoking (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). They reported poorer mental (35% vs. 6%) and physical (34% vs. 15%) health days, lower life satisfaction (15% vs. 3%), reduced emotional support (66% vs. 84%), and greater functional limitations (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Depression prevalence was highest among brain (38%) and gynecologic (36%) cancer survivors.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eComorbid depression among cancer survivors is strongly associated with poorer QoL across emotional, social, and functional domains.\u003c/p\u003e\u003ch2\u003eImplications for Cancer Survivors\u003c/h2\u003e\u003cp\u003eIntegrating depression screening and psychosocial interventions into survivorship care is critical to improving long-term well-being and daily functioning.\u003c/p\u003e","manuscriptTitle":"Beyond Survival: The Hidden Impact of Depression on Life After Cancer","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 16:29:13","doi":"10.21203/rs.3.rs-7964115/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-02T16:24:47+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-24T06:08:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T06:26:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"103778627058194509247737206347588452887","date":"2025-11-10T10:05:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"285276599623578597645292253454658741095","date":"2025-11-06T13:00:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"201823620854616356313795742782601859480","date":"2025-11-05T16:13:00+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"302806673255479990980153037676051197794","date":"2025-11-03T15:40:48+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-30T14:17:46+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-29T09:30:04+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-29T09:29:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cancer Survivorship","date":"2025-10-27T22:58:07+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cancer-survivorship","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcsu","sideBox":"Learn more about [Journal of Cancer Survivorship](https://www.springer.com/journal/11764)","snPcode":"11764","submissionUrl":"https://submission.nature.com/new-submission/11764/3","title":"Journal of Cancer Survivorship","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"40170b78-bec5-4009-8d09-055ccca29854","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-01-12T16:02:05+00:00","versionOfRecord":{"articleIdentity":"rs-7964115","link":"https://doi.org/10.1007/s11764-025-01962-7","journal":{"identity":"journal-of-cancer-survivorship","isVorOnly":false,"title":"Journal of Cancer Survivorship"},"publishedOn":"2026-01-07 15:57:37","publishedOnDateReadable":"January 7th, 2026"},"versionCreatedAt":"2025-11-11 16:29:13","video":"","vorDoi":"10.1007/s11764-025-01962-7","vorDoiUrl":"https://doi.org/10.1007/s11764-025-01962-7","workflowStages":[]},"version":"v1","identity":"rs-7964115","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7964115","identity":"rs-7964115","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}