The study team, led by Therese Christensson of Karolinska Institutet, identified 2,576 cancer survivors within the SCAPIS cohort, a population-based sample of roughly 30,000 randomly selected Swedes aged 50 to 64 recruited between 2013 and 2018 at six sites across the country. By linking SCAPIS data to the Swedish National Patient Registry using ICD-9 and ICD-10 codes, the researchers identified survivors of breast, prostate, lung, colorectal, and urinary bladder cancers as well as malignant melanoma, excluding childhood and young-adult cancers by setting the year 2000 as a diagnostic cut-off. The median participant was 59 years old, 57 percent were women, and the median time since diagnosis was a remarkable 13 years, making this a genuinely long-term survivorship population rather than a recently treated one. Malignant melanoma dominated the sample at about half of all cases, followed by breast cancer at 25 percent and prostate cancer at 15 percent.

What sets this analysis apart technically is its measurement strategy. Physical activity was captured with tri-axial ActiGraph accelerometers worn on the hip for seven consecutive days, with valid days defined as at least 600 minutes of wear time and intensity thresholds set at counts per minute: below 200 for sedentary behaviour, 200 to 2,689 for light activity, 2,690 to 6,166 for moderate activity, and above 6,167 for vigorous activity. Meeting the physical activity recommendation was operationalized as at least 150 minutes per week of moderate-to-vigorous activity, equivalent to 22 minutes per day under national Swedish guidance. Diet was scored with the Swedish dietary guideline index, or SweDGI, a 12-component food-based index spanning encouraged items such as fruits, vegetables, legumes, nuts, whole grains, fish, and unsaturated fats, alongside discouraged items including red and processed meat, high-fat dairy, added sugar, alcohol, and salt, with a maximum score of 48 and a cut-off of 26 points marking good adherence. Alcohol was screened with the AUDIT-C questionnaire, smoking status by self-report, and sleep quality with a single item from the Basic Nordic Sleep Questionnaire.

The accelerometer data reveal a population that is, on the surface, reasonably active but profoundly sedentary. Most survivors met the weekly physical activity recommendation, with the lowest figure, 76 percent, appearing among the oldest lung cancer survivors. Yet on average, survivors spent eight hours per day, or 55 percent of wear time, sedentary, only 46 minutes in moderate activity, and less than a single minute, just 0.08 percent of the day, in vigorous activity. Prostate cancer survivors were the most sedentary group at 8.4 hours per day, while breast cancer survivors were the least at 7.6 hours. Men consistently sat more than women, accumulating at least eight sedentary hours daily across all cancer types, and younger survivors were significantly more likely than older ones to meet the activity target, although no sex difference emerged on that specific measure.

Diet was the clearest failure point. Only 41 percent of survivors met the dietary recommendation overall, and the sex gap was dramatic: 53 percent of women achieved good adherence compared with just 26 percent of men, a highly significant difference. Breast cancer survivors fared best at 56 percent, while male lung cancer survivors sat at the bottom with only 17 percent meeting the recommendation. This matters because prior research, cited by the authors, links diet quality to survival: good-quality diets are associated with improved survival in breast and colorectal cancer survivors, while Western-style diets high in fat, red meat, and processed foods have been tied to recurrence in colorectal cancer and to higher all-cause mortality across several cancer groups.

Alcohol told a similar story of quiet excess. Roughly a third of survivors consumed alcohol above recommended levels, with cut-offs set at more than five points on the AUDIT-C for men and more than four for women, based on Swedish national guidance. Prostate cancer survivors had the lowest proportion meeting the alcohol recommendation at 62 percent, while breast cancer survivors had the highest at 71 percent. Women were significantly more likely than men to stay within limits, 73 percent versus 62 percent. The authors caution that comparisons with general population data are imperfect, since Swedish population surveys typically define risk consumption by weekly standard drinks, whereas AUDIT-C also captures episodes of heavy drinking and cannot be directly translated into weekly intake. Still, the contrast is suggestive: only about 16 percent of the general Swedish population is estimated to drink above recommended levels, compared with roughly a third of these survivors.

Not all the news was grim. Smoking, often the most damaging modifiable factor after a cancer diagnosis, was largely under control: 88 percent of survivors were former or never smokers, mirroring the roughly 11 percent smoking prevalence in the general Swedish population. The glaring exception was lung cancer, where a full third of survivors still smoked, a finding with serious consequences given evidence that cessation after a lung cancer diagnosis reduces the risk of second primary lung tumours and that continued smoking raises both overall and cancer-specific mortality. Sleep quality was also broadly satisfactory, with 82 percent reporting good sleep and most sleeping seven to eight hours per night, though men outperformed women across nearly all cancer types, and close to a third of female urinary bladder cancer survivors and older colorectal cancer survivors reported poor sleep. Given that the median survivor was 13 years past diagnosis, the authors note this may indicate that sleep disturbances can persist for many years after treatment ends.

Perhaps the most consequential finding concerns combinations. Nearly everyone, 99 percent, met at least one recommendation, but only about half met four or more of the five, and just a small minority achieved all five. Meeting multiple recommendations differed significantly across cancer types, with breast cancer and malignant melanoma survivors doing best; 22 percent of breast cancer survivors met all five lifestyle recommendations. Women were significantly more likely than men to meet multiple recommendations. The steepest drop-offs came at the harder end of the spectrum: the transition from three to four recommendations coincided with a 32 percentage-point decline among lung cancer survivors, while prostate cancer survivors showed the largest fall, 17 percentage points, between two and three. Prior research suggests this stacking matters biologically, since meeting four or five lifestyle factors has been associated with lower incidence of cancer, cardiovascular disease, and diabetes compared with meeting none, and meeting multiple recommendations appears more protective for survival than meeting any single one.

The authors are candid about limitations. Dietary data were self-reported and vulnerable to underreporting, overreporting, and social desirability bias, which means the true proportion failing dietary recommendations could be still higher than observed. Dichotomizing each lifestyle factor into met or not met inevitably discards nuance, multimorbidity, cancer stage, and treatment information were unavailable, and the 13-year median time since diagnosis raises the possibility of survival bias, since survivors who lived long enough to participate may be healthier overall. The restriction to adults aged 50 to 64 also limits generalizability to younger or older survivors and to populations outside Sweden, although the cohort broadly resembles the Swedish population in education, activity level, and country of birth.

Even with those caveats, the message for clinical practice is pointed. With roughly 600,000 people in Sweden living with cancer as of 2022 and survivor numbers rising worldwide as treatment improves, secondary prevention is becoming a central task of oncology follow-up. The World Cancer Research Fund encourages survivors to adhere to lifestyle recommendations as much as possible, and evidence continues to accumulate that structured exercise can improve survival and functioning, as a recent phase III trial in colorectal cancer demonstrated. This study suggests that follow-up care should move beyond single-issue advice and toward integrated interventions that target multiple behaviours simultaneously, with particular urgency around diet and alcohol, and with tailored outreach to the groups falling furthest behind, including male survivors, lung cancer survivors who continue to smoke, and prostate cancer survivors whose sedentary hours and drinking habits may quietly erode the survival their treatment won.

Subject of Research: Adherence to lifestyle recommendations among long-term cancer survivors

Article Title: Meeting lifestyle recommendations among cancer survivors – a cross-sectional descriptive analysis from the Swedish CArdioPulmonary BioImage study (SCAPIS)

Article References: Christensson, T., Hagströmer, M., Algurén, B., Bergman, F., Bäck, M., Drake, I., Porserud, A., Rossen, J., & von Rosen, P. (2026). Meeting lifestyle recommendations among cancer survivors – a cross-sectional descriptive analysis from the Swedish CArdioPulmonary BioImage study (SCAPIS). Journal of Cancer Survivorship. https://doi.org/10.1007/s11764-026-02140-z

Image Credits: AI Generated

DOI: 10.1007/s11764-026-02140-z

Keywords: cancer survivors, lifestyle recommendations, SCAPIS, physical activity, diet quality, alcohol consumption, smoking cessation, sleep quality, secondary prevention, accelerometry, survivorship, Sweden