Mortality Outcomes for Survivors of Cancer With Food Insecurity in the US.

Importance: Food insecurity, which is characterized by limited or uncertain access to adequate food, affects approximately 40 million individuals in the US, including many patients with cancer. Understanding the association between food insecurity and cancer mortality is crucial for improving patient outcomes and addressing health disparities. Objective: To investigate the association of food insecurity with cancer-specific and all-cause mortality among US adults with a diagnosis of cancer. Design, Setting, and Participants: This cohort study used nationally representative data from the 2011 to 2012 National Health Interview Survey that were linked to the National Death Index, with mortality follow-up through December 31, 2019. It included 5603 respondents to the National Health Interview Survey 40 years and older who reported receiving a diagnosis of cancer and responded to food security questions. Exposure: Food insecurity was measured using a validated 10-item National Center for Health Statistics food insecurity scale, categorized as food secure (0-2) or food insecure (3-10) based on US Department of Agriculture guidelines. Main Outcomes and Measures: The primary outcomes were cancer-specific mortality (International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes: C00-C97) and all-cause mortality. Cox proportional hazards models were used to estimate hazard ratios (HRs) for these outcomes, adjusting for age, sex, race and ethnicity, household income, US region, body mass index, smoking, alcohol use, comorbidities, and survey year. Results: Among the 5603 participants (mean [SD] age, 67.03 [12.03] years; 3298 female individuals [59%]; 320 Hispanic individuals [6%], 22 Native American individuals [0.4%], 136 non-Hispanic Asian individuals [2%], 529 non-Hispanic Black individuals [9%], 4519 non-Hispanic White individuals [81%], and 75 multiracial or multiethnic individuals [1%]), the prevalence of food insecurity was 10.3% among survivors of cancer. Food insecurity was associated with higher all-cause mortality (HR, 1.28; 95% CI, 1.07-1.53) but not cancer-specific mortality after full adjustment. Subgroup analyses indicated that food insecurity was associated with cancer and all-cause mortality for those individuals with household incomes 200% or greater than the federal poverty level (cancer-specific mortality: HR, 1.93; 95% CI, 1.18-3.15; all-cause mortality: HR, 1.89; 95% CI, 1.34-2.68) and those not receiving food assistance (cancer-specific mortality: HR, 1.42; 95% CI, 1.00-2.01; all-cause mortality: HR, 1.42; 95% CI, 1.14-1.76). However, there was no significant association between food insecurity and cancer-specific or all-cause mortality for people with incomes less than 100% of the federal poverty level and households participating in food assistance programs. Conclusions and Relevance: The results of this cohort study suggest that food insecurity is a substantial factor associated with increased mortality among survivors of cancer. Addressing food insecurity through routine screenings and connecting patients with food assistance programs may improve survival outcomes, and further research should examine the longitudinal effects of integrating routine food insecurity screenings within cancer care settings and expanding food assistance program eligibility.