A mixed method exploration of survivorship among Chinese American and non-Hispanic White breast cancer survivors: the role of socioeconomic well-being

Mediational roles of stress-coping factors in the relationship between patient-perceived communication quality and physical functioning: racial difference between Chinese and Non-Hispanic White American breast cancer survivors

PURPOSE

The assumption that patient-provider communication may mediate patients' sense of control over cancer to affect health outcomes has limited evidence. This study examines whether patient-perceived cancer care communication quality (PPCQ) mediates stress appraisal and coping behavior, affecting physical functioning across different racial groups.

METHODS

Two hundred and twenty Chinese American and 216 non-Hispanic White (NHW) women (ages 28-80) with stage 0-III breast cancer, 1-5 years post-diagnosis, and without recurrence, enrolled and completed a cross-sectional telephone survey. Physical functioning was measured by the NIH-PROMIS short form. Validated measures of PPCQ, patients' evaluation of their socioeconomic well-being, stress appraisal (perceived severity and control), use of coping strategies, treatment-related symptoms, and comorbidities were also assessed. Path analyses were used to examine the mediation for each racial group.

RESULTS

Regardless of race, treatment-related symptoms, comorbidities, and socioeconomic well-being were all directly related to physical functioning (p < 0.05). The impact of PPCQ on physical functioning was mediated by perceived control in the Chinese American group (p < 0.05), but not in the NHW group. Perceived severity and coping were not mediators of physical functioning in either group.

CONCLUSIONS

The mediational pathway from PPCQ to perceived control to physical functioning in Chinese American survivors may be partially explained by their lower socioeconomic well-being and culturally valued conformity to physicians as a medical authority. These sociocultural dynamics reinforce the importance of cancer care communication. For NHW survivors, the impact of treatment-related symptoms and socioeconomic well-being on physical functioning outweighed their PPCQ and perceived control.

Fatalism and Psychological Distress Among Chinese American Breast Cancer Survivors: Mediating Role of Perceived Self-control and Fear of Cancer Recurrence

BACKGROUND

Extant literature on the relationship between cancer fatalism and psychological distress among Chinese American breast cancer survivors has been mixed, and few studies have examined potential mediators of this relationship. The current study examined how cancer fatalism is associated with psychological distress by investigating perceived personal control and fear of cancer recurrence as mediators, and acculturation as a moderator of these relationships.

METHOD

A total of 220 Chinese American women diagnosed with stage 0-III breast cancer were recruited from California cancer registries and completed a telephone survey. The measurement of cancer fatalism examined one's view of health as a result of destiny. Validated measures of psychological distress (i.e., depressive and anxiety symptoms), fear of cancer recurrence, and perceived personal control were used. Acculturation was defined by English proficiency, preferred interview language, and number of years lived in the USA.

RESULTS

Higher cancer fatalism was directly associated with greater depressive and anxiety symptoms after controlling for covariates. This association was also mediated by higher fear of cancer recurrence, but not by perceived control. The mediation was not moderated by acculturation.

CONCLUSION

Our findings suggest that Chinese American breast cancer survivors' fatalistic beliefs may exacerbate fear of cancer recurrence, and, in turn, depressive and anxiety symptoms. Fear of recurrence was more salient than perceived control in their associations with psychological distress among Chinese American cancer survivors. Future intervention research may adopt cognitive approaches to alter Chinese survivors' fatalistic views of health outcomes to reduce their psychological distress.

Social Determinants of Health and Quality of Life in Endocrine Surgery Patients

INTRODUCTION

Quality of life (QoL) of endocrine surgery patients is an important patient outcome but the role of social determinants of health (SDH) on preoperative QoL is understudied.

METHODS

This study used preoperative data of 233 endocrine surgery patients participating in a longitudinal QoL study to examine the influence of SDH (patient-level and environmental) on preoperative QoL. Patient-level SDH was assessed with structured survey questions and environmental SDH with the Social Vulnerability Index. Multiple domains of QoL were assessed with the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29).

RESULTS

The average age of the sample was 52.9 y and 76.8% were female, 10% were Hispanic, 55.8% were White, 32.6% were Black, 6.9% were Other, and 4.7% were Asian. Patients with patient-level SDH were more likely to have worse preoperative QoL in multiple PROMIS domains. Patients who lived in the most socially vulnerable areas had the same or better QoL scores in the PROMIS-29 domains than those living in less vulnerable areas. Minority race patients were more likely to have patient-level SDH and to live in the most vulnerable areas.

CONCLUSIONS

This study is the first to our knowledge to examine the role of patient-level and environmental SDH on preoperative QoL among endocrine surgery patients. The results identified specific patient-level factors that could be used as the basis for interventions aimed to improve patients' QoL. Future studies that evaluate the role of preoperative SDH on long-term QoL and clinical outcomes would further enhance our understanding of the impact of SDH on patient wellbeing.

Lived experiences of young adult Chinese American breast cancer survivors: A qualitative analysis of their strengths and challenges using expressive writing

PURPOSE

Immigrant young adults of cancer survivors face unique challenges but their unmet needs are not well understood. The purpose of this study was to identify the challenges and strengths of immigrant young adult Chinese American breast cancer survivors.

METHOD

Descriptive phenomenology using a qualitative research approach was employed in this study. Expressive writing was used to explore the experiences of 15 young adult Chinese American immigrant breast cancer survivors. Thematic analysis was conducted to gain an understanding of the lived experiences of young adult Chinese American breast cancer survivors.

RESULTS

On average, participants had been diagnosed at 37 years (ranging from 32 to 39) and living in the USA for 12 years. Participants' writings revealed their challenges during and after treatment (major theme), including difficulty accepting having cancer at a young age, financial difficulties, self-blame, inadequate family support, uncertainty about their futures, and worries about their children and infertility (sub-themes). Participants' strengths and coping strategies (major theme) included physical recovery and positive self-perception, family as motivation for survival, and support from family and friends (sub-themes). Post-traumatic growth (major theme) included shifting life priorities and enjoying life and self-transcendence (i.e., forgiving and helping others) (sub-themes).

CONCLUSIONS

The overarching topic found across the major themes in the young adult Chinese American breast cancer survivors' essays was the importance of interpersonal relationships, especially with family and children. Healthcare providers should respond with culturally appropriate support, referrals, and resources based on these findings.

Survivorship Care Plan Preferences and Utilization Among Asian American Breast Cancer Survivors

PROBLEM IDENTIFICATION

The survivorship care plan (SCP) is an individualized document with cancer diagnosis, treatment, surveillance, and health promotion recommendations. This integrative review synthesizes the extant literature to understand preferences and utilization of SCPs among Asian American survivors.

LITERATURE SEARCH

The CINAHL®, Embase®, PsycINFO®, and PubMed® databases were searched for articles about Asian American women with breast or cervical cancer and SCPs.

DATA EVALUATION

Two independent reviewers evaluated 481 titles and abstracts according to inclusion and exclusion criteria. Of those 481 titles and abstracts, 14 articles were selected for inclusion.

SYNTHESIS

There was little evidence surrounding utilization of SCPs. Articles identified addressed only survivors of breast cancer, predominately of Southeast Asian descent. Asian American women with breast cancer reported preferences surrounding their survivorship needs. Barriers to delivery of the SCP were related to socioeconomic factors.

IMPLICATIONS FOR RESEARCH

There is a paucity of information guiding evidence-based delivery of SCPs in the vastly heterogenous population of Asian American survivors. More work is needed to provide high-quality care to these survivors.

The Asian Immigrant Cancer Survivor Experience in the United States: A Scoping Review of the Literature

BACKGROUND

Cancer is the leading cause of death for Asian Americans, a growing population in the United States. While cancer survivors often experience complex issues after diagnosis, being an immigrant and having cancer pose additional challenges.

OBJECTIVE

This scoping review analyzed research about immigrant cancer survivors of Asian ethnicity in the United States and provided a structured method to understand an area of research and evidence. Aims focused on immigrants' experiences and how findings could tailor evidence-based interventions, programs, and resources.

METHODS

The PubMed, CINAHL, and Scopus databases were searched to identify studies in English (2009-2018) targeting Asian immigrant cancer survivors in the United States. While 385 records were initially identified, 32 studies met the inclusion criteria.

RESULTS

Thematic analysis of charted study elements revealed 4 themes with subthemes: (1) survival patterns, (2) barriers, (3) culturally informed care, and (4) quality of life (QOL). While qualitative studies provided insight about the cancer experience from immigrants' perspectives, quantitative designs posed descriptions and associations among QOL concepts.

CONCLUSIONS

Study results illustrate the need for survival research that explores outcomes by Asian ethnic subgroups and tracks the influence of acculturation. Future research should test culturally informed interventions that minimize barriers and foster QOL across the cancer continuum. Culturally tailored instruments can expedite larger-scaled studies that allow generalization.

IMPLICATIONS FOR PRACTICE

Asian immigrants comprise an underserved, vulnerable, and growing group with various cancers. Nurses who care for immigrants and their families should be cognizant of cultural beliefs, values, practices, and issues related to communication, care access, and socioeconomics.

Experiences of Advanced Breast Cancer Among Latina Immigrants: A Qualitative Pilot Study

To explore the experiences of Latina immigrants with advanced breast cancer and their support networks. We conducted semi-structured interviews with low-income Latina immigrants with advanced breast cancer and their support networks (informal caregivers, physicians, and complementary medicine (CM) practitioners). Patient interviews explored patients' illness experience and end of life (EOL) concerns. Support network member interviews focused on the relationship of the interviewee with the patient and EOL conversations. Six authors independently coded transcripts and jointly conducted qualitative thematic analysis. 72 total interviews (13 patients, 12 informal caregivers, 6 CM practitioners, and 4 physicians) revealed two themes. (1) Staying positive was a primary patient coping mechanism. (2) Patients' language barriers and socioeconomic and immigration status posed challenges in participants' illness experience. Appropriately addressing language barriers and social context during medical visits is crucial for effective EOL care. Clinicians should consider patients' financial constraints and ensure support in applying for public benefits.

Factors associated with Chinese American and White cancer survivors' physical and psychological functioning

OBJECTIVE

To examine whether health-related stressors and resources are associated with physical function, depression, and anxiety in Chinese American and White breast cancer survivors.

METHOD

During 2011-2013, this cross-sectional study enrolled Chinese American and White women from California cancer registries diagnosed with Stage 0-III breast cancer between 2006 and 2012. Survivors completed a telephone survey assessing health-related factors including comorbidity, treatment-related symptoms, medical communication, perceived threat, use of coping, and social support resources. Outcomes were assessed using the Patient-Reported Outcome Measurement Information System® (PROMIS®) short forms. Chinese were classified as low- or high-acculturated based on English proficiency, years in the United States, and interview language. Analyses were conducted using Tobit regression models.

RESULTS

Low-acculturated Chinese (n = 136) had worse physical functioning than Whites (n = 216), controlling for demographics, cancer stage, and time since diagnosis (β = -3.33, p = .01). This disparity was attenuated after adjusting for comorbidity and symptoms (β = -1.63, p = .18). Perceived threat, disengagement coping, and lack of social support were associated with poorer psychological outcomes, regardless of ethnicity. Although low-acculturated Chinese had lower scores on all health-related factors than Whites, the former reported significantly lower level of depression (β = -3.23) and anxiety (β = -5.8) after adjusting for covariates (both p < .05). High-acculturated Chinese (n = 84) did not differ from Whites except that the former had significantly lower anxiety.

CONCLUSION

Low-acculturated Chinese may benefit from interventions aimed to improve their physical problems. However, despite experiencing greater psychosocial stress, they reported better emotional functioning. Whether Chinese culture shapes this resiliency, or if it is a reporting bias will need further investigation. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Successful Strategies for Engaging Chinese Breast Cancer Survivors in a Randomized Controlled Trial

Chinese immigrant breast cancer survivors face various challenges due to cultural and socioecological factors. Research efforts to develop culturally sensitive interventions have been limited by lack of knowledge regarding successful recruitment and implementation practices among Chinese immigrant populations. This paper documents strategies utilized during the development and implementation of a randomized controlled trial of a culturally sensitive psychosocial intervention for Chinese immigrant breast cancer survivors. In partnership with a community agency, we developed culturally and linguistically appropriate research materials, recruited participants from community channels, and conducted longitudinal data collection. Key strategies include building equitable research partnerships with community agencies to engage participants; being responsive to the needs of community agencies and participants; considering within-group diversity of the research population; utilizing recruitment as an opportunity for relationship-building with participants; and developing key strategies to promote retention. Successful participant engagement in cancer intervention research is the result of collaboration among breast cancer survivors, community leaders and agencies, and academic researchers. The engagement process for this study is novel because we have emphasized cultural factors in the process and taken a relational approach to recruitment and retention.

Acculturation and Adherence to Physical Activity Recommendations Among Chinese American and Non-Hispanic White Breast Cancer Survivors

Chinese American breast cancer survivors' adherence to recommended physical activity (PA) guidelines has been understudied. This study investigated their PA adherence by acculturation level (vs. non-Hispanic White (NHW) survivors). One hundred ninety five Chinese and 202 NHW breast cancer survivors (stage 0-III) responded to a cross-sectional survey including a self-reported PA questionnaire. PA adherence referred to meeting PA recommendations for cancer survivors. Acculturation among Chinese was defined by proxies of U.S. residency, English proficiency, and interview language. Logistic regression was performed to examine factors associated with PA adherence. More-acculturated Chinese survivors' PA adherence rate was 76%. Less-acculturated Chinese survivors' adherence rate (60%) was significantly lower than that of NHWs (80%) (OR 0.38, 95%CI 0.19, 0.75). Less-acculturated Chinese survivors were also less likely to engage in vigorous-intensity PA than NHWs (p < 0.01). Future research on less-acculturated Chinese survivors' motivation for PA to promote their adherence is needed.

Socioeconomic status and quality of life among Chinese American breast cancer survivors: The mediating roles of social support and social constraints

OBJECTIVE

Literature has well noted ethnic/racial disparities in cancer survival and cancer care. However, socioeconomic disparities in psychosocial adjustment to breast cancer have garnered little attention. This study addresses the research gap by investigating the associations between socioeconomic indicators (ie, education, annual personal, and household income) and quality of life (QOL) and the mediating roles of social support and social constraints (objective and subjective conditions that constrain individuals from disclosing cancer concerns) in these associations among Chinese American breast cancer survivors (CABCS).

METHODS

Ninety-six CABCS completed questionnaires assessing these variables.

RESULTS

After controlling for stage of cancer, annual personal and household income had indirect effects on QOL through social support, and education showed indirect effect on QOL through social support and social constraints. Subscale analyses indicated that controlling for years of immigration, annual personal and household income showed indirect effect on functional well-being through social support. When controlling for stage of cancer and income, education showed indirect effects on physical well-being through social support and social constraints and showed both direct and indirect effects on breast cancer concerns through social constraints.

CONCLUSION

This study suggested that socioeconomic indicators, education, and income could be associated with different aspects of QOL through unique interpersonal mechanisms among CABCS. Our findings implied that increasing social support and reducing social constraints when implementing psychosocial interventions for CABCS may help to address the SES-related health disparities.

A mixed-methods study to explore the supportive care needs of breast cancer survivors

OBJECTIVE

Needs assessment is the essence of quality cancer survivorship care. The aim of this study was to explore the supportive care needs of breast cancer survivors (BCS) in the first 5 years post treatment.

METHODS

A mixed-methods approach was employed. A quantitative study included a Supportive Care Needs Survey, which was completed by 250 BCS to identify the level of their needs for help. The quantitative data informed semistructured qualitative interviews undertaken with 60 BCS to explore in detail their posttreatment needs and experiences.

RESULTS

32.4% and 16.8% reported 1 to 5 and greater than or equal to 6 needs for help, respectively. The regression analyses revealed that women within 2 years posttreatment and with higher educational level had higher levels of Psychological and Health Care System/Information needs. The qualitative data revealed "continuity of care" and "lifestyle advice and self-management" as prominent survivorship concerns. It was shown that determination to continue normal life, social support, and feeling overwhelmed by information were all experienced as important influences on survivors' need for help.

CONCLUSIONS

Posttreatment needs vary with BCS characteristics and to the domains concerned. The approach to posttreatment care needs to be personalized and viable.

Health-related quality of life in patients with serious non-specific symptoms undergoing evaluation for possible cancer and their experience during the process: a mixed methods study

PURPOSE

The purpose of this research was to measure changes in HRQoL during the diagnostic evaluation of patients presenting with non-specific symptoms possibly attributable to cancer, to describe their experiences of HRQoL and to merge these findings with intent to obtain a more comprehensive understanding of their HRQoL experience during this stressful life event.

METHODS

A convergent mixed methods (MM) design was used and involved quantitative data about HRQoL measured by the EORTC-QLQ-C30 instrument and qualitative interview data about patients' HRQoL experiences. Participants completed the EORTC-QLQ-C30 questionnaire prior to and after evaluation. The baseline questionnaire informed the purposive sampling for the qualitative interview study, and open-end questions matched to the EORTC-QLQ-C30 constructs were used in the semi-structured interviews.

RESULTS

A total of 838 patients were enrolled in the quantitative study; 680 (81 %) also completed follow-up. Twenty-one patients participated in interviews. The MM findings are the meta-inferences drawn by looking across the matched quantitative and qualitative findings: physical function, social function, role function, emotional function, cognitive function, social function, symptoms and quality of life.

CONCLUSION

The survey results illustrate that HRQoL improved over time and the qualitative findings confirmed and further expanded the survey results. The MM analysis underlines that the HRQoL experience cannot be observed independently from context. Participants adapted to their situation over time, and this may change their perceptions of HRQoL. These findings can be used to enhance evidence-based care as clinicians need to be aware of how the context influences the HRQoL experience.

Differences in quality of life between American and Chinese breast cancer survivors

OBJECTIVE

It has been speculated that cancer survivors in Asia may have lower quality of life (QOL) compared with their Western counterparts. However, no studies have made international comparisons in QOL using a comprehensive measure. This study aimed to compare Chinese breast cancer survivors' QOL with US counterparts and examine if demographic and medical factors were associated with QOL across groups.

METHOD

The sample consisted of 159 breast cancer patients (97 Chinese and 62 American) who completed the Functional Assessment for Cancer Therapy Breast Cancer (FACT-B) scale before the start of radiotherapy in Shanghai, China and Houston, USA.

RESULTS

Higher income was associated with higher QOL total scores in both Chinese and American cancer patients, but QOL was not significantly associated with other factors including age, education, disease stage, mastectomy, and chemotherapy. Consistent with hypotheses, compared to their US counterparts, Chinese breast cancer survivors reported lower QOL and all four subdimensions including functional well-being (FWB), physical well-being (PWB), emotional well-being (EWB), and social well-being (SWB); they also reported more breast cancer-specific concerns (BCS). Differences were also clinically significant for Functional Assessment for Cancer Therapy General (FACT-G) scale total scores and the FWB subscale. After controlling for demographic and medical covariates, these differences remained except for the SWB and BCS. Furthermore, Chinese breast cancer survivors receiving chemotherapy reported significantly lower FACT-G scores than those who did not, but this difference did not emerge among US breast cancer survivors.

DISCUSSION

Chinese breast cancer survivors reported poorer QOL on multiple domains compared to US women. Findings indicate that better strategies are needed to help improve the QOL of Chinese breast cancer survivors, especially those who underwent chemotherapy.

Differences in breast cancer characteristics and outcomes between Caucasian and Chinese women in the US

Chinese breast cancer patients living in the United States (US) can experience different disease patterns than Caucasians, which might allow for predicting the future epidemiology of breast cancer in China. We aimed to compare the clinicopathologic characteristics and outcomes of Caucasian and Chinese female breast cancer patients residing in the US. The study cohort consisted of 3868 Chinese and 208621 Caucasian women (diagnosed from 1990 to 2009) in the US Surveillance, Epidemiology, and End Results (SEER) database. Compared with the Caucasian patients, the US-residing Chinese patients had a younger age at diagnosis and a higher family income, remained married longer, and more frequently lived in metropolitan areas. Other tumor characteristics were similarly distributed between the two races. Compared with the Caucasians, the Chinese patients had a significantly improved overall survival (OS) but similar breast cancer-specific survival (BCSS). Our analysis suggested that US-residing Chinese patients had significant differences in age, family income, marital status and area of residence, compared with their Caucasian counterparts. No significant disparities were noted in BCSS between the two races, whereas the Chinese patients had a significantly better OS. These findings warrant further investigation and should be considered in the screening and treatment of breast cancer.

Neutrophil to lymphocyte ratio (NLR) for prediction of distant metastasis-free survival (DMFS) in early breast cancer: a propensity score-matched analysis

Objective

To assess the correlation between presurgery neutrophil to lymphocyte ratio (NLR) and distant metastasis-free survival (DMFS) in patients with early breast cancer.

Design

Retrospective analysis.

Participants

300 Caucasian patients with early (T1–2, N0–1, non-metastatic) breast cancer who were followed from July 1999 to June 2015 at our Institution.

Main outcome measures

Distant metastasis-free survival (DMFS).

Results

Of whole populations (300 patients), 134 and 166 patients were grouped as low and high NLR, respectively, on the basis of NLR value of 1.97, as established by receiver operating characteristic (ROC) curve analysis (area under curve (AUC)=0.625, p=0.0160). The DMFS rates for 1, 3, 6, 9, 12 and 15 years were better in low NLR patients (100%, 98.9%, 91.7%, 82.7%, 82.7%, 82.7%, respectively), than in high NLR patients (99.4%, 94.3%, 84.5%, 69.2%, 66.0%, 51.4%, respectively), with a statistically significant association. On multivariate analysis, premenopausal status (HR=2.78, 95% CI 1.36 to 5.67, p=0.0049), N1 stage (HR=2.31, 95% CI 1.16 to 4.60, p=0.0167) and a high NLR value (HR=2.64, 95% CI 1.22 to 5.638, p=0.0133) were shown to be independent prognostic factors related to poor recurrence rate. To avoid risk of confounding bias, a propensity score-matched analysis was performed and multivariate analysis according to the Cox model confirmed premenopausal status (HR=2.94, 95% CI 1.25 to 6.93, p=0.0136), N1 stage (HR=2.77, 95% CI 1.25 to 6.12, p=0.0117) and high NLR values (HR=2.52, 95% CI 1.11 to 5.73, p=0.0271), as independent prognostic variables of worse outcome.

Conclusions

This is the first study, to our knowledge, to show a significant correlation between high NLR and worse prognosis in Caucasian patients with early breast cancer by means of propensity score-matched analysis. Further well designed prospective trials with a large sample size are needed to verify our findings and to justify introducing NLR assessment in clinical practice for prediction of cancer recurrence.