Sexual Minority Women's Coping and Psychological Adjustment after a Diagnosis of Breast Cancer

Theory of health promotion for sexual and gender minority populations with cancer

BACKGROUND

Structural factors (e.g., cisheteronormativity) promote minority stressors, which generate healthcare disparities among sexual and gender minority (SGM) populations (also known as lesbian, gay, bisexual, transgender, queer, intersexual, asexual, and other sexual and gender-expansive persons--LGBTQIA+) with cancer. The individual's biological, behavioral, social, and psychological response to minority stressors will vary throughout their life course. However, there is a lack of empirical and theoretical guidance for conceptualizing health outcomes among SGM subgroups.

PURPOSE

To propose a nursing theory for the health promotion of SGM populations with cancer.

METHODS

Walker and Avant's strategies for theoretical derivation were followed.

RESULTS

I present the definition, theoretical assumptions, concepts, propositions, and implications for practice, education, research, and policy of the derived theory.

DISCUSSION AND CONCLUSION

The theory provides a nursing framework to understand and address the multilevel impact of minority stress on the health of SGM individuals throughout their cancer care continuum.

Sexual and Gender Minority Invisibility in Cancer Studies: A Call for Effective Recruitment Methods to Address Cancer Disparities

#LGBTQ+ people with cancer are invisibilized: A call for #intersectional cancer research (link here) #healthequity

Disparities in cancer care among sexual and gender minority adolescent and young adult patients: A scoping review

BACKGROUND

Adolescent and young adult cancer patients (AYAs) who are sexual and gender minorities (SGM) are a rapidly increasing population that experiences unmet cancer-related needs. Despite emerging awareness, little is known about cancer care and outcomes for this vulnerable population. The purpose of this scoping review was to explore current knowledge and gaps in the literature on cancer care and outcomes for AYAs who identify as SGM.

METHODS

We reviewed empirical knowledge on SGM AYAs by identifying, describing, and critically appraising the literature to date. We conducted a comprehensive search on OVID MEDLINE, PsycINFO, and CINAHL in February 2022. Additionally, we developed and piloted a conceptual framework for appraising SGM AYA research.

RESULTS

A total of 37 articles were included in the final review. Most studies focused exclusively on SGM-related outcomes as the primary aim of the study (81.1%, n = 30), whereas others included some focus on SGM-related outcomes (18.9%, n = 7). The majority of studies included AYAs as part of a broader age range (86.0%, n = 32), and only a few studies examined exclusively AYA samples (14.0%, n = 5). Gaps in scientific evidence on SGM AYAs were seen across the cancer care continuum.

CONCLUSION

Numerous gaps in knowledge of cancer care and outcomes exist for SGM AYAs diagnosed with cancer. Future efforts should fill this void with high-quality empirical studies that reveal unknown disparities in care and outcomes and are inclusive of the intersectionality of SGM AYAs with other minoritized experiences, thereby advancing health equity in meaningful ways.

Breast Cancer Screening and Care Among Black Sexual Minority Women: A Scoping Review of the Literature from 1990 to 2017

Introduction: Black women are more likely to be diagnosed at later stages of breast cancer compared with White women due to lower frequency of screening and lack of timely follow-up after abnormal screening results. Disparities in breast cancer screening, risk, and mortality are present within both Black women and sexual minority communities; however, there exists limited research concerning breast cancer care among Black sexual minority women. Materials and Methods: This scoping review examines the literature from 1990 to 2017 of the breast cancer care continuum among Black sexual minority women, including behavioral risk factors, screening, treatment, and survivorship. A total of 91 articles were identified through PubMed, PsycINFO, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. Fifteen articles were selected for data extraction, which met the criteria for including Black/African American women, discussing breast cancer care among both racial and sexual minorities, and being a peer-reviewed article. Results: The 15 articles were primarily within urban contexts, and defined sexual minorities as lesbian or bisexual women. Across all the studies, Black sexual minority women were highly under-represented, and key conclusions are not fully applicable to Black sexual minority women. Sexual minority women had a higher prevalence of breast cancer risk factors (i.e., nulliparity, fewer mammograms, higher alcohol intake, and lower oral contraceptive use). Furthermore, some studies noted homophobia from health providers as potential barriers to engagement in care for sexual minority women. Conclusions: The lack of studies concerning Black sexual minority women in breast cancer care indicates the invisibility of a group that experiences multiple marginalized identities. More research is needed to capture the dynamics of the breast cancer care continuum for Black sexual minority women.

Care delivery, patient experiences, and health outcomes among sexual and gender minority patients with cancer and survivors: A scoping review

Sexual and gender minorities (SGMs) face a disproportionate burden of cancer, yet little is known about the experiences and specific needs of these underserved populations in cancer care delivery. The authors conducted a scoping review to characterize the literature on cancer care delivery, health outcomes, and health care experiences for patients with cancer and survivors identifying as SGM. In total, 1176 peer-reviewed citations were identified after a systematic search of the PubMed/Medline, PsycInfo, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Web of Sciences databases without restriction on publication date. The details captured included study aims, design, population, cancer site, and main findings. Thirty-seven studies published from 1998 to 2017 met the study criteria. Most studies were conducted in the post-treatment survivorship phase of the continuum (n = 30), and breast cancer was the most common cancer site (n = 20). There were only 2 intervention studies. The studies reviewed were classified under the following areas of focus: 1) disclosure of sexual orientation and gender identity, 2) quality of care, 3) psychosocial impact of/ adjustment to cancer, 4) social support, 5) sexual functioning, and 6) health risks/health behavior. Very little research reported an assessment of gender minority status or included a focus on gender minorities (n = 7). This review revealed substantial research gaps given a lack of population-based data and small sample sizes, likely related to the absence of systematic collection of sexual orientation and gender identity information in the cancer care context. Deficient research in this area likely perpetuates health disparities. Further research is needed to identify and remove the barriers to delivering high-quality care to SGM individuals with cancer.

Social Inequalities in Palliative Care for Cancer Patients in the United States: A Structured Review

OBJECTIVES

To identify patterns of access to and use or provision of palliative care services in medically underserved and vulnerable groups diagnosed with cancer.

DATA SOURCES

Google Scholar, PubMed, MEDLINE, and Web of Science were searched to identify peer-reviewed studies that described palliative care in medically underserved or vulnerable populations diagnosed with cancer.

CONCLUSION

Disparities in both access and referral to palliative care are evident in many underserved groups. There is evidence that some groups received poorer quality of such care.

IMPLICATIONS FOR NURSING PRACTICE

Achieving health equity in access to and receipt of quality palliative care requires prioritization of this area in clinical practice and in research funding.

Meaningful support for lesbian and bisexual women navigating reproductive cancer care in Canada: An exploratory study

Health inequities for sexual minorities are well documented, but there is a gap in nursing research addressing the specific experiences faced by lesbian and bisexual women with reproductive cancers. This critical feminist study explored interactions between sexual minority women with reproductive cancers and their health care providers and how these interactions enable and create barriers to meaningful support. Purposeful convenience sampling was used to recruit lesbian and bisexual reproductive cancer survivors from Ontario, Canada and providers who have cared for this population. Five lesbian and one bisexual woman who were reproductive cancer survivors participated, as well as one registered nurse who was not a survivor but who has cared for sexual minority women with reproductive cancers. Face-to-face interviews were conducted and conventional content analysis was used to analyze the data. The authors report on findings related to meaningful support, interactions with providers and organisational environments. Narratives showed that an understanding of gender norms influenced women’s perceptions of supportive and inclusive care, such as the acknowledgment of social supports and barriers to supportive care that included disclosure of sexual orientation. There are implications for nursing education and policy change to enhance inclusive interactions and environments for diverse sexual minority women with reproductive cancers.

Cancer and lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations

This article provides an overview of the current literature on seven cancer sites that may disproportionately affect lesbian, gay, bisexual, transgender/transsexual, and queer/questioning (LGBTQ) populations. For each cancer site, the authors present and discuss the descriptive statistics, primary prevention, secondary prevention and preclinical disease, tertiary prevention and late-stage disease, and clinical implications. Finally, an overview of psychosocial factors related to cancer survivorship is offered as well as strategies for improving access to care.

An Internet-Based Study Examining the Factors Associated with the Physical and Mental Health Quality of Life of LGBT Cancer Survivors

PURPOSE

The purpose of this study was to examine factors associated with the quality of life of lesbian, gay, bisexual, and transgender (LGBT) cancer survivors.

METHODS

Data were collected via a nationally advertised online short-form health survey.

RESULTS

Factors associated with lower physical quality of life included younger age at diagnosis, cancer type, medical co-morbidities, being overweight or obese, recurrence, and current cancer treatment. Lower mental quality of life was associated with younger age, smoking, lower perceived quality of care, lower perceived support, and higher cancer-related worry.

CONCLUSIONS

Findings highlight a need for health promotion interventions specifically for LGBT cancer survivors.

Perceived stress and sexual orientation among breast cancer survivors

Little is known about the cancer survivorship experiences of sexual minority women (SMW). SMW breast cancer survivors are hypothesized to experience more stress compared to heterosexual breast cancer survivors. A convenience sample of 211 breast cancer survivors (68 SMW, 143 heterosexual women) participated in this cross-sectional online investigation of perceived stress. Regression analyses indicated significant differences in reported stress between heterosexual and SMW breast cancer survivors (β= -.15, p = .03). Our findings may reflect unique experiences had by sexual minority breast cancer survivors. Future research should explore the factors that contribute to elevated perceived stress in this group.

Lesbian and bisexual women's adjustment after a breast cancer diagnosis

BACKGROUND

Little research has been devoted to lesbian and bisexual survivors' adjustment after breast cancer.

OBJECTIVES

To determine differences between lesbian and bisexual survivors and to examine whether sexual minority-specific issues contribute to these survivors' adjustment.

DESIGN

We recruited 180 lesbian and bisexual survivors with primary diagnoses of DCIS (ductal carcinoma in situ) or I-III nonrecurrent breast cancer from a cancer registry and the community.

RESULTS

The characteristics of lesbian and bisexual survivors of breast cancer were similar, with few exceptions, such as partner status and gender of partner. Sexual minority-specific factors contributed toward explaining lesbian and bisexual survivors' anxiety and depression but did not contribute toward explaining survivors' physical and mental health.

CONCLUSIONS

Awareness about vulnerabilities due to partner status and about the sexual minority-specific issues that contribute to adjustment is important for medical and mental health professionals who have lesbian and bisexual breast cancer survivors as patients.

Breast cancer survivors of different sexual orientations: which factors explain survivors' quality of life and adjustment?

BACKGROUND

Little is known about differences by sexual orientation in explanatory factors of breast cancer survivors' quality of life, anxiety, and depression.

PATIENTS AND METHODS

Survivors were recruited from a cancer registry and additional survivors recruited through convenience methods. Data were collected via telephone survey from all 438 survivors, who were disease free and diagnosed with non-metastatic breast cancer an average of 5 years earlier. To explain quality of life, anxiety, and depression, we focused on sexual orientation as the primary independent factors, in addition, considering demographic, psychosocial, clinical, and functional factors as correlates.

RESULTS

Sexual orientation had indirect associations with each of the outcomes, through disease-related and demographic factors as well as psychosocial and coping resources. The various explanatory models explain between 36% and 50% of the variance in outcomes and identified areas of strengths and vulnerabilities in sexual minority compared with heterosexual survivors.

CONCLUSIONS

This study's findings of strengths among specific subgroups of sexual minority compared with heterosexual survivors require further explorations to identify the reasons for this finding. Most of the identified vulnerabilities among sexual minority compared with heterosexual survivors of breast cancer are amenable to change by interventions.

Sexual minority status and long-term breast cancer survivorship

Sexual minority women, such as lesbians, bisexuals, and women who have a woman partner face unique challenges, such as deciding on disclosing their sexual minority status to health providers. The purpose of this qualitative study was to explore the perceptions of sexual minority women who were long-term breast cancer survivors. Twenty-two sexual minority women, diagnosed with non-metastatic breast cancer between 2000 and 2005, participated in semi-structured, open-ended interviews. Interviews were audio-recorded, transcribed, and analyzed to identify emergent themes to summarize sexual minority women's perceptions of breast cancer survivorship. Participants' perceptions about the impact of their sexual minority identity on breast cancer survivorship consisted of: (1) breast cancer is a women's issue, not a lesbian issue; (2) I can manage my identity in the context of breast cancer; and (3) I am better off than heterosexual women. The authors' findings suggest a possible disconnect between sexual minority women with breast cancer who de-emphasized the importance of sexual minority status and the research community that emphasizes the importance of this status. Prior to counting on sexual minority women's interest in studies, researchers may need to educate sexual minority women about the need of breast cancer studies.

Relationship between sexual orientation and quality of life in female breast cancer survivors

BACKGROUND

Some groups of breast cancer survivors bear a greater burden of diminished quality of life than others. Self-identified lesbians, or women who partner with other women in romantic and spousal relationships, are one group of women that has been hypothesized to experience and report poorer quality of life compared with heterosexual breast cancer survivors.

METHODS

A convenience sample of 204 breast cancer survivors (143 heterosexual and 61 self-identified lesbians) participated in this cross-sectional, online study by completing electronic surveys regarding their quality of life.

RESULTS

Multivariate linear regression indicated that quality of life was not related to sexual orientation (β=0.13, p=0.30). Quality of life scores were similar between heterosexual and self-identified lesbian breast cancer survivors.

CONCLUSION

Quality of life scores were similar between heterosexual and lesbian breast cancer survivors. Future survivorship research should include population-based sampling of lesbian breast cancer survivors for testing quality of life and reducing the healthy volunteer effect, and population-based methodologies should be made available to enhance researcher ability to study this rare population.

Health-related quality of life in breast cancer survivors of different sexual orientations

PURPOSE

Sexual minority women, e.g., lesbians and bisexuals, are an underserved population but not much is known about their quality of life (QOL) after a breast cancer diagnosis. For this reason, this study examines the physical and mental QOL and its association with sexual orientation in a cohort of long-term nonrecurring breast cancer survivors.

METHODS

Survivors were recruited from a cancer registry and additional sexual minority survivors through convenience methods. Data were collected via telephone survey from all 438 survivors, who were disease free and diagnosed with nonmetastatic breast cancer an average of 5 years earlier. Sexual orientation was the primary independent factor, and QOL, measured with the SF-12, was the outcome. Demographic and clinical factors were considered as correlates.

RESULTS

Sexual orientation was not significantly associated with survivors' physical or mental QOL. The majority of survivors reported good physical and mental QOL. The demographic and clinical factors explained about one-third of the variation in survivors' physical QOL, but did not account for most of survivors' mental QOL.

CONCLUSIONS

The lack of an association between sexual orientation and QOL suggests that if there is a link, it does not relate directly to clinical and demographic factors. Future studies need to identify areas of similarity and difference between sexual minority and heterosexual survivors and mechanisms to explain the similarity in QOL.

Breast cancer survivorship: the role of perceived discrimination and sexual orientation

Breast cancer disproportionately affects sexual minority women (SMW) compared to heterosexual women and a small but growing literature indicates that SMW may have diminished survivorship outcomes; outcomes that are measurably and importantly different from heterosexual breast cancer survivors. However, it remains unknown how sexual orientation influences breast cancer survivorship outcomes such as quality of life. One possible route of influence is SMW's perceived discrimination in the health care setting. This cross-sectional study examines SMW perceptions of discrimination as one of the multiple facets of the breast cancer survivorship process. This study assessed SMW breast cancer survivor's perceptions of discrimination during their breast cancer treatment experience and secondarily, examined the role of this perceived discrimination on SMW's quality of life. Sixty-eight purposefully sampled sexual minority breast cancer survivors completed assessments of quality of life, perceived discrimination, perceived social support and perceived stress via an online survey. Statistical analyses point to perceived discrimination and perceived social support as important indicators for predicting SMW's quality of life. Future research on SMW's breast cancer survivorship should include measures of perceived discrimination.

Lesbians and cancer: an overlooked health disparity

OBJECTIVE

To evaluate the breast, cervical, ovarian, lung, and colorectal cancer literatures using a novel application of the cancer disparities grid to identify disparities along domains of the cancer continuum focusing on lesbians as a minority population.

METHODS

Computerized databases were searched for articles published from 1981 to present. Cumulative search results identified 51 articles related to lesbians and disparities, which were classified by domain.

RESULTS

The majority of articles identified were related to breast and cervical cancer screening. Barriers to adequate screening for both cancers include personal factors, poor patient-provider communication, and health care system factors. Tailored risk counseling has been successful in increasing lesbian's mammography and Pap screening. Ovarian, lung, and colorectal cancer have been virtually unexplored in this population. An "Adjustment to Illness/Quality of Life" domain was added to capture literature on psychosocial aspects of cancer.

CONCLUSIONS

This review revealed a lack of research for specific cancers and for specific aspects of the cancer continuum. The limited number of studies identified focused on issues related to screening/prevention in cervical and breast cancers, with almost no attention to incidence, etiology, diagnosis, treatment, survival, morbidity, or mortality. We present implications for social and public health policy, research, and prevention.

Breast Reconstruction following Mastectomy for Breast Cancer: The Decisions of Sexual Minority Women

BACKGROUND

Prior research on decision-making for reconstructive surgery after mastectomy has not addressed the specific considerations of sexual minority women (women who partner with women, and lesbian or bisexual identified women). The purpose of this study is to explore which issues sexual minority women considered when making decisions on reconstructive surgery and to understand the influence and perspectives of these women's most important support persons.

METHODS

Study participants were recruited through targeted community-based sampling. The authors conducted individual semistructured interviews with 15 sexual minority women who had been treated with mastectomy after breast cancer diagnosis and 12 support persons who were identified by these women as their most important source of support. Using qualitative data analysis software, transcribed interviews were analyzed. Through constant comparison methods, themes related to the decision on and experiences and satisfaction with reconstructive choice were identified from the narrative data.

RESULTS

The considerations of women who decided for or against reconstruction are rooted in a value system and body image shaped by their sexual minority identity. Women who chose reconstruction experienced difficulties and regrets, whereas women without reconstruction adjusted well after time. Partners of sexual minority women matched the level of satisfaction with reconstructive choice achieved by the women themselves.

CONCLUSION

Providers who treat sexual minority women might benefit from knowing about issues important to this population to provide more comprehensive care.

Support providers of sexual minority women with breast cancer: who they are and how they impact the breast cancer experience

OBJECTIVE

The aim of this study was to identify the factors associated with adjustment to breast cancer among sexual minority women with breast cancer and their support person.

METHODS

In a cross-sectional study, sexual minority women with breast cancer and their support provider were asked to self-report social support, distress, and coping, using standardized measures.

RESULTS

Twenty-three (77%) women had a support provider participating in the study. Disclosure of sexual orientation, less helpless-hopeless coping, and support provider perception of high fighting spirit were related to lower patient distress. Lower support provider distress was related to more patient disclosure of sexual orientation, a larger social network, and an underestimation of fatalistic patient coping. An overestimation of patients' anxious preoccupation coping was linked to higher support provider distress.

CONCLUSIONS

Providing opportunities to sexual minority patients and their support providers to focus on issues such as disclosure of sexual orientation and coping may lower patient and support provider distress.