Keeping us all whole: Acknowledging the agency of African American breast cancer survivors and their systems of social support

Study Protocol for the Social Interventions for Support During Treatment for Endometrial Cancer and Recurrence (SISTER) study: a community engaged national randomized trial

Aim: Social isolation in cancer patients is correlated with prognosis and is a potential mediator of treatment completion. Black women with endometrial cancer (EC) are at increased risk for social isolation when compared with White patients. We developed the Social Interventions for Support during Treatment for Endometrial Cancer and Recurrence (SISTER) study to compare and evaluate interventions to address social isolation among Black women with high-risk EC in USA. The primary objective of the SISTER study is to determine whether virtual support interventions improve treatment completion compared with Enhanced Usual Care. Secondary objectives include comparing effectiveness virtual evidence-based interventions and evaluating barriers and facilitators to social support delivery. Patients & methods: This is a multi-site prospective, open-label, community-engaged randomized controlled trial, consisting of three intervention arms: enhanced usual care, facilitated support group and one-to-one peer support. Primary outcome will be measured using relative dose. Qualitative semi-structured interviews will be conducted with a subset of participants to contextualize the relative degree or lack thereof of social isolation, over time. Data analysis: Primary analysis will be based on an intent-to-treat analysis. Multivariable analysis will be performed to determine the effect of the intervention on the primary and secondary outcomes of interest, relative dose and social isolation score. Semi-structured interviews will be qualitatively analyzed using inductive and deductive approaches of content analysis. Discussion/conclusion: Endometrial cancer mortality disproportionately affects Black women, and social isolation contributes to this disparity. The SISTER study aims to identify whether and to what extent differing social support vehicles improve key outcomes for Black women in the United States with high-risk EC. Clinical Trial Registration: NCT04930159 (ClinicalTrials.gov).

"We need a little strength as well": Examining the social context of informal caregivers for Black women with breast cancer

BACKGROUND

Informal caregivers (e.g., partners, other family members, friends) often provide social support to Black women with breast cancer, and caregivers find both benefits and challenges in their caregiving role.

METHODS

In this qualitative study, twenty-four caregivers for Black women with breast cancer participated in focus groups and interviews. Participants responded to a brief close-ended questionnaire as well as semi-structured questions about their experiences as cancer caregivers. Demographic information was collected, and relationship satisfaction was measured by the Relationship Assessment Scale-General scale (RAS-G). Focus groups and interviews were recorded, transcribed verbatim, and coded by two independent coders. Using an iterative, discussion-based process, the study team developed and refined themes.

RESULTS

All caregivers described themselves as Black/African American, and the majority identified as female (79%). The mean RAS-G score was 4.5 (SD = 0.5), indicating high levels of relationship satisfaction. Qualitative themes included using a range of strategies to provide emotional support; shifting between roles; needing time and space; and trying to stay strong. Several female caregivers described how the cumulative experiences of providing care for multiple family members and friends could be draining, as could their own experiences in the patient role.

CONCLUSIONS

These findings show a complex, multilayered social context that affects both the patient-caregiver relationship and the health and wellbeing of caregivers. Clinicians providing treatment and support for Black women with breast cancer should be mindful of how the health context of the family may affect patient and caregiver outcomes.

"We're in this together": Perceived effects of breast cancer on African American survivors' marital relationships

Objective

We examined married African American breast cancer survivors' perceptions of how cancer affected their marriage, social support from their spouses, and spouses' physical and mental health.

Method

We conducted a thematic analysis of semi-structured interviews with 15 married African American breast cancer survivors who had participated in a larger randomized controlled trial. Interviews were professionally transcribed and then independently coded by two coders.

Results

Themes emerged related to the challenges of maintaining mutually supportive relationships. There was variability in the perceived effects of cancer on relationships, as well as uncertainty about cancer's effects on their husbands' emotional and physical health and the adequacy of emotional and tangible support from their husbands. Participants described husbands' key role in promoting wives' positive body image, as well as the challenges of negotiating sexual activity. Participants were receptive to help from medical professionals in dealing with relationship issues.

Conclusions

Findings show variability in couples' responses to cancer, with some patients and couples adapting well and others needing additional support. During treatment and at follow-up, oncology social workers can assess patients' and family members' social support needs, provide mental health services, and provide patient navigation to help patients and caregivers access health care and community resources.

Intersectionality Impacts Survivorship: Identity-Informed Recommendations to Improve the Quality of Life of African American Breast Cancer Survivors in Health Promotion Programming

(1) Background: African American women breast cancer survivors face unique experiences that impact their quality of life as they transition beyond treatments. Experiences may be complicated by living at the intersection of systemically oppressed identities, including gender, race, social class, and cancer-related disability. Using the Black Feminist Thought (BFT) framework and the PEN-3 cultural model, this qualitative study sought to: (a) understand African American women breast cancer survivors' lived experiences; (b) examine how the multiple intersecting factors of race, gender, social class/socioeconomic status, and cancer-related disability impact their quality of life; and (c) inform future health promotion programming that is culturally relevant to AAWBCS to improve their quality of life. (2) Methods: Seven focus groups were conducted with 30 African American breast cancer survivors in a Midwestern metropolitan region. Focus groups were audiotaped and transcribed verbatim. Framework analyses were conducted to identify themes with NVivo qualitative analysis software. (3) Results: Four themes emerged: (a) caregiving roles provide both support and challenges for survivors, (b) the "strong Black woman" is inherent in survivor experiences, (c) intersectionality impacts survivorship, and (d) African American women resist oppression through culturally specific supports and advocacy. (4) Conclusions: The intervention point of entry should be at the peer support group level and centered on family and provide community-based support and services. Future research should move upstream to address social determinants of health, including racism, sexism, and ableism; there is a critical need to discuss how structural racism affects health care and develop interventions to address racial discrimination and racial bias in health care.

Factors affecting timely breast cancer treatment among black women in a high-risk urban community: a qualitative study

BACKGROUND

Black women diagnosed with breast cancer in the U.S. tend to experience significantly longer waits to begin treatment than do their white counterparts, and such treatment delay has been associated with poorer survival. We sought to identify the factors driving or mitigating treatment delay among Black women in an urban community where treatment delay is common.

METHODS

Applying the SaTScan method to data from Ohio's state cancer registry, we identified the community within Cuyahoga County, Ohio (home to Cleveland) with the highest degree of breast cancer treatment delay from 2010 through 2015. We then recruited breast cancer survivors living in the target community, their family caregivers, and professionals serving breast cancer patients in this community. Participants completed semi-structured interviews focused on identifying barriers to and facilitators of timely breast cancer treatment initiation after diagnosis.

RESULTS

Factors reported to impact timely treatment fell into three primary themes: informational, intrapersonal, and logistical. Informational barriers included erroneous beliefs and lack of information about processes of care; intrapersonal barriers centered on mistrust, fear, and denial; while logistical barriers involved transportation and financial access, as well as patients' own caregiving obligations. An informational facilitator was the provision of objective and understandable disease information, and a common intrapersonal facilitator was faith. Logistical facilitators included financial counseling and mechanisms to assist with Medicaid enrollment. Crosscutting these themes, and mentioned frequently, was the centrality of both patient navigators and support networks (formal and, especially, informal) as critical lifelines for overcoming barriers and leveraging facilitating factors.

CONCLUSIONS

The present study describes the numerous hurdles to timely breast cancer treatment faced by Black women in a high-risk urban community. These hurdles, as well as corresponding facilitators, can be classified as informational, intrapersonal, and logistical. Observing similar results on a larger scale could inform the design of interventions and policies to reduce race-based disparities in processes of cancer care.

Psychosocial protective interventions associated with a better quality of life and psychological wellbeing for African American/Black female breast cancer survivors: an integrative review

PURPOSE

This integrative review provides an overview of current psychosocial interventions and qualitative studies exploring African American Breast Cancer Survivors (AABCS)' psychosocial wellbeing.

METHODS

We conducted a search of five databases: PubMed, Academic Search Ultimate, CINAHL, PsycINFO, and Web of Science. Peer-reviewed articles written in English and published from 2011 to May 26, 2021 were included. We critically appraised intervention studies and qualitative studies using established frameworks.

RESULTS

Of the 633 unique studies identified, seven interventions and twenty-one qualitative studies were included. Analysis of the interventions revealed the importance of alleviating structural barriers and facilitating peer support for AABCS. Analysis of the qualitative studies revealed seven themes: (1) spirituality/religion, (2) social support, (3) cultural perceptions of BC, (4) lack of representation, (5) negative impacts of treatment, (6) healthcare system experience, and (7) barriers to psychosocial care.

CONCLUSIONS

This review highlights the dearth of psychosocial interventions created specifically for AABCS. The qualitative literature in this review elucidates the unique psychosocial challenges that AABCS experience, providing rich data to inform the creation of future culturally competent interventions in this population.

IMPLICATIONS FOR CANCER SURVIVORS

This review found spirituality and social support to be protective factors for AABCS' psychosocial wellbeing. Further research using rigorous methodologies is needed to further evaluate how to most effectively alleviate structural barriers that AABCS face in obtaining long-term support.

Healthcare Predictors of Information Dissemination About Genetic Risks

Objectives

Despite the benefits of genetic counseling and testing (GCT), utilization is particularly low among African American (AA) women who exhibit breast cancer features that are common in BRCA-associated cancer. Underutilization is especially problematic for AA women who are more likely to die from breast cancer than women from any other race or ethnicity. Due to medical mistrust, fear, and stigma that can be associated with genetic services among racial/ethnic minorities, reliance on trusted social networks may be an impactful strategy to increase dissemination of knowledge about hereditary cancer risk. Informed by the social cognitive theory, the purpose of this study is to determine: 1) which AA patients diagnosed with breast cancer and with identified hereditary risk are sharing information about hereditary risk with their networks; 2) the nature of the information dissemination; and 3) if personal GCT experiences is associated with dissemination of information about hereditary risk.

Methods

Among consented participants (n = 100) that completed an interview administered using a 202-item questionnaire consisting of open- and closed-ended questions, 62 patients were identified to be at higher risk for breast cancer. Descriptive statistics, bivariable chi-square, Pearson’s exact tests, and regression analyses were conducted to examine differences in characteristics between high-risk participants who disseminated hereditary risk information and participants who did not.

Results

Among high-risk participants, 25 (40%) indicated they had disseminated information about hereditary risk to at least one member in their family/friend network and 37 (60%) had not. Receipt of both provider recommendations and receipt of GCT services was associated with greater odds of disseminating information about hereditary risk with networks, OR = 4.53, 95%CI [1.33, 15.50], p = .02.

Conclusion

Interventions that increase self-efficacy gained through additional personalized knowledge and experience gained through provider recommendations and by undergoing GCT may facilitate information dissemination among social/familial networks.

Financial toxicity in cancer care: origins, impact, and solutions

Financial toxicity describes the financial burden and distress that can arise for patients, and their family members, as a result of cancer treatment. It includes direct out-of-pocket costs for treatment and indirect costs such as travel, time, and changes to employment that can increase the burden of cancer. While high costs of cancer care have threatened the sustainability of access to care for decades, it is only in the past 10 years that the term "financial toxicity" has been popularized to recognize that the financial burdens of care can be just as important as the physical toxicities traditionally associated with cancer therapy. The past decade has seen a rapid growth in research identifying the prevalence and impact of financial toxicity. Research is now beginning to focus on innovations in screening and care delivery that can mitigate this risk. There is a need to determine the optimal strategy for clinicians and cancer centers to address costs of care in order to minimize financial toxicity, promote access to high value care, and reduce health disparities. We review the evolution of concerns over costs of cancer care, the impact of financial burdens on patients, methods to screen for financial toxicity, proposed solutions, and priorities for future research to identify and address costs that threaten the health and quality of life for many patients with cancer.

Psychometric validation of the Chinese version of the PROMIS Social Relationships Short Forms

AIM

This study aimed to culturally adapt and psychometrically validate the PROMIS Social Relationships Short Forms (PROMIS-SR) among Chinese patients with breast cancer.

DESIGN

A cross-sectional study.

METHOD

The PROMIS-SR was translated into simplified Chinese by strictly adhering to the Functional Assessment of Chronic Illness Therapy translation method and was subsequently tested among patients with breast cancer (N = 965). Eligible patients filled out the demographic information questionnaire, the PROMIS-SR, and the Functional Assessment of Cancer Therapy-Breast.

RESULTS

Confirmatory factor analysis (CFA) provided support for the original structure of the PROMIS-SR. All instruments reported strong known-group, cross-cultural and convergent validity, as hypothesized. Correlation coefficients ranged from 0.67 to 0.85, and Cronbach's α of all items were high (0.90-0.94).

Understanding the relationship between positive and negative social support and the quality of life among African American breast cancer survivors

PURPOSE

Social support improves several quality of life (QOL) domains among African American breast cancer survivors. How different dimensions of social support are associated with QOL among African American breast cancer survivors may however differ from other populations. This study explores this hypothesis by examining associations of positive social support (supportive interactions that promote affection) and negative social support (non-supportive interactions wherein the provider of support may not have the best intended actions) with QOL among Chicago-based African American breast cancer survivors.

METHODS

Study participants were eligible if they (1) were identified as being an African American female, (2) were at least 18 years of age or older, and (3) were diagnosed with breast cancer during or after navigation was implemented at the study hospital. Participants completed validated questionnaires via telephone or in-person interviews.

RESULTS

Among our sample of 100 participants, positive support was associated with greater mental well-being in non-imputed (Std β=1.60, CI: 0.51, 2.69, p= 0.004) and imputed models (Std β= 1.67, CI: 0.68, 2.73, p=0.001). There was also a weaker inverse association with negative support and mental well-being when using non-imputed data (Std β=-0.82, CI:-1.65, 0.02, p= 0.05).

CONCLUSIONS

Our findings suggest that positive support, in particular, is highly influential for improving mental well-being among African American breast cancer survivors. Simultaneously, negative support appears to be an independent, albeit weaker, determinant of mental well-being.

End-of-Life Concerns and Experiences of Living With Advanced Breast Cancer Among Medically Underserved Women

CONTEXT

Breast cancer morbidity and mortality disproportionately affect medically underserved women. Most studies of the experience of living with advanced breast cancer do not focus on this population. A deeper understanding of racial/ethnic minorities' and low-income patients' experiences is needed to reduce breast cancer health and health care disparities.

OBJECTIVES

This qualitative, community-based participatory research study explores the lived experiences of medically underserved women with advanced breast cancer.

METHODS

We conducted in-depth, semistructured interviews with low-income patients from a community clinic and safety-net hospital, focusing on issues related to advanced breast cancer and end of life. Six team members independently coded transcripts, jointly reconciled coding differences, and identified key themes.

RESULTS

All 63 participants (83% response rate) had an income ≤200% of the federal poverty level; 68% identified as a racial/ethnic minority. Four predominant themes emerged: compounding of pre-existing financial distress, perceived bias/lack of confidence in medical care received, balancing personal needs with the needs of others, and enhanced engagement with sources of life meaning.

CONCLUSION

Participants resiliently maintained engaged lives yet described extreme financial duress and perceived provider bias, which are known contributors to worse quality of life and health outcomes. Participants downplayed their desire to discuss dying to accommodate pressure to "stay positive" and to mitigate others' discomfort. Improving care for underserved women with advanced cancer will require addressing disparities from screening through hospice, developing personalized opportunities to discuss death and dying, and enhancing access to and affordability of medical and social support.