Financial Hardship and Unhealthy Lifestyles: Perspectives and Solutions From Breast Cancer Survivors and Their Care Teams

Abstract

Introduction

Financial hardship may undermine healthy lifestyle behaviors that are important for preventing avoidable recurrence and death during survivorship after breast cancer diagnosis. Significant research has characterized these challenges and disparities, but relatively little research has identified which strategies patients and their teams may prefer to overcome these challenges. We employ an assets lens to highlight patient-identified strategies to circumvent barriers across Social-Ecological Model (SEM) levels.

Methods

We conducted a secondary qualitative analysis of semi-structured interviews with 26 Black/Latina breast cancer survivors and 10 oncology providers recruited from a single health system (2019–2020). Transcripts (English/Spanish) were coded using deductive and inductive approaches, and these codes were subsequently organized into themes and mapped to SEM levels.

Results

Survivors used multi-level strategies to maintain healthy behaviors while navigating financial hardship. At the individual level, women budgeted proactively, substituted canned/frozen vegetables for fresh produce, and relied on home-based exercise, often supported by emotion-focused coping. Interpersonal strategies drew on family and friends for transportation, childcare, and accountability. Community-based solutions included church-based aid, food pantries, public benefits, and transportation vouchers, frequently facilitated by social workers. Organizational solutions centered on multidisciplinary survivorship clinics that provided financial navigation, consolidated appointments, and cost-tailored lifestyle counseling. Providers corroborated these strategies and emphasized clinic-level interventions (e.g., consolidated appointment scheduling, proactive financial and nutritional screening) to reduce financial hardships.

Conclusion

Black and Latina breast cancer survivors and their providers deploy pragmatic strategies across multiple SEM levels to sustain healthy behaviors under financial hardship. However, community- and organization-level solutions remain underutilized in interventions, and few trials have integrated financial navigation with lifestyle interventions. Embedding proactive financial and nutrition security screening, bilingual financial navigation, and community partnerships into lifestyle interventions and survivorship care could reduce structural barriers, improve lifestyle guideline adherence, and advance equity in cancer outcomes.

Plain Language Summary

Women treated for breast cancer often want to eat healthy and be active, but the cost of care can make it challenging. In our interviews with Black and Latina breast cancer survivors and oncology care providers, women shared how they adapted to financial stress by choosing more affordable options such as canned instead of fresh produce, walking or exercising at home instead of paying for gym fees, and leaning on family and friends for childcare and transportation. Some also used community resources such as churches and food pantries while others worked with members of their care team such as social workers and dietitians to look for resources and solve problems together. Connecting health care providers with community programs can help survivors get guidance that fits their budgets and allows them to pursue healthy habits during and after treatment.

Introduction

Healthy lifestyles are known to be important for cardiovascular health, emotional and psychological well-being, and physical function, but they also contribute to the maintenance of a healthy body weight and improved cancer outcomes for cancer survivors. ¹ The American Society of Clinical Oncology (ASCO), American Cancer Society (ACS), and the American Institute of Cancer Research (AICR) have issued several dietary and physical activity recommendations and guidelines for breast cancer survivors,^2,3 which have been directly linked to improvement in overall breast cancer-related health outcomes and reduced risk for breast cancer recurrence and mortality.^4,5

The Socioecological Model (SEM) provides a valuable framework for contextualizing cancer-related experiences by examining how health behaviors and outcomes are shaped by interacting influences at multiple levels. This approach is particularly important for research in minoritized populations, as it explicitly situates individual behaviors within broader interpersonal, institutional, community, and policy contexts. ⁶ Because determinants of adopting recommended healthy lifestyle behaviors are multifactorial, barriers and facilitators have been documented across all levels of the SEM, including individual (e.g., low income status, under- or uninsured status, gaps in identifying financial resources), interpersonal (e.g., reliance on social networks), community norms/dynamics (e.g., suboptimal built environment, limited access to affordable food or exercise facilities), and organizational/structural barriers (e.g., evolving/unclear treatment guidelines, inadequate provider counseling, limited referral to lifestyle experts, ⁷ lack of insurance coverage, instability and limited availability of financial assistance programs).^8-10

Cancer-related financial hardship, defined as “the adverse impact of a cancer diagnosis on a patient’s financial well-being resulting from direct or indirect costs of cancer diagnosis and treatement”, ¹¹ is disproportionally prevalent among Black and Latina breast cancer survivors.^12-14 Increased financial hardship may stem from treatment-related reduction in work hours, income loss, employment status change, loss of health insurance, difficulty paying for care, and the need to borrow money, incur debt, or file for bankruptcy following diagnosis.^15,16 Financial hardship has been linked to worse survivorship outcomes, including poorer quality of life, ¹⁷ greater psychosocial distress,^18,19 and increased mortality.^20,21 Prior to diagnosis, Black and Latina women are also more likely to experience financial hardship and food insecurity and to reside in low-income neighborhoods with limited access to affordable healthy foods and opportunities for physical activity.

Black, Latino, and immigrant patients are more likely than their White and non-immigrant counterparts to experience food insecurity, ²² rely on food pantries, ²³ and reduce food spending following a cancer diagnosis. ²⁴ As financial distress increases, survivors are also more likely to alter cancer treatment and lifestyle behaviors^25,26 and experience elevated nutritional risk, such as appetite changes or reliance on liquid diets.^23,27

Although a growing body of research has documented barriers to food security and healthy lifestyle behaviors among cancer survivors, relatively little work has examined which strategies patients and their care teams identify as feasible and effective for addressing these challenges. To address this gap, we adopt an assets-based lens to highlight patient- and provider-identified solutions that support healthy nutrition and physical activity among Black and Latina breast cancer survivors. We hypothesize that effective strategies extend beyond individual behaviors change and involve support from interpersonal, organizational and community systems.

In framing these solutions, we draw on an expanded Socioecological Model (SEM) as described by Lopez-Class and colleagues, which conceptualizes health behaviors as shaped by interacting influences across five domains: intrapersonal, interpersonal, institutional, community, and policy contexts. ²⁸ At the intrapersonal level, the model emphasizes how individual circumstances, beliefs, and resources are embedded within broader social and economic conditions. Interpersonal influences reflect the role of social relationships, norms, and support systems in shaping health-related decision-making. Community contexts encompass the social, cultural, and physical environments in which individuals live, including collective norms and locally available opportunities. Institutional factors capture how organizational structures, practices, and care delivery environments enable or constrain access to health-promoting resources. Finally, policy-level influences reflect the broader regulatory, economic, and political environments that shape access to services and protections. This expanded SEM is particularly relevant for cancer survivorship research among structurally marginalized populations because it explicitly places individual behavior within healthcare systems and policy environments, without assuming that responsibility for health rests solely with the individual. We apply this framework to examine how financial hardship operates across multiple contextual and ecological factors and identify multilevel solutions that support healthy lifestyle behaviors during survivorship.

Materials and Methods

Parent Study

This secondary qualitative analysis draws on interviews collected for a parent study that explored survivors’ experiences with healthy lifestyle behavior change during breast cancer survivorship. ¹⁰ Women were asked about diet and physical activity behavior changes before and after diagnosis, barriers and motivators for behavior change, and perceptions about lifestyle risk factors for cancer. Providers were asked about their perspectives and experiences with lifestyle counseling and the barriers they perceived for behavior change among their patients. The interview study guides have been published. ¹⁰

Halfway through recruitment and in order to capture a wide range of finance-related experiences with lifestyle behavior change, the authors of the parent study purposely sampled women who self-reported experiences with financial hardships since their diagnosis at the time of screening. Financial hardship was broadly defined as any experience with financial challenge, barriers, or distress at around the time of breast cancer diagnosis. The parent study did not pre-specify financial hardship as a research question nor were questions about hardship included in the original semi-structured interview guide. Nonetheless, a rich dataset on financial hardship as a determinant of behavior change emerged naturally, enabling us to ask a new research question with this focus.

The parent study recruited a convenience sample of 26 women and 10 healthcare providers who were associated with a single health system with an established multidisciplinary survivorship care clinic from March 2019 to March 2020 in New Haven, CT. ¹⁰ Survivors were identified through various mechanisms including the electronic health record, flyers, word of mouth, provider referral, during breast cancer clinic visits, and through community support groups. Women were then either approached in-person during a clinic visit and/or received a letter via mail describing the study. A total of 41 breast cancer survivors were approached selectively and invited to participate. A total of 26 enrolled in the study (15 Black, 10 Latina, 1 participant who identified as Black and Latina and was categorized with Black participants for coding purposes). Health care providers were identified through affiliations with the Yale New Haven Health System. An email with a brief study description was sent to each provider. A reminder email was sent approximately 3 weeks later. A total of 27 healthcare providers from diverse clinical specialties (e.g., surgical/medical oncology, dietary services, physical therapy, social work, nursing) were invited to the study, and 10 agreed to participate. Three healthcare providers worked directly with the survivorship clinic; none were part of the research team. All participants were informed that the general goal of the study was to understand behavior change during breast cancer survivorship and that the interviewer was a doctoral candidate studying the link between lifestyle behaviors and cancer.

The eligibility criteria for survivors included having a breast cancer diagnosis, self-identifying as Black and/or Latina, being 18 years or older, not having a psychiatric illness, and not being currently enrolled in a lifestyle intervention. Healthcare provider eligibility included practicing in a hospital and/or community oncology setting affiliated with the Yale New Haven Health System and being likely to provide lifestyle counseling or offer referrals in the setting of cancer survivorship (e.g., surgery, medicine, nursing, dietetics, and physical therapy and rehabilitation). ¹⁰ In this manuscript, we also refer to women participants as “survivors,” i.e., any person with a cancer diagnosis regardless of the time since diagnosis ²⁹ . Herein, we focus on post-treatment survivorship while acknowledging that some financial limitations began prior to diagnosis.

Audio-recorded Spanish and English interviews lasted about 60-120 minutes and were conducted by a trained, female bilingual team member (MSP, PhD Candidate at time of interview), in person, at participants’ homes or in the research office. Provider interviewers were conducted in person or over the phone and lasted 30-60 minutes. No other persons were present during interviews. All interviews were transcribed verbatim, and transcripts were analyzed in their original language to maintain culturally bound phrases. ³⁰ Bilingual team members (MSP, CN, KP) coded Spanish transcripts in Spanish and English transcripts in English, and monolingual team members also coded English transcripts (AG). Selected quotes were translated by MSP and CN for dissemination purposes. We ensured rigor through double coding of an initial subset of transcripts, iterative codebook reconciliation, peer debriefing, and triangulation; disagreements were resolved by consensus ³¹ meetings with a fourth team member (YM).

Current Study

In the present study, we decided to perform a focused secondary analysis with a new question—how survivors navigate the financial hardships that shape diet and physical activity in survivorship—applying the SEM framework and an assets lens to identify patient-generated solutions. We developed a deductive framework from survivorship guidance and financial hardship literature,^32,33 iteratively reviewed transcripts for inductive codes, and then mapped themes to SEM levels.

Statistical Analysis

We used all transcripts in their original de-identified forms (n=36) and recoded the data using sequential deductive and inductive coding in Dedoose. ³⁴ All other data not related to financial hardship were excluded. Second, financial hardship excerpts were re-read and coded in vivo to allow new ideas to emerge through an iterative process. All coders were fluent in Spanish and met to compare codes and translations to resolve discrepancies. Our research team (MSP, KP, AG, CN) held weekly consensus meetings to discuss coding and interpretation to foster agreement and generate a final codebook and also to come to an agreement on the themes. We also held peer debriefing meetings with another team member (YM) to finalize the grouping of codes into thematic categories. Interpretation of our data was informed by literature on financial hardship and the SEM and assets-lens frameworks. In doing so, we identified four broad themes that enabled participants to overcome barriers to the adoption and maintenance of a healthy lifestyle due to financial hardship. Our themes are presented within the dimensions of the SEM framework, a perspective that is optimal to inform equity-focused interventions and institutional and policy programming.

The parent study was conducted according to the guidelines of the Declaration of Helsinki of 1975 and approved by the Yale Human Investigation Committee on 3/7/2019 (HIC # 2000025065). Secondary analysis reported in this study was approved by the Institutional Review Board at the Perelman School of Medicine at the University of Pennsylvania on 10/10/2022 (Protocol ID # 852208). Verbal informed consent was obtained from all individual participants included in the parent study prior to the start of the interview. The reporting of this study conforms to the COREQ guidelines. ³⁵

Results

Study Sample

The study sample has been previously described in detail with tables containing the same demographic and clinical characteristics applicable to participants in the current study. ¹⁰

Among 26 breast cancer survivors, most were aged 51 years or older (85%, range=28-69 years, median = 50, SD = 10.67), 58% self-identified as Black, 38% as Hispanic/Latino and 4% as mixed-race/ethnicity. 54% of survivors were born in the continental USA, 12% in South America, 31% in the Caribbean islands, and 4% in West Africa. Most survivors reported not being married (65%) and interviewed in English (69%). In terms of education level, 8% of survivors had less than a high school degree, 50% had a high school/GED (50%), and 62% reported some college education or beyond.

Regarding time from diagnosis, 42% were at least 2 years beyond diagnosis, 12% were 3-5 years, 38% were 6-11 years, and 8% were 11 or more years from diagnosis. The stage breakdown was as follows: 23% had stage 0, 42% had stage I, 31% had stage II and 0% had stage III or IV, 4% had unknown stage. In terms of cancer therapy, 23% of women underwent lumpectomy, 65% had a mastectomy, and 4% received neoadjuvant, 2% had missing surgical therapy, 4% received chemotherapy only, 15% received surgery only, and 81% had combination therapy, none received only hormone therapy or only radiation therapy. At the time of interview, 58% reported being in long-term treatment. Among 10 healthcare providers, we interviewed equal proportions of male and female health care providers, with over 20 years of experience working in an oncology setting (70%) and included providers in the following occupations: nursing, n=1; dietetics, n=2; physician, n=4; physician assistant, n =1; and physical therapy/rehabilitation, n=2.

Individual and Interpersonal Solutions

Solutions involved patient-driven strategies working alongside support from social networks to navigate the sometimes cost-prohibitive reality of engaging in a healthier lifestyle in the context of financial stressors and low socioeconomic status that may have existed prior to diagnosis. Survivors employed various solutions to overcome cost-related barriers including budgeting and bulk-cooking for the week to reduce food expenses outside the home or at work and buying frozen or canned produce as opposed to more expensive fresh produce. Alongside financial strategies, women relied on emotion-focused coping such as positive thinking and stress-reduction and drew motivation from family or friends who were recruited as accountability partners. For example, some women moved in with family members to minimize bills, received rides from friends to avoid transportation expenses, and received food coupons from neighbors. One participant explained: “All I did was go to the doctors, and I stayed out of work for almost a year. I was pretty much depleting the little bit of money that I have in my savings. I just couldn’t take it anymore, I had to go from paying out bills that were $4,000.00, $5,000.00 a month to me only being able to get my basic needs which was like food.” (Survivor #25), adding: “So then I came back to Connecticut and moved in with my mom. That helped eliminate some of the stress because all I had to worry about was just eating, that was it.” (Survivor #25)

For exercise, many participants incorporated physical activity into their everyday routine, such as parking their car farther away from their offices so they could increase their daily steps, exercising at home, or recruiting family members as “exercise buddies” when a trainer or gym was not financially feasible. One survivor emphasized the importance of family support for physical activity: “We went to walk, and this helped me a lot… and I told my nephews, ‘We have to go there to walk because I need this exercise.’” (Translation for Survivor #4)

Providers corroborated these strategies, noting the value of low-cost substitutions, integrating movement into daily routines, and connecting patients to free programs in the community and/or access to home-based, equipment-free physical activity. “And then the exercise piece of trying to work around their barriers there, too – what they have accessible, what time they have to do it, what can they do at home? I have little workouts for in the kitchen, in the family room, making every moment count. It's just a matter of putting the pieces together and having a plan.” (Provider #2)

Community-Level Solutions

Survivors also sought support from community resources when financial hardship limited access to food or exercise. Churches, food pantries, public benefits, and organizational grants provided direct assistance. Neighbors shared resources such as coupons, and some survivors used transportation vouchers to reach care. For example, one woman described: “The man that lives on the third floor, he is disabled. So, they give him food stamps and to my husband also, because we have had many problems with work, he also had to ask for help for nutrition, and they give him coupons as well. And he helps me with that. That is what we shop with here, with the man’s coupons, he helps us with those coupons.” (Translation for Survivor #14)

Hospital partners also helped survivors access community-level resources. Another survivor recalled receiving coordinated community support through hospital-linked agencies: “They covered two months of rent, sent money to pay my bills, and gave me grocery vouchers.” (Translation for Survivor #15) Providers echoed the importance of community partnerships, identifying food deserts, gym fees, and transportation as barriers best mitigated by faith-based organizations, YMCAs, and social services.

Organizational Solutions

Organizational solutions included access to social work for financial navigation and multidisciplinary survivorship care clinics. A multidisciplinary survivorship clinic is one model of survivorship care that provides cancer survivors with care from separate health care specialties–oncology, nursing, social work, dietetics, physical therapy^36,37—within a single clinic visit. Because our participants and providers were recruited from a single hospital system with an established multidisciplinary survivorship clinic, ³⁸ some patients had prior experience with the survivorship clinic environment and three of the health care providers interviewed worked in the survivorship clinic. Oncology care that requires multiple appointments and visits to the hospital can be a barrier. Consolidated scheduling reduced travel costs and time away from work while facilitating same-day access to multiple providers. As a result, the multidisciplinary survivorship clinic framework was critically important for many study participants. As one participant highlighted: “It is an inconvenience for me to go to the hospital every moment. I have to pay for a taxi or uber or look for friends; I don’t even look for [friends], because it is more expensive—because then I have to give them [money] for gas or invite them for lunch. So, it’s worse for me.” (Translation for Survivor #14)

Survivors valued financial navigation through social workers, who connected them to grants, public funding, and cost-tailored lifestyle recommendations. As one survivor noted: “Even though I’m getting money from the church, and I was getting food, I never lacked anything; my social worker was helping me to apply for these different programs which I was getting money from.” (Survivor #23) Others mentioned receiving a compiled list of grant opportunities from social workers that helped provide financial support: “They approached us various times to […] offer us what we needed—from companionship, therapy or psychological [services], yoga classes for exercise; if I was interested in a nutritionist; economic help—because there were some […] foundations that collaborate […] to help with fuel, things like that when one lives far. The truth is that I always had options for help.” (Translation for Survivor #20)

Providers supported women’s experiences by identifying the need for additional programming that was home-based or easily accessible in the community to reduce transportation barriers. They also underscored the importance of multidisciplinary teams and clinic-level solutions (e.g., consolidated appointment scheduling, proactive financial or nutritional screening, and tailored lifestyle counseling) to minimize referrals and appointments that in turn would reduce time off from work.

When reflecting on interventions that have worked, providers highlighted that tailored lifestyle counseling sessions helped patients with strategies to balance competing priorities at home and incorporate solutions for meal planning, grocery shopping, and purchasing healthy economical foods: “We have this multidisciplinary approach; it lends itself well to these underserved populations because they don’t need to be referred to go to multiple appointments that might [be] difficult for them—for whatever reason, whether it’s transportation, finances, and so on.” (Provider #1) They also emphasized the financial stakes of fragmented care: “And, for many people, to lose one day worth of payments is not a big deal, but for many people, that’s a huge deal. In the current system, if the lifestyle counseling has to come separately, that’s another day of work loss or financial stress added.” (Provider #5)

Discussion

There has been a call for research to investigate the ways in which patients with breast cancer cope with financial hardship. ³⁹ In this secondary qualitative analysis, we demonstrate how survivors enlist multi-level strategies to address financial hardships that shape healthy lifestyle behaviors, thereby identifying patient-generated, pragmatic solutions across SEM levels in a sample of Black and Latina breast cancer survivors. Our findings support prior work that links financial hardships expressed by survivors (e.g., rising out-of-pocket healthcare costs, work constraints, income loss, and insurance gaps) to narrowed options for healthy foods and safe physical activity. These hardships also contribute both to unhealthy behaviors by reducing patients’ cognitive bandwidth and limiting their self-control ⁴⁰ and also to a deterioration in diet quality during times of financial hardship, especially among socioeconomically disadvantaged groups.^41-43 Our study extends this evidence to survivorship, detailing the workarounds survivors and healthcare providers use to adopt and maintain a healthy diet and engage in physical activity under financial pressure and highlighting multi-level solutions for intervention.^33,44

Solutions and Coping Styles Across SEM Levels

At the individual level, survivors budgeted, bulk-prepared, and substituted frozen and canned produce for fresh. They replaced gym memberships with home-based or walking routines. Alongside these cost-saving measures, survivors leveraged emotion-focused strategies ⁴⁵ such as positive thinking, stress-reduction techniques, and early engagement with social support.^21,45 These approaches overlap with some strategies employed in prior lifestyle interventions for Black and Latina women. ⁴⁶

At the interpersonal level, participants leveraged family/friends for childcare, rides, and behavior accountability. Survivors also applied problem-focused skills such as seeking financial support from family and friends or boundary setting within social networks to protect health-related spending. ⁴⁵ Relatively few lifestyle interventions engaged survivors’ family/friends in their programming. ⁴⁶

At the community level, survivors sought church-based aid, food pantries, public benefits, organization-based grants, and transportation vouchers; they benefited from social work and financial navigation. Despite their importance, community-level solutions are largely absent from lifestyle interventions for Black and Latina breast cancer survivors, and almost no trial has incorporated community-based financial navigation into lifestyle programming. ⁴⁶

At the organizational level, participants benefited from consolidated scheduling in multidisciplinary survivorship clinics, same-day access to multiple providers, and lifestyle counseling tailored to their financial realities. These organizational strategies reduced costs, travel, and time away from work, but they are not commonly available across health systems, and most lifestyle interventions among Black and Latina women are rarely incorporated into survivorship care frameworks.^46-48

Practice and Policy Implications

Because Black and Latina survivors disproportionately experience pre-diagnosis economic disadvantage and structural barriers to receiving health care, ⁶ financial hardship amplifies inequities in guideline-concordant lifestyle change.^12,49 Our findings suggest several opportunities for culturally tailored interventions to meet the needs of Black and Latina breast cancer survivors to improve reach and adherence, thereby helping reduce inequities in Black and Latino communities. These include culturally relevant dietary counseling that maintains heritage-based diets while reducing costs; Spanish-language financial navigation to address concurrent financial and language barriers; and neighborhood resources such as community centers and faith-based programs to minimize travel burdens and foster trust. These strategies align with equity-oriented survivorship care and reinforce the need to embed both financial and behavioral support into routine follow-up of survivors. ⁵⁰

Embedding bilingual financial navigation into survivorship care can connect survivors to grants, charity care, and public benefits. Clinics should implement early screening for financial hardship and food insecurity. A major consideration should be travel, which both survivors and providers highlighted as an institutional barrier that needs further addressing. Survivors shared that the current model of having multiple appointments across multiple days results in not just transportation costs, but wage loss that many are not able to withstand. Providers echoed this concern, noting that the separation of lifestyle counseling from medical visits contributes to the issue by increasing travel demands that are burdensome for patients with financial hardships. These experiences point to a need for care models that reduce travel burden, such as offering multidisciplinary services during the same visit. Lifestyle counseling should also integrate strategies such as home-based exercise routines, food vouchers, and early inclusion of family members and friends. Beyond survivorship clinics, health systems can partner with community organizations (e.g., YMCAs and local gyms, food pantries, transportation services, and faith-based networks) to expand access to affordable resources and further allow patients to access resources closer to home.

Study Strengths and Limitations

Our study highlights the voices of Black and Latina women, who remain underrepresented in breast cancer research. Specifically, our sample includes the perspectives of Spanish-speaking survivors, who were interviewed in their native language, and of immigrant women, who provided cultural and social perspectives that complemented those of English-speaking and U.S.-born participants, respectively. These demographic characteristics lent depth to our exploration into factors shaping financial coping strategies.

This study also highlights the voices of women with either pre-existing or new financial hardships and the effect these financial challenges have on lifestyle behavior change, but we cannot necessarily attribute participants’ financial hardships directly to their cancer diagnoses or treatments. While providers were not the focus of this study, their voices provided an opportunity to understand organization-level solutions to patient-identified barriers and enabled triangulation.

As a secondary analysis, we could not time-stamp onset of hardship relative to treatment and cannot pinpoint the precise point in the cancer continuum where financial-lifestyle interventions would be optimal. However, we do recommend starting early, around the time of diagnosis, when healthy behaviors are most at risk to worsen. ³² Furthermore, our modest sample prevented us for comparing experiences with hardship across the survivorship continuum or by disease stage. Future studies should purposely sample women across the cancer continuum by time from diagnosis and disease stage to assess how financial hardship changes over time and how disease stage influences the degree of hardship experienced. In doing so, researchers may be able to hone on the most optimal time and strategies for intervention at each phase of the survivorship period to provide timely, personalized multidisciplinary cancer care.

Data were derived from one geographic location and a single National Cancer Institute–designated Comprehensive Cancer Center with an established multidisciplinary survivorship clinic, which may limit transferability to areas with fewer institutional resources.

Most participants had higher education levels, and as such, their financial experiences may not represent those of lower-income Black and Latina women with breast cancer. However, because financial hardship remained prominent in our more educated group, the themes identified here are likely transferable to more impoverished individuals and communities. We did not conduct formal sample size calculations and instead recruited from a convenience sample of women with a self-reported history of breast cancer. We acknowledge the potential for self-selection bias, as participants willing to be interviewed may have been more resourceful or engaged. We did not quantify intercoder reliability, opting instead for qualitative rigor practices (triangulation, bilingual analysis, peer debriefing). ³¹ Finally, because the parent study was not designed specifically to evaluate financial hardship, our aim for the present study was an in-depth focus on the financial hardship–lifestyle link; therefore, we prioritized adequacy and thematic coherence over formal saturation claims.

Conclusion

Financial hardship is a major barrier to adopting and sustaining healthy lifestyle behaviors among cancer survivors and addressing it is likely a prerequisite for successful interventions.^33,44 Despite promising strategies at multiple levels, few lifestyle trials have integrated financial navigation, and financial hardship interventions rarely evaluate behavioral factors.^33,44 Future research should address this gap, with special attention to food insecurity and resource constraints among survivors from low socio-economic status and racially minoritized backgrounds and should test delivery models that are cost-effective, equitable, and scalable. Implementation considerations include workforce training for bilingual navigators, sustainable reimbursement, and community partnerships. Policy interventions should include proactive financial screening within survivorship care, expanding multidisciplinary teams to community settings, and tailoring the lifestyle counseling provided by experienced oncology care providers. Ensuring insurance coverage for lifestyle-related services and transportation subsidies will also be critical as will be implementation and dissemination of oncology-related, community-based lifestyle programs such as food-as-medicine ⁵¹ and novel initiatives such as low-cost food-swaps. ⁵² By weaving financial navigation and lifestyle interventions into routine survivorship care—consistent with national recommendations ³² —programs can reduce structural barriers, improve adherence, and help close gaps in cancer inequities and outcomes.