Residential mobility among adult cancer survivors in the United States

The places people reside throughout their lives play an important role in their health-related behaviors and their propensity to develop diseases [1]. While socioeconomic status (SES), demographic factors, environmental exposure conditions, and access to healthcare in the neighborhoods in which people reside are recognized as critical elements in promoting health and health equity [2, 3], the geospatial context of health and place has not been routinely incorporated in health research and healthcare delivery [4, 5]. In studies that have incorporated neighborhood level factors, the emphasis has largely been on the current place of residence, while little information is available regarding residential mobility, particularly in the context of cancer.

A cancer diagnosis may trigger relocation for a variety of reasons which may have a positive or negative impact on care delivery and coordination, quality of life, and ultimately survival. Relocation has been used as a proxy for household financial hardship, disruption of care continuity, and disruption of social networks, all of which carry negative impacts to health and psychosocial wellbeing, as well as survival of cancer patients [6‐8]. Relocation has been found to be associated with an increased rate of late stage cancer diagnosis and an increased risk of 10-year cancer-specific mortality based on cancer registry data [6]. Geographic mobility has also been used as a proxy for social re-integration and the morbidity burden associated with mortality among survivors of childhood cancer [9]. In addition age, sex, and SES were found to be associated with mobility regardless of cancer type and relapse status [9]. Despite the potential influence of residential mobility on cancer care and survival, we know little about the dynamic patterns of relocation, reasons for relocation, and their subsequent effects on a variety of health outcomes among cancer patients and survivors.

To address these knowledge gaps, we used data from the National Health Interview Survey (NHIS) to understand residential mobility for a representative sample of the non-institutionalized U.S. civilian adult population. We aimed to compare neighborhood tenure between those with and without a history of cancer and identify sociodemographic factors associated with neighborhood tenure and relocation after the first cancer diagnosis. To the best of our knowledge, this is the first estimate of residential mobility among the non-institutionalized civilian adult population with and without cancer and identified sociodemographic factors influencing their residential mobility. Understanding these residential history patterns and risk factors, particularly modifiable ones, among cancer survivors is a first step towards a better assessment of the unmet needs among this vulnerable population. With continued growth of the cancer survivor population [10, 11], results from this study may provide novel insights into improving coordinated cancer care continuity for cancer survivors and reducing cancer disparities.

Little is known about residential mobility and its associated risk factors among cancer survivors and people in general despite the fact that neighborhood environment plays a critical role in people’s health and their health-related behaviors. Based on a large nationally representative sample, we presented a first estimate of residential mobility among the non-institutionalized civilian adult population with and without cancer, and identified sociodemographic factors influencing their residential mobility. Our results provide new insights into incorporating the spatiotemporal contexts of where people live into health research in general, and among vulnerable subpopulation groups such as cancer survivors.

We found that a quarter of the US non-institutionalized civilian adults had a neighborhood tenure between 4 and 10 years, and 59% had resided in their neighborhood for less than 10 years. Our findings of the general residential tenure are aligned with the estimates from the U.S. Census, which showed that the average 5-year moving rate in the U.S. population was approximately 35% and the median residence duration was approximately 5 years [17, 18]. The percentage of < 1 year neighborhood tenure was 13.1% overall, which is similar to that found in the general population based on census data, where 11.7% of the US population (35.9 million) had moved between 2012 and 2013 [19]. The proportion of moving for “health reasons” was small in the census data, and was collapsed into the “other” category, which only represented 2.3% of the sample, while the three major reasons for moving were family-related (30.3%), employment-related (19.4%), and housing-related (48.0%) [19]. In NHIS samples, a sizable proportion of cancer survivors (25.6%, equivalent to 5.4 million) had changed neighborhoods after their first cancer diagnosis.

Our results expand upon the descriptive epidemiology in the current literature by quantifying the associations between multiple risk factors and neighborhood tenure and relocation. Neighborhood tenure in both cancer and non-cancer groups in general was affected by a similar set of common socioeconomic and demographic factors, including age, education, income, health insurance, and family structure. Sensitivity analyses indicated these main findings were robust. These observed associations were consistent with the set of factors for neighborhood relocation among those with cancer. For example, we found that adults with family income below the poverty threshold, with a lower level of education and without health insurance coverage were more likely to move after their first cancer diagnosis. Among cancer survivors, detailed reasons of neighborhood tenure and relocation may differ by cancer status (e.g. cancer types, cancer treatment and survival status). We found that the proportion of relocation among participants with a history of lung cancer, which has a low survival rate (5-year survival rate ~ 20% [20]), was one quarter of that among participants with a history of cervical cancer (5-year survival rate 66% [21]).

Despite the similarities in neighborhood tenure between people with and without a history of cancer, cancer survivors may face unique challenges. This is supported by results from the propensity-score-matched analysis, where cancer survivors experienced increased odds of shorter neighborhood tenure than their non-cancer counterparts. A relocation may result from or inflict a larger health, psychosocial, and economic burden among cancer survivors than those without cancer. Our stratified analysis showed that unemployment status increased the odds of shorter neighborhood tenure among cancer survivors, while the opposite was true for non-cancer adults. Changes in employment status may be a direct result of a cancer diagnosis and its related treatment, which tend to adversely affect cancer survivors. Work ability and performance [22, 23]. Moreover, changes in employment status may also adversely contribute to financial toxicity among cancer survivors, such as reduced income and loss of employer-sponsored health insurance coverage [23, 24], all of which may in turn prompt a move. For people who were already facing financial hardship predating a cancer diagnosis, relocation may add additional strain and psychosocial stress. Qualitative investigations have found a potential spiral to acute and irreversible financial stress among patients who had to relocate for specialist treatment for hematological malignancy [25]. Other studies have demonstrated extra financial burden and physiologic stress associated with cancer diagnosis and treatment that led to delaying or forgoing treatments and medications, reduced quality of life, and ultimately mortality [26‐31]. However, few studies have investigated the sequelae of residential mobility among cancer patients and survivors. We were only able to find one such study, where a recent relocation (within 3 years) prior to a second cancer diagnosis was associated with an approximately 30% increased risk of late-stage presentation and a 26% increase in 10-year cancer-specific mortality, and the negative impact was larger for patients living in the least wealthy counties [6].

It stands to reason to postulate that a shorter residential tenure and neighborhood relocation may cast a stronger negative impact on the overall well-being of cancer survivors, as residential mobility is closely related to household financial hardship, disruption of care continuity, and disruption of social networks [6‐8, 10]. Alternatively, a relocation to be closer to family members and friends, closer to cancer treatment facilities, to a more affordable and/or friendly neighborhood, to be closer to a job, or a combination of these, may also help alleviate the financial and psychosocial stress among cancer survivors. Our analysis showed that those who considered their own neighborhoods to have strong social cohesion were more likely to stay in the neighborhood. This previously unreported finding may have potential implications in improving care and outcomes while reducing disparities in cancer survivorship. Indeed, longitudinal studies have shown that the overall, cardiovascular disease-specific, and cancer-specific mortality rates were positively associated with neighborhood improvement while negatively associated with neighborhood deterioration [32].

With continued improvement in early detection and treatment options for cancer, the proportion of people who have had a cancer diagnosis is expected to grow. Our estimates of residential mobility among adult cancer survivors are critical to inform policies and practices aimed at improving survivorship care and outcomes as well as reducing cancer disparities. Shorter neighborhood tenure and neighborhood relocation may increase financial hardship, disrupt cancer patients’ social and care support networks, and interrupt continuity of care. These negative impacts are potentially greater among those with low socioeconomic status. On the other hand, sound neighborhood built environments including high social cohesion can provide positive impacts among cancer survivors. To examine the long-term implications for health and economic well-being associated with cancer, awareness of residential mobility, an important aspect that has often been neglected, should be incorporated into medical care research and practice.