Functional Disability and Multidimensional Hardship Among Cancer Survivors in the United States: A Nationally Representative Study

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Pawlik This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7437296/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Feb, 2026 Read the published version in Journal of Cancer Survivorship → Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: Functional disability presents an emerging concern among cancer survivors, yet its contribution to long-term hardship has not been well defined. This study assessed the association between functional disabilities and survivor hardship in a nationally representative U.S. cohort. Methods: Data from the 2017–2022 Behavioral Risk Factor Surveillance System (BRFSS) were used to identify adult cancer survivors. Functional disability was defined as self-reported mobility, cognitive, or self-care limitation. Survivor hardship was defined as experiencing ≥2 of the following: inability to work, frequent mental distress (≥14 days/month), cost-related unmet medical care, or physical inactivity. Weighted multivariable logistic regression assessed the association between disability and hardship. Difference-in-differences analysis evaluated the role of Medicaid expansion among low-income survivors. Results: Among 3.57 million weighted survivors, disability prevalence was 28.0% for mobility, 12.9% for cognitive, and 6.4% for self-care disability. Each disability type was independently associated with greater hardship, with cognitive disability demonstrating the strongest association (aOR 4.15, 95% CI 3.03–5.67). Sex-stratified models showed greater hardship among women for cognitive and self-care disability compared with men. Medicaid expansion was not significantly associated with reductions in hardship among low-income cancer survivors. Conclusion: Functional disability is highly prevalent and strongly associated with multidimensional hardship among cancer survivors. Sex-based disparities and socioeconomic vulnerability underscore the need for disability-informed survivorship care and supportive policy. Implications for Cancer Survivors: Functional disability substantially increases the risk of hardship; religiosity-independent policy levers such as targeted rehabilitation, mental health support, and financial navigation may be required to mitigate long-term adverse impacts. BRFSS cancer survivorship disability health disparities functional limitation Medicaid expansion Figures Figure 1 Figure 2 Introduction Cancer survivorship in the United States has risen substantially in recent decades. As of 2025, approximately 18.6 million Americans are living with a history of cancer, a number expected to surpass 22 million by 2035. 1 Advances in early detection and treatment have prolonged survival, allowing more individuals to live longer following a cancer diagnosis. 2 However, many cancer survivors face long-term physical and cognitive sequelae, such as cardiopulmonary complications and “chemo brain,” that can impair daily functioning. 2 As such, functional disability has emerged as a key concern in the growing survivor population. Recent studies indicate that nearly two-thirds of U.S. cancer survivors experience difficulties with routine activities - a rate almost twice that of the general population. 3 Approximately 30% of survivors report serious difficulty walking or climbing stairs, and 7.4% struggle with self-care tasks like dressing or bathing. 4 In addition, nearly half of cancer survivors experience persistent cognitive challenges affecting memory, concentration, and other mental functions. 5 These functional deficits are strongly linked to reduced quality of life and greater hardship among survivors. 6 Despite these concerns, there remains a notable gap in the literature on the full extent and impact of mobility, cognitive, and self-care disabilities among U.S. cancer survivors; particularly regarding their associations with employment disruption, barriers to medical care, and mental health distress. 7 , 8 , 9 The aforementioned patterns highlight the need not only to prolong survival after cancer, but also to improve survivors’ quality of life. 3 However, to date, few studies have comprehensively assessed the burden of specific types of disability or examined their downstream effects on cancer survivors’ well-being. Therefore, the objective of the current study was to evaluate the prevalence and impact of functional disability among U.S. cancer survivors between 2017 and 2022. We introduced a composite “survivor hardship” metric and examined disability-specific associations with employment, mental health, access to care, and physical activity. Methods Data source, cohort selection, and outcomes This crosssectional analysis used pooled data from the 2017–2022 Behavioral Risk Factor Surveillance System (BRFSS), an annual, statebased telephone survey administered by the Centers for Disease Control and Prevention that samples noninstitutionalized U.S. adults aged ≥ 18 years. 10 BRFSS employs a complex, multistage probability design; all estimates were calculated with the CDCsupplied sampling weights, strata, and primary sampling units to yield nationally representative results. Among 2,591,503 respondents in the analytic sample, cancer survivors were identified using self-reported cancer diagnosis. We excluded respondents with incomplete state residence data (necessary to apply survey weights correctly) and individuals with missing responses on all four primary survivorship outcomes (unable to work, ≥ 14 days of poor mental health, costrelated unmet medical need, no leisuretime physical activity), as their hardship status could not be assessed. Functional disability was assessed based on three standardized BRFSS questions, each recoded as a binary indicator (1 = "yes", 0 = "no"). These included: cognitive disability ("Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?"), mobility disability ("Do you have serious difficulty walking or climbing stairs?"), and selfcare disability ("Do you have difficulty dressing or bathing?"). Participants who reported more than one limitation were included in each corresponding disability category. For example, respondents with both mobility and cognitive disability were counted in both respective groups for stratified analyses. The primary outcomes of interest were four adverse survivorship indicators: (1) selfreported inability to work because of health 1 1, 1 2 ; (2) experiencing ≥ 14 days of poor mental health in the past 30 days 1 3 ; (3) needing but being unable to obtain medical care due to cost 1 4 ; and (4) no reported leisuretime physical activity in the past month. 15 A composite “survivor hardship” outcome was constructed and defined as reporting ≥2 adverse survivorship indicators, allowing for an assessment of cumulative burden among cancer survivors. The selection of these indicators for “hardship” were based on previous studies of cancer survivor health, aligning with established survey metrics and outcomes. 1 6 , 17 Each indicator represented a critical domain of survivorship, and together the factors provided a comprehensive picture of post-cancer hardship as documented in oncologic and public health research. 18 This study used publicly available and de-identified and was deemed exempt by The Ohio State University Institutional Review Board. Covariates Demographic covariates included age (< 65, ≥ 65 years), sex assigned at birth (male, female), and race/ethnicity (White, Black, Hispanic, Asian, Native American, Other). Educational attainment was categorized as less than high school, high school diploma or some college, and college degree or above. Residence was classified as urban or rural, and marital status as married or not married. Annual household income was grouped as < $ 25,000, $ 25,000– $ 74,999, and ≥ $ 75,000. 19 Health-related covariates included insurance status (uninsured, government-sponsored, private), presence of comorbidities (diabetes, heart disease, chronic obstructive pulmonary disease, stroke, and arthritis), and age at cancer diagnosis (< 40, 40–50, 51–64, ≥ 65 years). Access to care variables comprised having had a primary care visit in the past year and living in a Medicaid-expansion state. Statistical Analysis Descriptive statistics for categorical variables were presented as frequencies and percentages (%) and were analyzed using the Chi-square test or Fisher's exact test, as appropriate. Continuous variables were reported as median values with interquartile ranges (IQR); comparisons between groups were conducted using the Kruskal-Wallis test. All weighting, clustering, and stratification variables supplied by BRFSS were applied in accordance with CDC guidance to generate nationally representative estimates. Associations between each disability domain and the four adverse survivorship outcomes: unable to work, ≥ 14 days of poor mental health, costrelated unmet medical need, and no leisure time physical activity, were examined using weighted multivariable logisticregression models. Separate models were fit for (1) cognitive, (2) mobility, and (3) selfcare disability, as well as for the composite survivor hardship outcome. Each model was adjusted for the full set of covariates outlined above. Variables with 15 % missing data were excluded from regression analyses. Adjusted odds ratios (aORs) with95 % CIs were reported. To evaluate the policy level impact of Medicaid expansion on disabilityrelated hardship among economically vulnerable survivors, a differenceindifferences (DID) framework compared changes in hardship risk between residents of expansion versus nonexpansion states, restricting the analysis to respondents with annual household income < $ 25,000. The DID models included interaction terms for disability type, Medicaidexpansion status, and survey year, and were adjusted for age, sex, race/ethnicity, educational attainment, insurance type, and primarycare access. All tests were twosided and pvalues < 0.05 were considered statistically significant. All analyses were conducted in Stata 18 (StataCorp, College Station, TX). Results Baseline Characteristics Among 2,591,503 respondents included in the unweighted sample, 26,864 (1.0%) were self-reported cancer survivors. Cancer survivors were older than the general population (62 years [IQR: 53–73] vs. 58 years [IQR: 41–69). Cancer survivors were more frequently female (65.6% vs. 53.8), White (81.3% vs. 75.7%;), rural residents (26.4% vs. 23.0%; p < 0.001), and publicly insured (30.6% vs. 15.6%) compared with the general population (all p < 0.001). Of note, a higher prevalence of self-care, mobility, and cognitive disabilities was observed in the Southeast and Appalachian states, whereas rates were markedly lower across the Mountain West and Upper Midwest (Fig. 1 ). Overall, functional limitations were much more common among cancer survivors than the general population, including mobility disability (28.0% vs. 15.9%), cognitive disability (12.9% vs 10.5%), and self-care disability (6.4% vs 4.0%) (all p < 0.001, eTable 1 ). Following application of survey weights, the estimated cancer survivor cohort included 3,570,518 adults. Within this weighted group, mobility disability was the most prevalent (n = 999,362, 28.0%), followed by cognitive (n = 462,308, 12.9%) and self-care disability (n = 227,696, 6.4%). Notably, survivors reporting mobility disability were more frequently diagnosed < 40 years old (n = 362,691, 36.2%) compared with self-care (72,485, 31.7%) or cognitive disability (n = 123,158, 26.6%) (p < 0.001, Table 1 ). Respondents with low household incomes (< $ 25,000) more frequently reported self-care disability (n = 60,116, 26.4%) versus cognitive (n = 112,385, 24.2%) and mobility disability (n = 209,741, 20.9%) (p < 0.001). Additionally, recent primary care visits were common among all disability types, although slightly less frequent among individuals with cognitive disability (n = 403,522, 87.3%) compared with mobility disability (n = 908,390, 90.1%) and self-care disability (n = 201,761, 91.1%) (p < 0.001). National cancer type estimates among survivors are detailed in Table 1 . Table 1 Weighted characteristics of cancer survivors by disability domain. Characteristics Cancer survivors (n = 3,570,518) Self-care disability 1 (n = 227,696, 6.4%) Mobility disability 2 (n = 999,362, 28.0%) Cognitive disability 3 (n = 462,308 12.9%) p value Age, years < 0.001 65 2,372,853(66.4) 135,394(59.5) 699,580(70.0) 233,149(50.4) Sex < 0.001 Male 1,228,258(34.4) 72,407 (31.8) 296,810 (29.7) 130,370(28.2) Female 2,342,259(65.6) 155,289(68.2) 702,551 (70.3) 331,937(71.8) Ethnicity < 0.001 White 2,903,656(81.3) 161,329(70.9) 768,873(76.9 341,012 (73.8) Black 233,149(6.5) 22,743(9.7) 80,332(8.0) 33,250 (7.1) Asian 66,766(1.8) 3,724(1.3) 16,093(1.6) 8,379 (1.7) Native American 71,953(2.0) 9,310(4.0) 28,329(2.8) 17,822 (3.7) Hispanic 190,988(5.3) 21,945(9.3) 70,756(7.0) 42,560 (9.1) Other 106,400(3.0) 8,645(3.5) 34,979(3.4) 19,285 (4.1) Area < 0.001 Urban 2,116,562(59.3) 123,690(54.2) 555,009(55.6) 249,774 (53.9) Rural 942,039(26.4) 65,835(28.6) 284,354(28.4) 136,857 (29.4) Level of education < 0.001 Less than high school 207,879 (5.8) 30,324(13.2) 103,607(10.3) 61,712 (13.2) High school/ some college 1,945,125(54.5) 139,783(61.2) 626,297(62.7) 296,191 (64.1) ≥ College degree 1,412,593(39.6) 56,924(24.7) 266,532(26.6) 102,942 (22.1) Annual household income ($) < 0.001 75,000 462,707(12.9) 10,640(4.40) 56,259 (5.6) 21,945 (4.5) Marital status < 0.001 Married 1,825,425(51.1) 79,401(34.8) 380,912 (38.0) 169,575 (36.6) Comorbidities < 0.001 Diabetes 2,821,329(79.0) 79,534(34.8) 322,658 (32.2) 131,138 (28.4) Heart disease 367,878(10.3) 44,555(19.4) 174,097 (17.4) 66,766 (14.3) COPD 525,616(14.7) 77,539(33.9) 276,640 (27.6) 128,079 (27.7) Stroke 258,685(7.2) 42,826(18.5) 135,261(13.5) 64,239 (13.9) Arthritis 1,849,365(51.8) 173,033(76.2) 737,618(73.7) 307,762 (66.5) Age at diagnosis, years < 0.001 ≥ 65 563,255(15.8) 52,801(22.9) 169,176(16.9) 129,808 (27.9) 51–64 649,705(18.2) 38,969(16.7) 159,068(15.9) 83,258 (18.0) 40–50 1,213,625(34.0) 63,441(27.8) 308,427(30.8) 126,084 (27.3) < 40 1,146,327(32.1) 72,485(31.7) 362,691(36.2) 123,158 (26.6) Treatment status Completed 470,421(13.2) 39,501(17.2) 149,359(14.9) 70,490 (15.2) < 0.001 Primary care visit Had PCP visit (past year) 3,203,172(89.7) 201,761(91.1) 908,390(90.1) 403,522 (87.3) < 0.001 Health insurance status Uninsured 16,891 (0.4) 1,330(0.6) 5,719(0.5) 4,256(0.9) < 0.001 Government insurance 1,092,063(30.6) 82,726(36.1) 356,440(35.6) 156,674(34.2) Private 442,092(12.4) 16,625(7.0) 73,815(7.3) 44,023(9.9) State Medicaid Expansion Status Yes 2,908,577(81.5) 182,742(80.2) 796,803(79.7) 362,206(78.4) < 0.001 Cancer types Brain 26,467(0.7) 3,325 (1.32) 9,975 (1.0) 9,177 (1.9) < 0.001 Breast 1,265,628(35.4) 66,500 (29.0) 338,219 (33.8) 134,596 (29.0) < 0.001 Lung 183,407(5.1) 15,694 (6.6) 77,539 (7.7) 30,856(6.7) < 0.001 Thyroid 186,732(5.21) 11,837 (4.8) 43,890 (4.3) 21,413 (4.5) < 0.001 Esophagus 25,403 (0.7) 1,862 (0.4) 7,847 (0.7) 5,054 (1.0) < 0.001 Stomach 27,398 (0.9) 1,995 (0.8) 9,576 (1.0) 4,788 (1.0) < 0.001 Liver 34,447 (1.0) 3,742 (1.6) 13,034 (1.3) 7,049 (1.5) < 0.001 Colon 310,156 (8.6) 19,817 (8.3) 95,760 (9.5) 43,890 (9.2) < 0.001 Rectal 32,585 (1.1) 2,527 (1.1) 9,709 (1.0) 4,655 (1.0) < 0.001 Kidney 119,833 (3.3) 9,709 (4.3) 40,432 (4.0) 16,492 (3.4) < 0.001 Cervical 269,591 (7.5) 27,664 (11.8) 88,977 (8.9) 73,017(15.7) < 0.001 Ovarian 109,858 (3.0) 9,044 (4.0) 33,915 (3.3) 19,551(4.1) < 0.001 Endometrial 179,018 (5.0) 11,704 (4.8) 61,978(6.1) 24,472(5.1) < 0.001 Prostate 789,621 (22.1) 38,969 (26.7) 164,388(16.4) 64,904(13.7) < 0.001 1 Mobility disability defined as self-reported serious difficulty walking or climbing stairs. 2 Cognitive disability defined as serious difficulty concentrating, remembering, or making decisions due to a physical, mental, or emotional condition. 3 Self-care disability defined as difficulty dressing or bathing. Association between Functional Limitations and Cancer Survivorship Indicators Cancer survivors with self-care disability and mobility disability demonstrated approximately 7-fold (aOR 6.92, 95%CI 5.10–7.31) and 6-fold (aOR 5.50, 95%CI 5.10–8.73) increased likelihood of being unable to work, respectively, whereas cognitive disability was associated with a lower risk for inability to work (aOR 3.27, 95%CI 2.72–3.92). Of note, cognitive disability among cancer survivors was associated with 310% (aOR 4.10, 95% CI 3.55–4.68) greater odds of poor mental health, followed by self-care (aOR 2.62, 95% CI 2.18–3.14) and mobility disability (aOR 1.94, 95% CI 1.75–2.15). All three functional disability types were associated with an approximately two-fold increased likelihood of unmet medical needs due to cost. Furthermore, the association of mobility disability (aOR 3.44, 95% CI 3.10–3.81) and self-care disability (aOR 2.97, 95% CI 2.47–3.57) with low activity levels was greater than the association between cognitive disability and physical activity levels (aOR 1.78, 95% CI 1.55–2.03). Regarding the composite outcome, multivariable analysis demonstrated that cognitive disability was associated with 315% higher odds of survivor hardship (aOR 4.14, 95% CI 3.03–5.67), whereas self-care and mobility disability were associated with a three-fold (aOR 2.65, 95% CI 1.81–3.88) and two-fold (aOR 2.10, 95% CI 1.65–2.58) greater likelihood of survivor hardship, respectively (all p < 0.001, Table 2 ). Table 2 Adjusted Odds Ratios (95% CI) for Unemployment, Mental Health Burden, and Cost barrier and physical activity level by Disability Domain Self-care disability aOR (95% CI) Mobility disability aOR (95% CI) Cognitive disability aOR (95% CI) No Yes No Yes No Yes Employment Unable to work Ref. 6.92 (5.10–7.31) Ref. 5.50(5.10–8.73) Ref. 3.27(2.72–3.92) Mental health burden Poor mental health Ref. 2.62(2.18–3.14) Ref. 1.94(1.75–2.15) Ref. 4.10(3.55–4.68) Cost barrier Unmet medical need Ref. 1.92(1.50–2.50) Ref. 1.92(1.62–2.28) Ref. 2.34(1.94–2.84) Physical activity level Low activity (no leisure-time exercise) Ref. 2.97(2.47–3.57) Ref. 3.44(3.10–3.81) Ref. 1.78(1.55–2.03) Survivor hardship* Ref. 2.65(1.81–3.88) Ref. 2.10(1.65–2.58) Ref. 4.15(3.03–5.67) * “Hardship” means the survivor reported at least two of the following problems in the past year: unable to work, frequent poor mental-health days, skipping needed medical care because of cost, or no leisure-time physical activity all p < 0.001 Models adjusted for age, sex, race/ethnicity, education, marital status, residence, income, insurance type, comorbidities, primary care access, treatment status, and age at cancer diagnosis. Association between various factors and survivor hardship Several sociodemographic factors independently predicted greater survivor hardship (Table 3 ). Multivariable analysis, after adjusting for relevant factors, demonstrated that older age at cancer diagnosis (≥ 65 years) was associated with greater odds for hardship among respondents with self-care (aOR 1.42, 95%CI 1.16–1.63), mobility (aOR 1.54, 95%CI 1.14–1.88), and cognitive disability (aOR 1.69, 95% CI 1.20–2.13). Furthermore, female survivors with self-care and cognitive disability demonstrated 16% (aOR 1.16, 95%CI 1.02–1.31) and 13% (aOR 1.13, 95%CI 1.04–1.27) increased odds of survivor hardship compared with male cancer survivors, respectively, yet 11% lower odds for hardship when reporting mobility disability (aOR 0.89, 95%CI 0.75–0.97). Of note, household income ≥ $ 75,000 was consistently associated with decreased likelihood for survivor hardship, across all functional disability types (all p < 0.001). A recent primary-care visit was associated with approximately 55–60% lower odds of survivor hardship among survivors with mobility disability (aOR 0.40, 95%CI 0.25–0.64), self-care disability (aOR 0.42, 95%CI 0.26–0.66), and cognitive disability (aOR 0.45, 95%CI 0.28–0.71) (Table 3 ). Interestingly, private insurance was associated with 65–70% lower odds of survivor hardship among cancer survivors with cognitive (aOR 0.35, 95%CI 0.26–0.46), self-care (aOR 0.35, 95%CI 0.26–0.48) and mobility disability (aOR 0.40, 95%CI 0.30–0.53). Table 3 Adjusted Odds of Survivor Hardship Among Cancer Survivors, by Type of Functional Disability Self-care disability b aOR a (95% CI) Mobility disability b aOR a (95% CI) Cognitive disability b aOR a (95% CI) Age at diagnosis < 40 Ref. Ref. Ref. 40–50 1.22(0.92–1.45) 1.39(0.84–1.94) 1.42(0.77–1.98) 51–64 1.25(0.74–1.51) 1.21(0.61–1.84) 1.34(0.64–1.75) ≥ 65 1.42(1.16–1.63) 1.54(1.14–1.88) 1.69(1.20–2.13) Sex at birth Male Ref. Ref. Ref. Female 1.16(1.02–1.31) 0.89(0.75–0.97) 1.13(1.04–1.27) Level of education Less than high school Ref. Ref. Ref. High school/ some college 1.2(0.75–1.93) 1.25(0.77–2.02) 1.40(0.78–2.45) College degree or higher 0.80(0.46–1.30) 0.86(0.50–1.49) 0.92(0.491.70) Income category Low income (< $ 25,000) Ref. Ref. Ref. Middle income ( $ 25k– $ 75k) 0.40(0.27–0.58) 0.44(0.31–0.62) 0.44(0.29–0.64) High income (≥ $ 75,000) 0.20(0.12–0.33) 0.24(0.14–0.40) 0.22(0.13–0.39) Marital status Unmarried Ref. Ref. Ref. Married 0.88(0.62–1.26) 0.91(0.65–1.29) 0.94(0.65–1.37) Primary care visit No PCP visit (past year) Ref. Ref. Ref. Had PCP visit (past year) 0.42(0.26–0.66) 0.40(0.25–0.64) 0.45(0.28–0.71) Treatment status Not completed Ref. Ref. Ref. Completed 1.16(1.01–1.32) 1.20(1.02–1.46) 1.22(1.05–1.42) Health insurance coverage Uninsured Ref. Ref. Ref. Government sponsored 0.71(0.57–0.88) 0.67(0.54–0.82) 0.69(0.55–0.87) Private insurance 0.35(0.26–0.48) 0.40(0.30–0.53) 0.35(0.26–0.46) State Medicaid Expansion Status No Ref. Ref. Ref. Yes 1.15 (0.66–2.00) 1.18 (0.81–1.72) 0.90 (0.61–1.32) Abbreviations : aOR, adjusted odds ratio; CI, confidence interval; PCP, primary care provider; Ref, reference. Footnotes : a. Adjusted odds ratios were derived from survey-weighted multivariable logistic regression models. b. Models adjusted for: age at diagnosis, sex at birth, education, household income, marital status, residence (urban vs. rural), insurance type, comorbidities (diabetes, heart disease, COPD, stroke, arthritis), primary care access, treatment status, and state Medicaid expansion status. Survivor hardship was defined as reporting ≥ 2 of the following: (1) unable to work due to health; (2) ≥ 14 days of poor mental health in past month; (3) cost-related unmet medical need; (4) no leisure-time physical activity. State Medicaid expansion status was not associated with survivor hardship in the overall cohort. Among low-income cancer survivors, increases of disability-related hardship were smaller among respondents in Medicaid expansion states compared with non-expansion states, demonstrating interesting, but non-significant trends (difference-in-differences: self-care disability − 2.8%, mobility disability − 2.0%, cognitive disability − 1.8%; all p > 0.05; eTable 2 ). Sex Differences in Disability-Related Survivor Hardship Of note, women with cognitive disability exhibited higher adjusted probability of hardship compared with men (51.0% vs. 47.4%; difference + 3.6%, p < 0.001). Similarly, female cancer survivors reporting self-care disability demonstrated 4.4% greater survivor hardship probabilities than male survivors (46.4% vs. 42.1%; difference + 4.4%, p < 0.001) ( eTable 3 ). On the contrary, among survivors with mobility disability, women demonstrated 1.7% lower probability of experiencing survivor hardship compared with men (19.0% vs. 20.7%; difference − 1.7%, p < 0.001). ( Fig. 2 a, 2 b, 2 c ) These findings underscore important sex-based disparities in disability-associated hardship among cancer survivors. Discussion As cancer survivorship continues to grow in the U.S., attention has shifted towards quality of life among survivors, particularly in light of evidence that nearly two-thirds of U.S. cancer survivors report difficulties with routine activities. 3 , 20 Functional impairments in mobility, self-care, or cognition can substantially affect a survivor’s quality of life, by limiting daily functioning and contributing to various downstream hardships. 21 , 22 The current study was important because it was the first nationally representative analysis to assess specific types of functional disability and their associations with survivorship hardship among U.S. cancer survivors, using BRFSS data from 2017 to 2022. The data demonstrated that mobility, self-care, and cognitive disabilities were associated with various hardship indicators, as well as with a composite survivorship hardship metric. Of note, female survivors with disabilities experienced a greater burden of hardship than their male counterparts, suggesting that gender influenced how disability affected quality of life among cancer survivors. These findings highlight the multifaceted challenges faced by survivors living with disability and underscore the the need to not only prolong cancer survival, but to actively support the well-being and daily functioning among those who survive. Understanding how different disability types affect survivor hardship is key to guide care and improve the quality of life among cancer survivors. Of note, survivors who reported serious difficulty concentrating, remembering, or making decisions had higher rates of frequent mental distress, consistent with evidence that cancer related cognitive impairment (“chemo brain”) can exacerbate mood and anxiety disorders. 23 Clinically, these data highlight the need for routine cognitive and psychological screening, alongside interventions like cognitive rehabilitation and counseling. Interestingly, cancer survivors with mobility limitations were more likely to be unable to work or exercise, reflecting prior findings linking physical impairment to job loss, prolonged unemployment, and reduced activity. 24 As such, integrating physical therapy, tailored exercise programs, and vocational rehabilitation into survivorship care serves a dual goal of improving functional capacity and maintaining engagement in work and recreation. 25 Meanwhile, self-care disability among cancer survivors was associated with cost-related unmet healthcare needs and work limitations. Self-care impairment often reflects high dependency - survivors requiring home health services, caregiving support, and assistive devices - and financial barriers due to increased medical needs and out-of-pocket costs. 26 Addressing these challenges requires coordinated care involving oncology, primary care, rehabilitation, social work, and home health services. 27 Overall, a “disability-informed” approach tailored to each cancer survivor’s functional status is critical towards advancing patient-centered care. Understanding demographic and socioeconomic factors is essential to contextualize these disparities, as they may shape both the experience and reporting of survivorship hardship. In the current study, female cancer survivors with self-care or cognitive disabilities were more likely to experience survivorship hardship compared with male survivors (self-care: 46.4% vs. 42.1%; cognitive: 51.0% vs. 47.4%; eTable 3 ). These disparities likely stem from a combination of biological, social, and behavioral factors. For instance, women are more frequently prescribed certain cancer treatments, such as endocrine therapy, that can impair cognitive and physical functioning. 28 Furthermore, women often face disproportionate caregiving responsibilities, which may cause additional emotional and practical distress, particularly when self-care ability is also compromised. 29 Of note, financial vulnerability, including lower average incomes and fewer resources among women may further exacerbate the impact of disability on work and access to care. 30 , 31 In contrast, hardship associated with mobility limitations was more pronounced among male survivors (20.7% vs. 19.0%; p = 0.0004), potentially reflecting stronger ties between physical independence and identity in men. Men may also be less likely to seek or engage with supportive services like physical therapy or counseling, in turn experiencing greater hardship burden when mobility is impaired. 32 These findings highlight the importance of incorporating sex-specific considerations into survivorship care. As such, female survivors might benefit from early cognitive rehabilitation, structured mental health interventions, and caregiver resources, while male survivors may require proactive mobility screening, tailored physical rehabilitation, and interventions to promote the use of supportive services. Overall, integrating sex-sensitive functional assessments and interventions within survivorship care could help improve equitable outcomes among cancer survivors. Beyond clinical care, our findings carry important policy implications. Of note, Medicaid expansion was not associated with decreased survivor hardship, highlighting that insurance coverage alone cannot mitigate the complex needs of survivors with disabilities. 26 Many individuals require extended rehabilitation, long-term mental health care, assistive devices, or in-home services that are often under-covered and financially inaccessible. As such, routine functional assessments, akin to distress screening, should be integrated to oncology and survivorship care to facilitate timely intervention. 33 Coverage policy must ensure that multidisciplinary rehabilitation - including physical, occupational, cognitive, psychosocial services - is covered as an essential benefit across Medicare, Medicaid, and private insurers. 34 Disability-inclusive care models that embed rehabilitation specialists and care coordinators within oncology teams, along with survivorship plans outlining workplace and home accommodations, can help close critical care gaps. 35 Broader system level reforms are also important, including anti-ableist care standards, expanded eligibility for disability benefits, employment protections, and publicly-funded community exercise and vocational programs. 36 Overall, coordinated clinical and policy actions that identify high-risk survivors and align resources with their functional needs are essential to alleviate hardship among the rising cancer survivor population. The findings of the current study should be interpreted in light of certain limitations. The use of survey-based data such as BRFSS limited the ability to incorporate detailed clinical information on cancer survivors, including cancer type, stage at diagnosis, treatment modalities, or time since treatment completion. Similarly, survey-based data may be susceptible to information bias compared with other methods of data collection. Nonetheless, the BRFSS dataset has been validated in multiple prior studies and has demonstrated reliability relative to other self-reported national health surveys. 37 Observational data are inherently prone to selection bias (i.e., the representativeness of the target population); however, this is generally mitigated in BRFSS through the use of raking methodology, which adjusts for sampling differences and enhances population-level generalizability. 38 Notwithstanding these limitations, the current study offers valuable insights into the relationship between functional disability and survivor hardship using a large, nationally representative dataset. In conclusion, functional disability emerged as an important factor of multidimensional hardship among U.S. cancer survivors, with cognitive and self-care limitations particularly burdening women and mobility impairment more consequential for men. These patterns underscore the clinical imperative to embed routine functional screening and tailored rehabilitation into survivorship care to preserve quality of life alongside survival. Policy makers should classify multidisciplinary rehabilitation and supportive services as essential benefits and adopt disability inclusive standards to ensure that all survivors, regardless of functional status or sex, receive equitable post-cancer support. Declarations Conflict of interest: none Funding: none Author Contribution A.M. and A.S. wrote the main manuscript text; O.P.C. contributed to methodology and interpretation; A.M. prepared the figures and tables; T.M.P. provided critical revisions and supervision. All authors reviewed and approved the final manuscript. Acknowledgements: none Data Availability https://www.cdc.gov/brfss/annual_data/annual_2022.html References Cancer Prevalence: How Many People Have Cancer? https://www.cancer.org/cancer/survivorship/cancer-prevalence.html. Accessed June 13, 2025. Disparities in Cancer Survivorship | AACR. https://cancerprogressreport.aacr.org/disparities/cdpr24-contents/cdpr24-disparities-in-cancer-survivorship/. Accessed June 13, 2025. Study Finds Functional Limitations Increasing in Survivors of Cancer. https://www.hopkinsmedicine.org/news/newsroom/news-releases/2023/06/study-finds-functional-limitations-increasing-in-survivors-of-cancer. Accessed June 13, 2025. Cancer Survivors Have Higher Risk of Functional Disability- Cancer Therapy Advisor. https://www.cancertherapyadvisor.com/news/cancer-survivors-functional-disability/. Accessed June 13, 2025. Schmidt JE, Beckjord E, Bovbjerg DH, et al. Prevalence of perceived cognitive dysfunction in survivors of a wide range of cancers: results from the 2010 LIVESTRONG survey. J Cancer Surviv Res Pract . 2016;10(2):302-311. doi:10.1007/s11764-015-0476-5 Muhandiramge J, Orchard SG, Warner ET, van Londen GJ, Zalcberg JR. Functional Decline in the Cancer Patient: A Review. Cancers . 2022;14(6):1368. doi:10.3390/cancers14061368 Magasi S, Marshall HK, Winters C, Victorson D. Cancer Survivors’ Disability Experiences and Identities: A Qualitative Exploration to Advance Cancer Equity. Int J Environ Res Public Health . 2022;19(5):3112. doi:10.3390/ijerph19053112 Tak HJ, Horner RD, Lee MS, Shih YCT. Impact of functional disability on health-care use and medical costs among cancer survivors. JNCI Cancer Spectr . 2023;7(5):pkad059. doi:10.1093/jncics/pkad059 CDC - BRFSS - BRFSS Statistical Briefs. https://www.cdc.gov/brfss/data_documentation/statistic_brief.htm. Published February 5, 2025. Accessed April 13, 2025. Behavioral Risk Factor Surveillance System. https://www.cdc.gov/brfss/index.html. Published June 4, 2025. Accessed June 15, 2025. Earle CC, Chretien Y, Morris C, et al. Employment Among Survivors of Lung Cancer and Colorectal Cancer. J Clin Oncol . 2010;28(10):1700-1705. doi:10.1200/JCO.2009.24.7411 Dowling E, Yabroff KR, Mariotto A, McNeel T, Zeruto C, Buckman D. Burden of Illness in Adult Survivors of Childhood Cancers: Findings from a Population-based National Sample. Cancer . 2010;116(15):3712-3721. doi:10.1002/cncr.25141 Barnett M, McDonnell G, DeRosa A, et al. Psychosocial outcomes and interventions among cancer survivors diagnosed during adolescence and young adulthood (AYA): a systematic review. J Cancer Surviv Res Pract . 2016;10(5):814-831. doi:10.1007/s11764-016-0527-6 Cancer Survivorship. The Cancer Atlas. http://canceratlas.cancer.org/rky. Accessed June 13, 2025. Cao C, Friedenreich CM, Yang L. Association of Daily Sitting Time and Leisure-Time Physical Activity With Survival Among US Cancer Survivors. JAMA Oncol . 2022;8(3):395-403. doi:10.1001/jamaoncol.2021.6590 Altice CK, Banegas MP, Tucker-Seeley RD, Yabroff KR. Financial Hardships Experienced by Cancer Survivors: A Systematic Review. JNCI J Natl Cancer Inst . 2016;109(2):djw205. doi:10.1093/jnci/djw205 Aaronson NK, Mattioli V, Minton O, et al. Beyond treatment – Psychosocial and behavioural issues in cancer survivorship research and practice. Eur J Cancer Suppl . 2014;12(1):54-64. doi:10.1016/j.ejcsup.2014.03.005 Rajapakse P. An Update on Survivorship Issues in Lung Cancer Patients. World J Oncol . 2021;12(2-3):45-49. doi:10.4021/wjon.v12i2-3.1368 Prevalence and Cancer-Specific Patterns of Functional Disability Among US Cancer Survivors, 2017-2022 | Journal of Clinical Oncology. https://ascopubs.org/doi/10.1200/JCO.23.02536. Accessed June 13, 2025. Cancer statistics, 2022. https://acsjournals.onlinelibrary.wiley.com/doi/epdf/10.3322/caac.21708?getft_integrator=mendeley&src=getftr&utm_source=mendeley. Accessed June 13, 2025. Health Care Expenses and Financial Hardship Among Medicare Beneficiaries With Functional Disability | Health Policy | JAMA Network Open | JAMA Network. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2820090. Accessed June 13, 2025. Fingerman KL, Ng YT, Huo M, Birditt KS, Charles ST, Zarit S. Functional Limitations, Social Integration, and Daily Activities in Late Life. J Gerontol B Psychol Sci Soc Sci . 2021;76(10):1937-1947. doi:10.1093/geronb/gbab014 Haywood D, Henry M, Dauer E, et al. Cancer-related cognitive impairment as a key contributor to psychopathology in cancer survivors: implications for prevention, treatment and supportive care. Support Care Cancer . 2024;32(7):480. doi:10.1007/s00520-024-08696-9 Cancer Survivors and Unemployment: A Meta-analysis and Meta-regression | Breast Cancer | JAMA | JAMA Network. https://jamanetwork.com/journals/jama/fullarticle/183387. Accessed June 13, 2025. Ma JK, Floegel TA, Li LC, et al. Tailored physical activity behavior change interventions: challenges and opportunities. Transl Behav Med . 2021;11(12):2174-2181. doi:10.1093/tbm/ibab106 Medical financial hardship among cancer survivors in the United States - Zheng - 2019 - Cancer - Wiley Online Library. https://acsjournals.onlinelibrary.wiley.com/doi/10.1002/cncr.31913. Accessed June 13, 2025. Leung DYP, Chan HYL, Chiu PKC, Lo RSK, Lee LLY. Source of Social Support and Caregiving Self-Efficacy on Caregiver Burden and Patient’s Quality of Life: A Path Analysis on Patients with Palliative Care Needs and Their Caregivers. Int J Environ Res Public Health . 2020;17(15):5457. doi:10.3390/ijerph17155457 Haggstrom LR, Vardy JL, Carson EK, Segara D, Lim E, Kiely BE. Effects of Endocrine Therapy on Cognitive Function in Patients with Breast Cancer: A Comprehensive Review. Cancers . 2022;14(4):920. doi:10.3390/cancers14040920 Sharma N, Chakrabarti S, Grover S. Gender differences in caregiving among family - caregivers of people with mental illnesses. World J Psychiatry . 2016;6(1):7-17. doi:10.5498/wjp.v6.i1.7 Eliminating Barriers to Employment for Disabled Women - Center for American Progress. https://www.americanprogress.org/article/playbook-for-the-advancement-of-women-in-the-economy/eliminating-barriers-to-employment-for-disabled-women/. Accessed June 15, 2025. WISDOM JP, McGEE MG, HORNER-JOHNSON W, MICHAEL YL, ADAMS E, BERLIN M. Health Disparities Between Women With and Without Disabilities: A Review of the Research. Soc Work Public Health . 2010;25(3):368-386. doi:10.1080/19371910903240969 Kwon M, Lawn S, Kaine C. Understanding Men’s Engagement and Disengagement When Seeking Support for Mental Health. Am J Mens Health . 2023;17(2):15579883231157971. doi:10.1177/15579883231157971 Kline RM, Arora NK, Bradley CJ, et al. Long-Term Survivorship Care After Cancer Treatment - Summary of a 2017 National Cancer Policy Forum Workshop. JNCI J Natl Cancer Inst . 2018;110(12):1300-1310. doi:10.1093/jnci/djy176 Lage DE, Keating NL, Temel JS. Integrating Functional Assessment Into Clinical Decision-Making for Older Adults Across the Cancer Care Continuum. JCO Oncol Pract . 2022;18(7):e1056-e1059. doi:10.1200/OP.22.00231 Recklitis CJ, Syrjala KL. Provision of integrated psychosocial services for cancer survivors post-treatment. Lancet Oncol . 2017;18(1):e39-e50. doi:10.1016/S1470-2045(16)30659-3 Ferro AM, Mercado J, Quinn L. On “Training an Anti-Ableist Physical Therapist Workforce: Critical Perspectives of Health Care Education That Contribute to Health Inequities for People With Disabilities” Whalen Smith CN, Havercamp SM, Tosun L, et al. Phys Ther. 2024;104:pzae092. 10.1093/ptj/pzae092. Phys Ther . 2025;105(5):pzaf035. doi:10.1093/ptj/pzaf035 Pierannunzi C, Hu SS, Balluz L. A systematic review of publications assessing reliability and validity of the Behavioral Risk Factor Surveillance System (BRFSS), 2004-2011. BMC Med Res Methodol . 2013;13:49. doi:10.1186/1471-2288-13-49 Sedani AE, Frank-Pearce SG, Beebe LA, et al. Cannabis Use and Subsequent Cigarette Discontinuation Among U.S. Adults in the Population Assessment of Tobacco and Health Study, Waves 1–5. Nicotine Tob Res . 2024;27(2):208-216. doi:10.1093/ntr/ntae202 Additional Declarations No competing interests reported. Supplementary Files SupplementarytablesHardship.docx Cite Share Download PDF Status: Published Journal Publication published 12 Feb, 2026 Read the published version in Journal of Cancer Survivorship → Version 1 posted Editorial decision: Revision requested 19 Jan, 2026 Reviews received at journal 19 Jan, 2026 Reviewers agreed at journal 08 Dec, 2025 Reviews received at journal 29 Sep, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviewers agreed at journal 08 Sep, 2025 Reviewers invited by journal 08 Sep, 2025 Editor assigned by journal 24 Aug, 2025 Submission checks completed at journal 24 Aug, 2025 First submitted to journal 22 Aug, 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7437296","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":512149673,"identity":"deea2c4f-7bd9-48ee-8ff3-ec6aff0a5268","order_by":0,"name":"Areesh Mevawalla","email":"","orcid":"","institution":"The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Areesh","middleName":"","lastName":"Mevawalla","suffix":""},{"id":512149674,"identity":"d6d7ebe1-3a97-4447-a782-694faece3af2","order_by":1,"name":"Odysseas P Chatzipanagiotou","email":"","orcid":"","institution":"The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Odysseas","middleName":"P","lastName":"Chatzipanagiotou","suffix":""},{"id":512149675,"identity":"6be5a10c-bbf5-4cf8-8f54-c0b826d900ff","order_by":2,"name":"Azza Sarfraz","email":"","orcid":"","institution":"The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center","correspondingAuthor":false,"prefix":"","firstName":"Azza","middleName":"","lastName":"Sarfraz","suffix":""},{"id":512149676,"identity":"6ca0165f-8024-4e9b-b056-f6028bbec503","order_by":3,"name":"Timothy M. Pawlik","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2ElEQVRIiWNgGAWjYDACZgglw8bDfAAmZoBXBw9UCw8bD1sCkVrgNA8PXCV+Lfbs3AnMBTWHefh4znx8+LNtmzwDe/M2CfwO493APOPYYR423t7Nxrxttw0beI6VEdbCw3abh42fd5s0Y9vtBAaJHDMitPwDaeF5JvkTpEX+DRFagO4BOqyHTYIXbAsPAS2HeTccntn3HxjIx4yNec7dNmzjSSu2wKeFvf/sxscF39Lk5HuSHz78UXZbnp/98MYb+LSAwGEUHhsh5SDATIyiUTAKRsEoGMEAABpAPGOQYxg2AAAAAElFTkSuQmCC","orcid":"","institution":"The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center","correspondingAuthor":true,"prefix":"","firstName":"Timothy","middleName":"M.","lastName":"Pawlik","suffix":""}],"badges":[],"createdAt":"2025-08-22 20:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7437296/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7437296/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11764-026-01981-y","type":"published","date":"2026-02-12T15:58:52+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91366682,"identity":"ca89e36b-b198-485e-b6a1-10cd90b697af","added_by":"auto","created_at":"2025-09-15 17:49:06","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":90172,"visible":true,"origin":"","legend":"\u003cp\u003eGeographic Variation in Functional Disability Prevalence Among U.S. Cancer Survivors, 2017–2022.\u003c/p\u003e","description":"","filename":"Figure1Hardshipandcancer.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7437296/v1/5ec20b02d09eaeff5adc2022.jpg"},{"id":91367560,"identity":"7d7e89ff-4872-4367-8249-c4a9bbe3956b","added_by":"auto","created_at":"2025-09-15 17:57:06","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":434428,"visible":true,"origin":"","legend":"\u003cp\u003eAdjusted Probability of Survivor Hardship by Disability Type, Sex, and Income Level.\u003c/p\u003e","description":"","filename":"Figure2Hardshipandcancer.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7437296/v1/75084395d4fd60cc35a0413d.jpg"},{"id":102786371,"identity":"cdeb704e-30be-4763-a395-890e7443e470","added_by":"auto","created_at":"2026-02-16 16:13:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2162527,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7437296/v1/9cfda9f8-ac20-496f-9521-5f5cdbc6fe39.pdf"},{"id":91366684,"identity":"b116fb0f-5f93-41a5-b3f9-69abc24baecc","added_by":"auto","created_at":"2025-09-15 17:49:06","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":24406,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementarytablesHardship.docx","url":"https://assets-eu.researchsquare.com/files/rs-7437296/v1/7e20bfdd0f9329abc16513d0.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Functional Disability and Multidimensional Hardship Among Cancer Survivors in the United States: A Nationally Representative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCancer survivorship in the United States has risen substantially in recent decades. As of 2025, approximately 18.6\u0026nbsp;million Americans are living with a history of cancer, a number expected to surpass 22\u0026nbsp;million by 2035.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e Advances in early detection and treatment have prolonged survival, allowing more individuals to live longer following a cancer diagnosis.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e However, many cancer survivors face long-term physical and cognitive sequelae, such as cardiopulmonary complications and \u0026ldquo;chemo brain,\u0026rdquo; that can impair daily functioning.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e As such, functional disability has emerged as a key concern in the growing survivor population.\u003c/p\u003e\u003cp\u003eRecent studies indicate that nearly two-thirds of U.S. cancer survivors experience difficulties with routine activities - a rate almost twice that of the general population.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Approximately 30% of survivors report serious difficulty walking or climbing stairs, and 7.4% struggle with self-care tasks like dressing or bathing.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e In addition, nearly half of cancer survivors experience persistent cognitive challenges affecting memory, concentration, and other mental functions.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e These functional deficits are strongly linked to reduced quality of life and greater hardship among survivors.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Despite these concerns, there remains a notable gap in the literature on the full extent and impact of mobility, cognitive, and self-care disabilities among U.S. cancer survivors; particularly regarding their associations with employment disruption, barriers to medical care, and mental health distress.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThe aforementioned patterns highlight the need not only to prolong survival after cancer, but also to improve survivors\u0026rsquo; quality of life.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e However, to date, few studies have comprehensively assessed the burden of specific types of disability or examined their downstream effects on cancer survivors\u0026rsquo; well-being. Therefore, the objective of the current study was to evaluate the prevalence and impact of functional disability among U.S. cancer survivors between 2017 and 2022. We introduced a composite \u0026ldquo;survivor hardship\u0026rdquo; metric and examined disability-specific associations with employment, mental health, access to care, and physical activity.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData source, cohort selection, and outcomes\u003c/h2\u003e\u003cp\u003eThis crosssectional analysis used pooled data from the 2017\u0026ndash;2022 Behavioral Risk Factor Surveillance System (BRFSS), an annual, statebased telephone survey administered by the Centers for Disease Control and Prevention that samples noninstitutionalized U.S. adults aged\u0026thinsp;\u0026ge;\u0026thinsp;18 years.\u003csup\u003e10\u003c/sup\u003e BRFSS employs a complex, multistage probability design; all estimates were calculated with the CDCsupplied sampling weights, strata, and primary sampling units to yield nationally representative results. Among 2,591,503 respondents in the analytic sample, cancer survivors were identified using self-reported cancer diagnosis. We excluded respondents with incomplete state residence data (necessary to apply survey weights correctly) and individuals with missing responses on all four primary survivorship outcomes (unable to work, \u0026ge;\u0026thinsp;14 days of poor mental health, costrelated unmet medical need, no leisuretime physical activity), as their hardship status could not be assessed.\u003c/p\u003e\u003cp\u003eFunctional disability was assessed based on three standardized BRFSS questions, each recoded as a binary indicator (1 = \"yes\", 0 = \"no\"). These included: cognitive disability (\"Because of a physical, mental, or emotional condition, do you have serious difficulty concentrating, remembering, or making decisions?\"), mobility disability (\"Do you have serious difficulty walking or climbing stairs?\"), and selfcare disability (\"Do you have difficulty dressing or bathing?\"). Participants who reported more than one limitation were included in each corresponding disability category. For example, respondents with both mobility and cognitive disability were counted in both respective groups for stratified analyses.\u003c/p\u003e\u003cp\u003eThe primary outcomes of interest were four adverse survivorship indicators: (1) selfreported inability to work because of health\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e1, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e2\u003c/sup\u003e; (2) experiencing\u0026thinsp;\u0026ge;\u0026thinsp;14 days of poor mental health in the past 30 days\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e3\u003c/sup\u003e; (3) needing but being unable to obtain medical care due to cost\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e4\u003c/sup\u003e; and (4) no reported leisuretime physical activity in the past month.\u003csup\u003e15\u003c/sup\u003e A composite \u0026ldquo;survivor hardship\u0026rdquo; outcome was constructed and defined as reporting \u0026ge;2 adverse survivorship indicators, allowing for an assessment of cumulative burden among cancer survivors. The selection of these indicators for \u0026ldquo;hardship\u0026rdquo; were based on previous studies of cancer survivor health, aligning with established survey metrics and outcomes.\u003csup\u003e1\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, 17\u003c/sup\u003e Each indicator represented a critical domain of survivorship, and together the factors provided a comprehensive picture of post-cancer hardship as documented in oncologic and public health research.\u003csup\u003e18\u003c/sup\u003e This study used publicly available and de-identified and was deemed exempt by The Ohio State University Institutional Review Board.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eDemographic covariates included age (\u0026lt;\u0026thinsp;65, \u0026ge;\u0026thinsp;65 years), sex assigned at birth (male, female), and race/ethnicity (White, Black, Hispanic, Asian, Native American, Other). Educational attainment was categorized as less than high school, high school diploma or some college, and college degree or above. Residence was classified as urban or rural, and marital status as married or not married. Annual household income was grouped as \u0026lt; \u003cspan\u003e$\u003c/span\u003e25,000, \u003cspan\u003e$\u003c/span\u003e25,000\u0026ndash;\u003cspan\u003e$\u003c/span\u003e74,999, and \u0026ge; \u003cspan\u003e$\u003c/span\u003e75,000.\u003csup\u003e19\u003c/sup\u003e Health-related covariates included insurance status (uninsured, government-sponsored, private), presence of comorbidities (diabetes, heart disease, chronic obstructive pulmonary disease, stroke, and arthritis), and age at cancer diagnosis (\u0026lt;\u0026thinsp;40, 40\u0026ndash;50, 51\u0026ndash;64, \u0026ge;\u0026thinsp;65 years). Access to care variables comprised having had a primary care visit in the past year and living in a Medicaid-expansion state.\u003c/p\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eDescriptive statistics for categorical variables were presented as frequencies and percentages (%) and were analyzed using the Chi-square test or Fisher's exact test, as appropriate. Continuous variables were reported as median values with interquartile ranges (IQR); comparisons between groups were conducted using the Kruskal-Wallis test. All weighting, clustering, and stratification variables supplied by BRFSS were applied in accordance with CDC guidance to generate nationally representative estimates. Associations between each disability domain and the four adverse survivorship outcomes: unable to work, \u0026ge;\u0026thinsp;14 days of poor mental health, costrelated unmet medical need, and no leisure time physical activity, were examined using weighted multivariable logisticregression models. Separate models were fit for (1) cognitive, (2) mobility, and (3) selfcare disability, as well as for the composite survivor hardship outcome. Each model was adjusted for the full set of covariates outlined above. Variables with 15 % missing data were excluded from regression analyses. Adjusted odds ratios (aORs) with95 % CIs were reported. To evaluate the policy level impact of Medicaid expansion on disabilityrelated hardship among economically vulnerable survivors, a differenceindifferences (DID) framework compared changes in hardship risk between residents of expansion versus nonexpansion states, restricting the analysis to respondents with annual household income \u0026lt; \u003cspan\u003e$\u003c/span\u003e25,000. The DID models included interaction terms for disability type, Medicaidexpansion status, and survey year, and were adjusted for age, sex, race/ethnicity, educational attainment, insurance type, and primarycare access. All tests were twosided and pvalues\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. All analyses were conducted in Stata 18 (StataCorp, College Station, TX).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eBaseline Characteristics\u003c/h2\u003e\u003cp\u003eAmong 2,591,503 respondents included in the unweighted sample, 26,864 (1.0%) were self-reported cancer survivors. Cancer survivors were older than the general population (62 years [IQR: 53\u0026ndash;73] vs. 58 years [IQR: 41\u0026ndash;69). Cancer survivors were more frequently female (65.6% vs. 53.8), White (81.3% vs. 75.7%;), rural residents (26.4% vs. 23.0%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and publicly insured (30.6% vs. 15.6%) compared with the general population (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Of note, a higher prevalence of self-care, mobility, and cognitive disabilities was observed in the Southeast and Appalachian states, whereas rates were markedly lower across the Mountain West and Upper Midwest (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Overall, functional limitations were much more common among cancer survivors than the general population, including mobility disability (28.0% vs. 15.9%), cognitive disability (12.9% vs 10.5%), and self-care disability (6.4% vs 4.0%) (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, \u003cb\u003eeTable 1\u003c/b\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFollowing application of survey weights, the estimated cancer survivor cohort included 3,570,518 adults. Within this weighted group, mobility disability was the most prevalent (n\u0026thinsp;=\u0026thinsp;999,362, 28.0%), followed by cognitive (n\u0026thinsp;=\u0026thinsp;462,308, 12.9%) and self-care disability (n\u0026thinsp;=\u0026thinsp;227,696, 6.4%). Notably, survivors reporting mobility disability were more frequently diagnosed\u0026thinsp;\u0026lt;\u0026thinsp;40 years old (n\u0026thinsp;=\u0026thinsp;362,691, 36.2%) compared with self-care (72,485, 31.7%) or cognitive disability (n\u0026thinsp;=\u0026thinsp;123,158, 26.6%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Respondents with low household incomes (\u0026lt;\u003cspan\u003e$\u003c/span\u003e25,000) more frequently reported self-care disability (n\u0026thinsp;=\u0026thinsp;60,116, 26.4%) versus cognitive (n\u0026thinsp;=\u0026thinsp;112,385, 24.2%) and mobility disability (n\u0026thinsp;=\u0026thinsp;209,741, 20.9%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Additionally, recent primary care visits were common among all disability types, although slightly less frequent among individuals with cognitive disability (n\u0026thinsp;=\u0026thinsp;403,522, 87.3%) compared with mobility disability (n\u0026thinsp;=\u0026thinsp;908,390, 90.1%) and self-care disability (n\u0026thinsp;=\u0026thinsp;201,761, 91.1%) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). National cancer type estimates among survivors are detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eWeighted characteristics of cancer survivors by disability domain.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCancer survivors\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;3,570,518)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSelf-care disability\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;227,696, 6.4%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMobility disability\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;999,362, 28.0%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCognitive disability\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;462,308 12.9%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,159,893(32.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e90,174(39.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e291,270(29.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e225,435 (48.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,372,853(66.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e135,394(59.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e699,580(70.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e233,149(50.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,228,258(34.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72,407 (31.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e296,810 (29.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e130,370(28.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,342,259(65.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e155,289(68.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e702,551 (70.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e331,937(71.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWhite\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,903,656(81.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e161,329(70.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e768,873(76.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e341,012 (73.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlack\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e233,149(6.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22,743(9.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e80,332(8.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e33,250 (7.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAsian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e66,766(1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,724(1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e16,093(1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8,379 (1.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNative American\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e71,953(2.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9,310(4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e28,329(2.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e17,822 (3.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHispanic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e190,988(5.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21,945(9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e70,756(7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e42,560 (9.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOther\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e106,400(3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e8,645(3.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e34,979(3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e19,285 (4.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eArea\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,116,562(59.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e123,690(54.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e555,009(55.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e249,774 (53.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e942,039(26.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e65,835(28.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e284,354(28.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e136,857 (29.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel of education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e207,879 (5.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30,324(13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e103,607(10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e61,712 (13.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school/ some college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,945,125(54.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e139,783(61.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e626,297(62.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e296,191 (64.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; College degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,412,593(39.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e56,924(24.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e266,532(26.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e102,942 (22.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAnnual household income ($)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; 25, 000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e444,752(12.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e60,116(26.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e209,741 (20.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e112,385 (24.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25,000\u0026ndash;74, 999\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e717,668(20.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e30,989(13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e182,210 (18.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e71,554 (15.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;75,000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e462,707(12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e10,640(4.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e56,259 (5.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21,945 (4.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,825,425(51.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79,401(34.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e380,912 (38.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e169,575 (36.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComorbidities\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,821,329(79.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e79,534(34.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e322,658 (32.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e131,138 (28.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeart disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e367,878(10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e44,555(19.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e174,097 (17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e66,766 (14.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCOPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e525,616(14.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e77,539(33.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e276,640 (27.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e128,079 (27.7)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStroke\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e258,685(7.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42,826(18.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e135,261(13.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64,239 (13.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eArthritis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,849,365(51.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e173,033(76.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e737,618(73.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e307,762 (66.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at diagnosis, years\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e563,255(15.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e52,801(22.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e169,176(16.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e129,808 (27.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e51\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e649,705(18.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38,969(16.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e159,068(15.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e83,258 (18.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,213,625(34.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e63,441(27.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e308,427(30.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e126,084 (27.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,146,327(32.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e72,485(31.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e362,691(36.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e123,158 (26.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTreatment status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCompleted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e470,421(13.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e39,501(17.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e149,359(14.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e70,490 (15.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrimary care visit\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHad PCP visit (past year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3,203,172(89.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e201,761(91.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e908,390(90.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e403,522 (87.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealth insurance status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUninsured\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e16,891 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,330(0.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5,719(0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,256(0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,092,063(30.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e82,726(36.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e356,440(35.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e156,674(34.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e442,092(12.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e16,625(7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e73,815(7.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e44,023(9.9)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eState Medicaid Expansion Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,908,577(81.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e182,742(80.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e796,803(79.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e362,206(78.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCancer types\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBrain\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e26,467(0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,325 (1.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9,975 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e9,177 (1.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,265,628(35.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e66,500 (29.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e338,219 (33.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e134,596 (29.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLung\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e183,407(5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e15,694 (6.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e77,539 (7.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e30,856(6.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThyroid\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e186,732(5.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11,837 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e43,890 (4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e21,413 (4.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEsophagus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25,403 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,862 (0.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e7,847 (0.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e5,054 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStomach\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27,398 (0.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,995 (0.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9,576 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,788 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiver\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34,447 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,742 (1.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e13,034 (1.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7,049 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eColon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e310,156 (8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19,817 (8.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e95,760 (9.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e43,890 (9.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRectal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e32,585 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,527 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e9,709 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e4,655 (1.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKidney\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e119,833 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9,709 (4.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40,432 (4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e16,492 (3.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCervical\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e269,591 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e27,664 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e88,977 (8.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e73,017(15.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOvarian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e109,858 (3.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e9,044 (4.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33,915 (3.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e19,551(4.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEndometrial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e179,018 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e11,704 (4.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e61,978(6.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e24,472(5.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProstate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e789,621 (22.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e38,969 (26.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e164,388(16.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e64,904(13.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003eMobility disability defined as self-reported serious difficulty walking or climbing stairs.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003eCognitive disability defined as serious difficulty concentrating, remembering, or making decisions due to a physical, mental, or emotional condition.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003eSelf-care disability defined as difficulty dressing or bathing.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eAssociation between Functional Limitations and Cancer Survivorship Indicators\u003c/h2\u003e\u003cp\u003eCancer survivors with self-care disability and mobility disability demonstrated approximately 7-fold (aOR 6.92, 95%CI 5.10\u0026ndash;7.31) and 6-fold (aOR 5.50, 95%CI 5.10\u0026ndash;8.73) increased likelihood of being unable to work, respectively, whereas cognitive disability was associated with a lower risk for inability to work (aOR 3.27, 95%CI 2.72\u0026ndash;3.92). Of note, cognitive disability among cancer survivors was associated with 310% (aOR 4.10, 95% CI 3.55\u0026ndash;4.68) greater odds of poor mental health, followed by self-care (aOR 2.62, 95% CI 2.18\u0026ndash;3.14) and mobility disability (aOR 1.94, 95% CI 1.75\u0026ndash;2.15). All three functional disability types were associated with an approximately two-fold increased likelihood of unmet medical needs due to cost. Furthermore, the association of mobility disability (aOR 3.44, 95% CI 3.10\u0026ndash;3.81) and self-care disability (aOR 2.97, 95% CI 2.47\u0026ndash;3.57) with low activity levels was greater than the association between cognitive disability and physical activity levels (aOR 1.78, 95% CI 1.55\u0026ndash;2.03).\u003c/p\u003e\u003cp\u003eRegarding the composite outcome, multivariable analysis demonstrated that cognitive disability was associated with 315% higher odds of survivor hardship (aOR 4.14, 95% CI 3.03\u0026ndash;5.67), whereas self-care and mobility disability were associated with a three-fold (aOR 2.65, 95% CI 1.81\u0026ndash;3.88) and two-fold (aOR 2.10, 95% CI 1.65\u0026ndash;2.58) greater likelihood of survivor hardship, respectively (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAdjusted Odds Ratios (95% CI) for Unemployment, Mental Health Burden, and Cost barrier and physical activity level by Disability Domain\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSelf-care disability\u003c/p\u003e\u003cp\u003eaOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eMobility disability\u003c/p\u003e\u003cp\u003eaOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eCognitive disability\u003c/p\u003e\u003cp\u003eaOR (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployment\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnable to work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.92 (5.10\u0026ndash;7.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5.50(5.10\u0026ndash;8.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3.27(2.72\u0026ndash;3.92)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMental health burden\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePoor mental health\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.62(2.18\u0026ndash;3.14)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.94(1.75\u0026ndash;2.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.10(3.55\u0026ndash;4.68)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eCost barrier\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnmet medical need\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.92(1.50\u0026ndash;2.50)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.92(1.62\u0026ndash;2.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2.34(1.94\u0026ndash;2.84)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePhysical activity level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c7\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow activity (no leisure-time exercise)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.97(2.47\u0026ndash;3.57)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3.44(3.10\u0026ndash;3.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.78(1.55\u0026ndash;2.03)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurvivor hardship*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.65(1.81\u0026ndash;3.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.10(1.65\u0026ndash;2.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4.15(3.03\u0026ndash;5.67)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e* \u0026ldquo;Hardship\u0026rdquo; means the survivor reported at least two of the following problems in the past year: unable to work, frequent poor mental-health days, skipping needed medical care because of cost, or no leisure-time physical activity\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eall p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eModels adjusted for age, sex, race/ethnicity, education, marital status, residence, income, insurance type, comorbidities, primary care access, treatment status, and age at cancer diagnosis.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eAssociation between various factors and survivor hardship\u003c/h3\u003e\n\u003cp\u003eSeveral sociodemographic factors independently predicted greater survivor hardship (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Multivariable analysis, after adjusting for relevant factors, demonstrated that older age at cancer diagnosis (\u0026ge;\u0026thinsp;65 years) was associated with greater odds for hardship among respondents with self-care (aOR 1.42, 95%CI 1.16\u0026ndash;1.63), mobility (aOR 1.54, 95%CI 1.14\u0026ndash;1.88), and cognitive disability (aOR 1.69, 95% CI 1.20\u0026ndash;2.13). Furthermore, female survivors with self-care and cognitive disability demonstrated 16% (aOR 1.16, 95%CI 1.02\u0026ndash;1.31) and 13% (aOR 1.13, 95%CI 1.04\u0026ndash;1.27) increased odds of survivor hardship compared with male cancer survivors, respectively, yet 11% lower odds for hardship when reporting mobility disability (aOR 0.89, 95%CI 0.75\u0026ndash;0.97). Of note, household income \u0026ge;\u003cspan\u003e$\u003c/span\u003e75,000 was consistently associated with decreased likelihood for survivor hardship, across all functional disability types (all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). A recent primary-care visit was associated with approximately 55\u0026ndash;60% lower odds of survivor hardship among survivors with mobility disability (aOR 0.40, 95%CI 0.25\u0026ndash;0.64), self-care disability (aOR 0.42, 95%CI 0.26\u0026ndash;0.66), and cognitive disability (aOR 0.45, 95%CI 0.28\u0026ndash;0.71) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Interestingly, private insurance was associated with 65\u0026ndash;70% lower odds of survivor hardship among cancer survivors with cognitive (aOR 0.35, 95%CI 0.26\u0026ndash;0.46), self-care (aOR 0.35, 95%CI 0.26\u0026ndash;0.48) and mobility disability (aOR 0.40, 95%CI 0.30\u0026ndash;0.53).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAdjusted Odds of Survivor Hardship Among Cancer Survivors, by Type of Functional Disability\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelf-care disability\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eaOR\u003csup\u003ea\u003c/sup\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMobility disability\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eaOR\u003csup\u003ea\u003c/sup\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCognitive disability\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eaOR\u003csup\u003ea\u003c/sup\u003e (95% CI)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge at diagnosis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;50\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.22(0.92\u0026ndash;1.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.39(0.84\u0026ndash;1.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.42(0.77\u0026ndash;1.98)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e51\u0026ndash;64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.25(0.74\u0026ndash;1.51)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.21(0.61\u0026ndash;1.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.34(0.64\u0026ndash;1.75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.42(1.16\u0026ndash;1.63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.54(1.14\u0026ndash;1.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.69(1.20\u0026ndash;2.13)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSex at birth\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.16(1.02\u0026ndash;1.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.89(0.75\u0026ndash;0.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.13(1.04\u0026ndash;1.27)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLevel of education\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLess than high school\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh school/ some college\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.2(0.75\u0026ndash;1.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.25(0.77\u0026ndash;2.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.40(0.78\u0026ndash;2.45)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCollege degree or higher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.80(0.46\u0026ndash;1.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.86(0.50\u0026ndash;1.49)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.92(0.491.70)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eIncome category\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow income (\u0026lt;\u003cspan\u003e$\u003c/span\u003e25,000)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMiddle income (\u003cspan\u003e$\u003c/span\u003e25k\u0026ndash;\u003cspan\u003e$\u003c/span\u003e75k)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.40(0.27\u0026ndash;0.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.44(0.31\u0026ndash;0.62)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.44(0.29\u0026ndash;0.64)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh income (\u0026ge;\u003cspan\u003e$\u003c/span\u003e75,000)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.20(0.12\u0026ndash;0.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.24(0.14\u0026ndash;0.40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.22(0.13\u0026ndash;0.39)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnmarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.88(0.62\u0026ndash;1.26)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.91(0.65\u0026ndash;1.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.94(0.65\u0026ndash;1.37)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePrimary care visit\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo PCP visit (past year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHad PCP visit (past year)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.42(0.26\u0026ndash;0.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.40(0.25\u0026ndash;0.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.45(0.28\u0026ndash;0.71)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTreatment status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot completed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCompleted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.16(1.01\u0026ndash;1.32)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.20(1.02\u0026ndash;1.46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.22(1.05\u0026ndash;1.42)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHealth insurance coverage\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUninsured\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGovernment sponsored\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.71(0.57\u0026ndash;0.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.67(0.54\u0026ndash;0.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.69(0.55\u0026ndash;0.87)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrivate insurance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.35(0.26\u0026ndash;0.48)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.40(0.30\u0026ndash;0.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.35(0.26\u0026ndash;0.46)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eState Medicaid Expansion Status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.15 (0.66\u0026ndash;2.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.18 (0.81\u0026ndash;1.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.90 (0.61\u0026ndash;1.32)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eAbbreviations\u003c/b\u003e:\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eaOR, adjusted odds ratio; CI, confidence interval; PCP, primary care provider; Ref, reference.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003cb\u003eFootnotes\u003c/b\u003e:\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ea. Adjusted odds ratios were derived from survey-weighted multivariable logistic regression models.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eb. Models adjusted for: age at diagnosis, sex at birth, education, household income, marital status, residence (urban vs. rural), insurance type, comorbidities (diabetes, heart disease, COPD, stroke, arthritis), primary care access, treatment status, and state Medicaid expansion status.\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eSurvivor hardship was defined as reporting\u0026thinsp;\u0026ge;\u0026thinsp;2 of the following: (1) unable to work due to health; (2)\u0026thinsp;\u0026ge;\u0026thinsp;14 days of poor mental health in past month; (3) cost-related unmet medical need; (4) no leisure-time physical activity.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eState Medicaid expansion status was not associated with survivor hardship in the overall cohort. Among low-income cancer survivors, increases of disability-related hardship were smaller among respondents in Medicaid expansion states compared with non-expansion states, demonstrating interesting, but non-significant trends (difference-in-differences: self-care disability \u0026minus;\u0026thinsp;2.8%, mobility disability \u0026minus;\u0026thinsp;2.0%, cognitive disability \u0026minus;\u0026thinsp;1.8%; all p\u0026thinsp;\u0026gt;\u0026thinsp;0.05; \u003cb\u003eeTable 2\u003c/b\u003e).\u003c/p\u003e\n\u003ch3\u003eSex Differences in Disability-Related Survivor Hardship\u003c/h3\u003e\n\u003cp\u003eOf note, women with cognitive disability exhibited higher adjusted probability of hardship compared with men (51.0% vs. 47.4%; difference\u0026thinsp;+\u0026thinsp;3.6%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Similarly, female cancer survivors reporting self-care disability demonstrated 4.4% greater survivor hardship probabilities than male survivors (46.4% vs. 42.1%; difference\u0026thinsp;+\u0026thinsp;4.4%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (\u003cb\u003eeTable 3\u003c/b\u003e). On the contrary, among survivors with mobility disability, women demonstrated 1.7% lower probability of experiencing survivor hardship compared with men (19.0% vs. 20.7%; difference \u0026minus;\u0026thinsp;1.7%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec\u003cb\u003e)\u003c/b\u003e These findings underscore important sex-based disparities in disability-associated hardship among cancer survivors.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs cancer survivorship continues to grow in the U.S., attention has shifted towards quality of life among survivors, particularly in light of evidence that nearly two-thirds of U.S. cancer survivors report difficulties with routine activities.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e Functional impairments in mobility, self-care, or cognition can substantially affect a survivor\u0026rsquo;s quality of life, by limiting daily functioning and contributing to various downstream hardships.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e The current study was important because it was the first nationally representative analysis to assess specific types of functional disability and their associations with survivorship hardship among U.S. cancer survivors, using BRFSS data from 2017 to 2022. The data demonstrated that mobility, self-care, and cognitive disabilities were associated with various hardship indicators, as well as with a composite survivorship hardship metric. Of note, female survivors with disabilities experienced a greater burden of hardship than their male counterparts, suggesting that gender influenced how disability affected quality of life among cancer survivors. These findings highlight the multifaceted challenges faced by survivors living with disability and underscore the the need to not only prolong cancer survival, but to actively support the well-being and daily functioning among those who survive.\u003c/p\u003e\u003cp\u003eUnderstanding how different disability types affect survivor hardship is key to guide care and improve the quality of life among cancer survivors. Of note, survivors who reported serious difficulty concentrating, remembering, or making decisions had higher rates of frequent mental distress, consistent with evidence that cancer related cognitive impairment (\u0026ldquo;chemo brain\u0026rdquo;) can exacerbate mood and anxiety disorders.\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e Clinically, these data highlight the need for routine cognitive and psychological screening, alongside interventions like cognitive rehabilitation and counseling. Interestingly, cancer survivors with mobility limitations were more likely to be unable to work or exercise, reflecting prior findings linking physical impairment to job loss, prolonged unemployment, and reduced activity.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e As such, integrating physical therapy, tailored exercise programs, and vocational rehabilitation into survivorship care serves a dual goal of improving functional capacity and maintaining engagement in work and recreation.\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e\u003c/sup\u003e Meanwhile, self-care disability among cancer survivors was associated with cost-related unmet healthcare needs and work limitations. Self-care impairment often reflects high dependency - survivors requiring home health services, caregiving support, and assistive devices - and financial barriers due to increased medical needs and out-of-pocket costs.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Addressing these challenges requires coordinated care involving oncology, primary care, rehabilitation, social work, and home health services.\u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e Overall, a \u0026ldquo;disability-informed\u0026rdquo; approach tailored to each cancer survivor\u0026rsquo;s functional status is critical towards advancing patient-centered care.\u003c/p\u003e\u003cp\u003eUnderstanding demographic and socioeconomic factors is essential to contextualize these disparities, as they may shape both the experience and reporting of survivorship hardship. In the current study, female cancer survivors with self-care or cognitive disabilities were more likely to experience survivorship hardship compared with male survivors (self-care: 46.4% vs. 42.1%; cognitive: 51.0% vs. 47.4%; \u003cb\u003eeTable 3\u003c/b\u003e). These disparities likely stem from a combination of biological, social, and behavioral factors. For instance, women are more frequently prescribed certain cancer treatments, such as endocrine therapy, that can impair cognitive and physical functioning.\u003csup\u003e\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e Furthermore, women often face disproportionate caregiving responsibilities, which may cause additional emotional and practical distress, particularly when self-care ability is also compromised.\u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e Of note, financial vulnerability, including lower average incomes and fewer resources among women may further exacerbate the impact of disability on work and access to care.\u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e,\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e In contrast, hardship associated with mobility limitations was more pronounced among male survivors (20.7% vs. 19.0%; p\u0026thinsp;=\u0026thinsp;0.0004), potentially reflecting stronger ties between physical independence and identity in men. Men may also be less likely to seek or engage with supportive services like physical therapy or counseling, in turn experiencing greater hardship burden when mobility is impaired.\u003csup\u003e\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e\u003c/sup\u003e These findings highlight the importance of incorporating sex-specific considerations into survivorship care. As such, female survivors might benefit from early cognitive rehabilitation, structured mental health interventions, and caregiver resources, while male survivors may require proactive mobility screening, tailored physical rehabilitation, and interventions to promote the use of supportive services. Overall, integrating sex-sensitive functional assessments and interventions within survivorship care could help improve equitable outcomes among cancer survivors.\u003c/p\u003e\u003cp\u003eBeyond clinical care, our findings carry important policy implications. Of note, Medicaid expansion was not associated with decreased survivor hardship, highlighting that insurance coverage alone cannot mitigate the complex needs of survivors with disabilities.\u003csup\u003e\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e Many individuals require extended rehabilitation, long-term mental health care, assistive devices, or in-home services that are often under-covered and financially inaccessible. As such, routine functional assessments, akin to distress screening, should be integrated to oncology and survivorship care to facilitate timely intervention.\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e\u003c/sup\u003e Coverage policy must ensure that multidisciplinary rehabilitation - including physical, occupational, cognitive, psychosocial services - is covered as an essential benefit across Medicare, Medicaid, and private insurers.\u003csup\u003e\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e Disability-inclusive care models that embed rehabilitation specialists and care coordinators within oncology teams, along with survivorship plans outlining workplace and home accommodations, can help close critical care gaps.\u003csup\u003e\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u003c/sup\u003e Broader system level reforms are also important, including anti-ableist care standards, expanded eligibility for disability benefits, employment protections, and publicly-funded community exercise and vocational programs.\u003csup\u003e\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u003c/sup\u003e Overall, coordinated clinical and policy actions that identify high-risk survivors and align resources with their functional needs are essential to alleviate hardship among the rising cancer survivor population.\u003c/p\u003e\u003cp\u003eThe findings of the current study should be interpreted in light of certain limitations. The use of survey-based data such as BRFSS limited the ability to incorporate detailed clinical information on cancer survivors, including cancer type, stage at diagnosis, treatment modalities, or time since treatment completion. Similarly, survey-based data may be susceptible to information bias compared with other methods of data collection. Nonetheless, the BRFSS dataset has been validated in multiple prior studies and has demonstrated reliability relative to other self-reported national health surveys.\u003csup\u003e\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e\u003c/sup\u003e Observational data are inherently prone to selection bias (i.e., the representativeness of the target population); however, this is generally mitigated in BRFSS through the use of raking methodology, which adjusts for sampling differences and enhances population-level generalizability.\u003csup\u003e\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e\u003c/sup\u003e Notwithstanding these limitations, the current study offers valuable insights into the relationship between functional disability and survivor hardship using a large, nationally representative dataset.\u003c/p\u003e\u003cp\u003eIn conclusion, functional disability emerged as an important factor of multidimensional hardship among U.S. cancer survivors, with cognitive and self-care limitations particularly burdening women and mobility impairment more consequential for men. These patterns underscore the clinical imperative to embed routine functional screening and tailored rehabilitation into survivorship care to preserve quality of life alongside survival. Policy makers should classify multidisciplinary rehabilitation and supportive services as essential benefits and adopt disability inclusive standards to ensure that all survivors, regardless of functional status or sex, receive equitable post-cancer support.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of interest:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA.M. and A.S. wrote the main manuscript text; O.P.C. contributed to methodology and interpretation; A.M. prepared the figures and tables; T.M.P. provided critical revisions and supervision. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003enone\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ehttps://www.cdc.gov/brfss/annual_data/annual_2022.html\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCancer Prevalence: How Many People Have Cancer? https://www.cancer.org/cancer/survivorship/cancer-prevalence.html. Accessed June 13, 2025.\u003c/li\u003e\n\u003cli\u003eDisparities in Cancer Survivorship | AACR. https://cancerprogressreport.aacr.org/disparities/cdpr24-contents/cdpr24-disparities-in-cancer-survivorship/. 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Health Disparities Between Women With and Without Disabilities: A Review of the Research. \u003cem\u003eSoc Work Public Health\u003c/em\u003e. 2010;25(3):368-386. doi:10.1080/19371910903240969\u003c/li\u003e\n\u003cli\u003eKwon M, Lawn S, Kaine C. Understanding Men\u0026rsquo;s Engagement and Disengagement When Seeking Support for Mental Health. \u003cem\u003eAm J Mens Health\u003c/em\u003e. 2023;17(2):15579883231157971. doi:10.1177/15579883231157971\u003c/li\u003e\n\u003cli\u003eKline RM, Arora NK, Bradley CJ, et al. Long-Term Survivorship Care After Cancer Treatment - Summary of a 2017 National Cancer Policy Forum Workshop. \u003cem\u003eJNCI J Natl Cancer Inst\u003c/em\u003e. 2018;110(12):1300-1310. doi:10.1093/jnci/djy176\u003c/li\u003e\n\u003cli\u003eLage DE, Keating NL, Temel JS. Integrating Functional Assessment Into Clinical Decision-Making for Older Adults Across the Cancer Care Continuum. \u003cem\u003eJCO Oncol Pract\u003c/em\u003e. 2022;18(7):e1056-e1059. doi:10.1200/OP.22.00231\u003c/li\u003e\n\u003cli\u003eRecklitis CJ, Syrjala KL. Provision of integrated psychosocial services for cancer survivors post-treatment. \u003cem\u003eLancet Oncol\u003c/em\u003e. 2017;18(1):e39-e50. doi:10.1016/S1470-2045(16)30659-3\u003c/li\u003e\n\u003cli\u003eFerro AM, Mercado J, Quinn L. On \u0026ldquo;Training an Anti-Ableist Physical Therapist Workforce: Critical Perspectives of Health Care Education That Contribute to Health Inequities for People With Disabilities\u0026rdquo; Whalen Smith CN, Havercamp SM, Tosun L, et al. Phys Ther. 2024;104:pzae092. 10.1093/ptj/pzae092. \u003cem\u003ePhys Ther\u003c/em\u003e. 2025;105(5):pzaf035. doi:10.1093/ptj/pzaf035\u003c/li\u003e\n\u003cli\u003ePierannunzi C, Hu SS, Balluz L. 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Cannabis Use and Subsequent Cigarette Discontinuation Among U.S. Adults in the Population Assessment of Tobacco and Health Study, Waves 1\u0026ndash;5. \u003cem\u003eNicotine Tob Res\u003c/em\u003e. 2024;27(2):208-216. doi:10.1093/ntr/ntae202\u003c/li\u003e\n\u003c/ol\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":"BRFSS, cancer survivorship, disability, health disparities, functional limitation, Medicaid expansion","lastPublishedDoi":"10.21203/rs.3.rs-7437296/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7437296/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose:\u003c/strong\u003e Functional disability presents an emerging concern among cancer survivors, yet its contribution to long-term hardship has not been well defined. This study assessed the association between functional disabilities and survivor hardship in a nationally representative U.S. cohort.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e Data from the 2017–2022 Behavioral Risk Factor Surveillance System (BRFSS) were used to identify adult cancer survivors. Functional disability was defined as self-reported mobility, cognitive, or self-care limitation. Survivor hardship was defined as experiencing ≥2 of the following: inability to work, frequent mental distress (≥14 days/month), cost-related unmet medical care, or physical inactivity. Weighted multivariable logistic regression assessed the association between disability and hardship. Difference-in-differences analysis evaluated the role of Medicaid expansion among low-income survivors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Among 3.57 million weighted survivors, disability prevalence was 28.0% for mobility, \u0026nbsp;12.9% for cognitive, and 6.4% for self-care disability. Each disability type was independently associated with greater hardship, with cognitive disability demonstrating the strongest association (aOR 4.15, 95% CI 3.03–5.67). Sex-stratified models showed greater hardship among women for cognitive and self-care disability compared with men. Medicaid expansion was not significantly associated with reductions in hardship among low-income cancer survivors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eFunctional disability is highly prevalent and strongly associated with multidimensional hardship among cancer survivors. Sex-based disparities and socioeconomic vulnerability underscore the need for disability-informed survivorship care and supportive policy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Cancer Survivors: \u003c/strong\u003eFunctional disability substantially increases the risk of hardship; religiosity-independent policy levers such as targeted rehabilitation, mental health support, and financial navigation may be required to mitigate long-term adverse impacts.\u003c/p\u003e","manuscriptTitle":"Functional Disability and Multidimensional Hardship Among Cancer Survivors in the United States: A Nationally Representative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-15 17:49:01","doi":"10.21203/rs.3.rs-7437296/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-19T19:04:02+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T19:02:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230030491678573637349180762735654432701","date":"2025-12-08T19:05:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-29T16:56:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"156261220020356020860375592200257035587","date":"2025-09-16T14:13:13+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"168529462938224714864035820390787125476","date":"2025-09-08T21:12:19+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-08T17:59:31+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-25T02:38:02+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-08-25T02:37:17+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cancer Survivorship","date":"2025-08-22T20:33:21+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":"19b4e87c-f87a-4696-be7e-d62bbd1b5f68","owner":[],"postedDate":"September 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:07:11+00:00","versionOfRecord":{"articleIdentity":"rs-7437296","link":"https://doi.org/10.1007/s11764-026-01981-y","journal":{"identity":"journal-of-cancer-survivorship","isVorOnly":false,"title":"Journal of Cancer Survivorship"},"publishedOn":"2026-02-12 15:58:52","publishedOnDateReadable":"February 12th, 2026"},"versionCreatedAt":"2025-09-15 17:49:01","video":"","vorDoi":"10.1007/s11764-026-01981-y","vorDoiUrl":"https://doi.org/10.1007/s11764-026-01981-y","workflowStages":[]},"version":"v1","identity":"rs-7437296","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7437296","identity":"rs-7437296","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}