Needs of low-income african american cancer survivors: multifaceted and practical

A Scoping Review of Food Insecurity and Related Factors among Cancer Survivors

Despite growing awareness of the financial burden that a cancer diagnosis places on a household, there is limited understanding of the risk for food insecurity among this population. The current study reviewed literature focusing on the relationship between food insecurity, cancer, and related factors among cancer survivors and their caregivers. In total, 49 articles (across 45 studies) were reviewed and spanned topic areas: patient navigation/social worker role, caregiver role, psychosocial impacts, and food insecurity/financial toxicity. Patient navigation yielded positive impacts including perceptions of better quality of care and improved health related quality of life. Caregivers served multiple roles: managing medications, emotional support, and medical advocacy. Subsequently, caregivers experience financial burden with loss of employment and work productivity. Negative psychosocial impacts experienced by cancer survivors included: cognitive impairment, financial constraints, and lack of coping skills. Financial strain experienced by cancer survivors was reported to influence ratings of physical/mental health and symptom burden. These results highlight that fields of food insecurity, obesity, and cancer control have typically grappled with these issues in isolation and have not robustly studied these factors in conjunction. There is an urgent need for well-designed studies with appropriate methods to establish key determinants of food insecurity among cancer survivors with multidisciplinary collaborators.

The Challenges of Enrollment and Retention: A Systematic Review of Psychosocial Behavioral Interventions for Patients With Cancer and Their Family Caregivers

CONTEXT

Psychosocial behavioral interventions (PBIs) that target patients with cancer and their caregivers face challenges in participant enrollment and retention.

OBJECTIVES

1) Describe characteristics of the patient-caregiver PBI studies; 2) examine participant enrollment and retention rates; 3) identify factors influencing participant enrollment and retention rates; and 4) explore the strategies to promote enrollment and retention rates.

METHODS

We identified randomized controlled trials that tested PBIs among adult patients with cancer and caregivers in five electronic databases. We conducted narrative and quantitative analyses to synthesize our findings.

RESULTS

Among 55 qualified studies reviewed, most tested the efficacy of PBIs (n = 42) and used two study arms (n = 48). In-person meeting was the most common PBI delivery mode. The primary outcomes included quality of life, physical health, and symptoms. The average of enrollment rates of patient-caregiver dyads was 33% across studies (range 8%-100%; median = 23%). The average retention rate at the end of follow-ups was 69% (range 16%-100%; median = 70%). The number of study arms, recruitment method, type of patient-caregiver relationship, and intervention duration influenced enrollment rates. Study design (efficacy vs. pilot), follow-up duration, mode of delivery, type of relationship, and intervention duration influenced retention rates. Sixteen studies reported retention strategies, including providing money/gift cards upon study completion and/or after follow-up survey, and excluding patients with advanced cancer.

CONCLUSION

Researchers need to incorporate effective strategies to optimize enrollment and retention in patient-caregiver PBI trials. Researchers need to report detailed study processes and PBI information to improve research transparency and increase consistency.

Reflections: a Daughter's Experience of Parental Cancer and the Beginnings of Un Abrazo Para La Familia™

The author describes her impetus and journey in developing Un Abrazo Para La Familia™ [Embracing the Family] (Abrazo), 3 hours of cancer information presented in an educational and modular format and designed for low-income informal caregivers who are co-survivors of cancer. A rehabilitation-informed preventive intervention, Abrazo reflects the importance of family, culture, and socioeconomic background in its approach.

Racial Differences in the Influence of Health Care System Factors on Informal Support for Cancer Care Among Black and White Breast and Lung Cancer Survivors

This retrospective, secondary qualitative analysis investigates whether health system factors influence social support among Black and white breast and lung cancer survivors and racial differences in support. These data come from race- and cancer-stratified focus groups (n = 6) and interviews (n = 2) to inform a randomized controlled trial utilizing antiracism and community-based participatory research approaches. Findings indicate social support was helpful for overcoming treatment-related challenges, including symptom management and patient-provider communication; racial differences in support needs and provision were noted. Resources within individual support networks reflect broader sociostructural factors. Reliance on family/friends to fill gaps in cancer care may exacerbate racial disparities.

Do Patients and Oncologists Discuss the Cost of Cancer Treatment? An Observational Study of Clinical Interactions Between African American Patients and Their Oncologists

PURPOSE

Financial toxicity negatively affects patients with cancer, especially racial/ethnic minorities. Patient-oncologist discussions about treatment-related costs may reduce financial toxicity by factoring costs into treatment decisions. This study investigated the frequency and nature of cost discussions during clinical interactions between African American patients and oncologists and examined whether cost discussions were affected by patient sociodemographic characteristics and social support, a known buffer to perceived financial stress. Methods Video recorded patient-oncologist clinical interactions (n = 103) from outpatient clinics of two urban cancer hospitals (including a National Cancer Institute-designated comprehensive cancer center) were analyzed. Coders studied the videos for the presence and duration of cost discussions and then determined the initiator, topic, oncologist response to the patient's concerns, and the patient's reaction to the oncologist's response.

RESULTS

Cost discussions occurred in 45% of clinical interactions. Patients initiated 63% of discussions; oncologists initiated 36%. The most frequent topics were concern about time off from work for treatment (initiated by patients) and insurance (initiated by oncologists). Younger patients and patients with more perceived social support satisfaction were more likely to discuss cost. Patient age interacted with amount of social support to affect frequency of cost discussions within interactions. Younger patients with more social support had more cost discussions; older patients with more social support had fewer cost discussions.

CONCLUSION

Cost discussions occurred in fewer than one half of the interactions and most commonly focused on the impact of the diagnosis on patients' opportunity costs rather than treatment costs. Implications for ASCO's Value Framework and design of interventions to improve cost discussions are discussed.

Health information needs and preferences in relation to survivorship care plans of long-term cancer survivors in the American Cancer Society's Study of Cancer Survivors-I

PURPOSE

Survivorship care plans (SCPs) provide cancer patients and health care providers with a treatment summary and outline of recommended medical follow-up. Few studies have investigated the information needs and preferred sources among long-term cancer survivors.

METHODS

Cancer survivors of the ten most common cancers enrolled in the longitudinal Study of Cancer Survivors-I (SCS-I) completed a survey 9 years post-diagnosis (n = 3138); at time of diagnosis of the SCS-I cohort, SCPs were not considered usual care. We assessed participants' current desire and preferred sources for information across ten SCP items and evaluated factors associated with information need 9 years after diagnosis.

RESULTS

The proportion of long-term cancer survivors endorsing a need for cancer and health information 9 years post-diagnosis ranged from 43 % (cancer screening) to 9 % (consequences of cancer on ability to work). Print media and personalized reading materials were the most preferred information sources. Younger age, higher education, race other than non-Hispanic white, later cancer stage, having breast cancer, having ≥2 comorbidities, and self-reporting poor health were associated with greater informational need (p < 0.05).

CONCLUSIONS/IMPLICATIONS FOR CANCER SURVIVORS

Long-term cancer survivors continue to report health information needs for most SCP items and would prefer a print format; however, level of need differs by socio-demographic and cancer characteristics. Cancer survivors who did not previously receive a SCP may still benefit from receiving SCP content, and strategies for enabling dissemination to long-term survivors warrant further investigation.

Health-Related Quality of Life of Food-Insecure Ethnic Minority Patients With Cancer

PURPOSE

The association between food insecurity and health-related quality of life (QOL) of racial/ethnic minority patients with cancer has not been examined. The purpose of this study is to determine the relationship between food insecurity and health-related QOL reported by racial/ethnic minority patients with cancer.

METHODS

A consecutive sample of 1,390 underserved ethnic minority patients receiving cancer care in 10 cancer clinics and hospitals in New York City participated in this study. Health-related QOL was measured by the Functional Assessment of Cancer Therapy-General (FACT-G) and food security was assessed by the US Department of Agriculture Core Food Security Module.

RESULTS

Of the 1,390 patients, 581 (41.8%) were classified as food secure, 571 (41.1%) with low food security, and 238 (17.1%) with very low food security. Health-related QOL decreased with each lower food security level. Patient self-reported physical, functional, social, and emotional well-being subscale scores decrease significantly with increasing food insecurity. After controlling for demographic and medical-related factors, the decreases in QOL, physical, functional, social and emotional well-being scores with increasing food insecurity remained significant.

CONCLUSION

Food insecurity was associated with lower QOL in this sample of underserved racial/ethnic minority patients with cancer. Underserved ethnic minority patients diagnosed with cancer are a vulnerable patient population, at significant risk for inadequate food access and the related lower QOL.

Economic hardship of minority and non-minority cancer survivors 1 year after diagnosis: another long-term effect of cancer?

BACKGROUND

Current literature suggests that racial/ethnic minority survivors may be more likely than whites to experience economic hardship after a cancer diagnosis; however, little is known about such hardship.

METHODS

Patients with lung cancer (LC) and colorectal cancer (CRC) participating in the Cancer Care Outcomes Research and Surveillance (CanCORS) Consortium were surveyed approximately 4 months (baseline) and 12 months (follow-up) after diagnosis. Economic hardship at follow-up was present if participants 1) indicated difficulty living on household income; and/or 2) for the following 2 months, anticipated experiencing hardships (inadequate housing, food, or medical attention) or reducing living standards to the bare necessities of life. The authors tested whether African Americans (AAs) and Hispanics were more likely than whites to experience economic hardship controlling for sex, age, education, marital status, cancer stage, treatment, and economic status at baseline (income, prescription drug coverage).

RESULTS

Of 3432 survivors (39.7% with LC, 60.3% with CRC), 14% were AA, 7% were Hispanic, and 79% were white. AAs and Hispanics had lower education and income than whites. Approximately 68% of AAs, 58% of Hispanics, and 44.5% of whites reported economic hardship. In LC survivors, the Hispanic-white disparity was not significant in unadjusted or adjusted analyses, and the AA-white disparity was explained by baseline economic status. In CRC survivors, the Hispanic-white disparity was explained by baseline economic status, and the AA-white disparity was not explained by the variables that were included in the model.

CONCLUSIONS

Economic hardship was evident in almost 1 in 2 cancer survivors 1 year after diagnosis, especially AAs. Research should evaluate and address risk factors and their impact on survival and survivorship outcomes.

Dealing with the financial burden of cancer: perspectives of older breast cancer survivors

PURPOSE

Financial burden among cancer survivors is often overlooked in survivorship care planning. Cancer survivors with limited incomes may be particularly affected. Yet, little data are available to address financial issues among them. Eliciting the survivors' perspectives on how to deal with this financial burden is a first crucial step to identifying the means to provide this supportive care.

METHODS

In this pilot study, three nominal group technique (NGT) sessions were conducted with a convenience sample of 23 older breast cancer survivors (age 52 to 83) recruited from a county safety net hospital and a Comprehensive Cancer Center. One single NGT question was posed in these sessions, namely "What could help women deal with the financial burden that cancer brings to them and their families?" Survivors responded in an iterative fashion and then ranked the most relevant responses.

RESULTS

The most relevant responses addressed the (1) need for affordable insurance; (2) need to have prompt information on treatment costs patients will face, insurance coverage, and agencies or programs that provide needed products and services; and (3) need to access social workers, navigators, support groups, or others knowledgeable about available resources. Survivors also suggested that physicians become aware of cancer costs and financial issues faced by patients and consider costs in their treatment plans.

CONCLUSIONS

Older survivors face financial challenges for which there are few available resources. They suggested several avenues to address cancer-related financial issues that may be considered in developing supportive interventions.

Meeting the information needs of lower income cancer survivors: results of a randomized control trial evaluating the american cancer society's "I can cope"

The American Cancer Society is a leader in the development of cancer survivorship resources. One resource of the American Cancer Society is the I Can Cope program, an educational program for cancer survivors and their families. Evaluations of this program indicate that cancer patients highly rate its objectives. Yet, there are gaps in the understanding of the full impact of the program on diverse cancer survivors. In this study, the authors used a randomized trial to evaluate the program. Participants included 140 low-income survivors (79% Black; 38% breast cancer) from community hospitals who were randomized to 4 sessions of I Can Cope (learning about cancer; understanding cancer treatments; relieving cancer pain; and keeping well in mind and body) or 4 sessions of a wellness intervention (humor, meditation, relaxation, and music therapy). The authors' primary outcome was "met information needs." After controlling for covariates, their analysis indicated that I Can Cope was no more effective than the wellness intervention in addressing survivor information needs relative to the learning objectives. Participants provided high overall ratings for both interventions. Self-efficacy for obtaining advice about cancer, age, education, and income were associated with information needs. Educational programs tailored to levels of self-efficacy and patient demographics may be needed.

Opportunities to reduce cancer barriers: community town halls and provider focus groups

This paper presents the findings from town hall meetings held with community residents and focus groups with health care providers. A total of five town halls (N = 139) were conducted. Four were conducted in English and a fifth was conducted in Spanish to obtain the input of the local Hispanic community. Surveys were provided to town hall participants to assess their perceptions of cancer and screening as well as their cancer screening behaviors. Participants were asked questions designed to determine local gaps and needs in health and cancer care, and their attitudes regarding breast cancer resources, education, treatment, and clinical trials. Additionally, four focus groups (N = 45) were held with a wide range of providers to obtain their perspectives on barriers to breast cancer screening, local cancer prevention and care, and clinical trials. Results indicate gaps in local resources and support services, particularly in terms of education and integrated care.

Do socially deprived urban areas have lesser supplies of cancer care services?

PURPOSE

Area social deprivation is associated with unfavorable health outcomes of residents across the full clinical course of cancer from the stage at diagnosis through survival. We sought to determine whether area social factors are associated with the area health care supply.

PATIENTS AND METHODS

We studied the area supply of health services required for the provision of guideline-recommended care for patients with breast cancer and colorectal cancer (CRC) in each of the following three distinct clinical domains: screening, treatment, and post-treatment surveillance. We characterized area social factors in 3,096 urban zip code tabulation areas by using Census Bureau data and the health care supply in the corresponding 465 hospital service areas by using American Hospital Association, American Medical Association, and US Food and Drug Administration data. In two-level hierarchical models, we assessed associations between social factors and the supply of health services across areas.

RESULTS

We found no clear associations between area social factors and the supply of health services essential to the provision of guideline recommended breast cancer and CRC care in urban areas. The measures of health service included the supply of physicians who facilitate screening, treatment, and post-treatment care and the supply of facilities required for the same services.

CONCLUSION

Because we found that the supply of types of health care required for the provision of guideline-recommended cancer care for patients with breast cancer and CRC did not vary with markers of area socioeconomic disadvantage, it is possible that previously reported unfavorable breast cancer and CRC outcomes among individuals living in impoverished areas may have occurred despite an apparent adequate area health care supply.

Cancer support and resource needs among African American older adults

Older African Americans face substantial barriers to state-of-the-art cancer care. Implementing culturally appropriate support throughout cancer therapy is critical to improving cancer outcomes and quality of life for this vulnerable population. The purpose of this study was to obtain experiential data regarding cancer diagnosis and treatment, and analyze survivors' recommendations regarding treatment-related needs, psychosocial support, and strategies and resources. Four main issues emerged from the study: (a) the need for more health-related and cancer-specific education, (b) the importance of faith and spirituality, (c) the availability of support, and (d) participants' difficulty identifying and articulating financial needs. Few participants reported requesting or receiving assistance (financial or otherwise) outside of the family during their cancer experience. However, treatment-related medication costs posed a significant hardship for many.