Differences in Health-Related Quality of Life and Health Behaviors Among Lesbian, Bisexual, and Heterosexual Women Surviving Cancer from the 2013 to 2018 National Health Interview Survey

Development of Communication Skills Training for Oncology Clinicians to Promote Inclusion of the Family Members of LGBTQ+ People with Cancer

Background: LGBTQ+ persons with cancer and their families consistently face discriminatory care. In addition, clinicians report inadequate population-specific knowledge and communication skills to effectively promote LGBTQ+ inclusion. To fill this gap, we designed a communication skills training based on extant literature; multidisciplinary perspectives; and patient, family, and clinician expert engagement. Methods: Training content comprised didactic information, including exemplar videos of communication strategies, and experiential learning roleplay opportunities with standardized patient and family member actors. Two training sessions were conducted virtually with invited multidisciplinary clinicians using convenience sampling. Each training was followed by a one-hour, semi-structured focus group to solicit feedback on participants' experiences and recommendations for improvement. Focus group transcripts were thematically analyzed using a constant comparative approach. Results: Two major themes were identified: key takeaways from the training and recommendations for improvement. Participants reported favorable learning experiences and believed the training would have a positive influence on future clinical interactions. We synthesized recommendations into five discrete pieces of feedback related to (1) the advanced level of training material; (2) diversity throughout the training; (3) complexity of family dynamics; and (4) recovery from communication mistakes; and (5) additional topics for future training. Based on feedback, corresponding changes for each item and a refined communication skills blueprint are provided. Conclusions: Our innovative training on inclusive cancer care for LGBTQ+ patients' families will provide both knowledge-based and experiential learning opportunities to advance clinicians' confidence in communicating empathically with members of diverse sexual orientation and gender identities. The training is poised for feasibility and efficacy testing.

Chronic Health Conditions, Disability, and Physical and Cognitive Limitations among LGBTQ+ Cancer Survivors

BACKGROUND

Cancer survivors are at high risk for chronic health conditions and physical and cognitive limitations. However, few studies have explored these outcomes among Lesbian, Gay, Bisexual, Transgender, Queer, Plus (LGBTQ+) survivors.

METHODS

We used pooled, weighted Behavioral Risk Factor Surveillance System data from 23 states that completed two specific modules at least once from 2020 to 2022. We calculated age-adjusted prevalence for heart disease, asthma, chronic obstructive pulmonary disease, depressive disorders, myocardial infarction, kidney disease, stroke, diabetes, hearing disability, vision disability, cognitive limitations, and difficulty walking, dressing, and running errands in LGBTQ+, lesbian, gay, or bisexual, transgender or gender nonconforming (TGNC), and non-LGBTQ+ cancer survivors. Four multivariable logistic regression models controlling for different factors were run for each outcome.

RESULTS

Of 40,990 cancer survivors, 1,715 were LGBTQ+. LGBTQ+ survivors had significantly higher age-adjusted prevalence of all outcomes. The prevalence of all outcomes was the highest among TGNC survivors, except for depressive disorders and cognitive limitations. LGBTQ+ survivors had higher odds of reporting asthma [adjusted OR (aOR): 1.5; 95% confidence interval (CI), 1.2-1.9], depressive disorders (aOR: 1.9; 95% CI, 1.6-2.4), kidney disease (aOR: 1.5; 95% CI, 1.1-2.1), stroke (aOR: 1.7; 95% CI, 1.3-2.3), diabetes (aOR: 1.3; 95% CI, 1.0-1.6), vision disability (aOR: 1.6; 95% CI, 1.2-2.2), cognitive limitations (aOR: 2.3; 95% CI, 1.8-2.9), difficulty walking (aOR: 1.7; 95% CI, 1.3-2.0), dressing (aOR: 2.0; 95% CI, 1.5-2.7), and running errands (aOR: 1.6; 95% CI, 1.3-2.1). In TGNC models, TGNC cancer survivors had increased odds of most outcomes in comparison to cisgender survivors.

CONCLUSIONS

LGBTQ+ cancer survivors have an elevated burden of all chronic health conditions, disabilities, and limitations assessed. TGNC cancer survivors experience even higher burden of the same outcomes.

IMPACT

Findings highlight substantial disparities regarding the health of LGBTQ+ cancer survivors. See related In the Spotlight, p. 1395.

Understanding and Addressing LGBTQ+ Cancer Health Disparities

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) cancer survivors disproportionately experience physical and mental health comorbidities compared with their heterosexual and cisgender counterparts. A recent study by Waters and colleagues evaluates associations between LGBTQ+ identity and physical and mental health comorbidities and activity limitations using Behavioral Risk Factor Surveillance System data. Consistent with previous work, their findings suggest that LGBTQ+ survivors have higher odds of several chronic conditions, including asthma, depressive disorders, heart attacks, kidney disease, stroke, and diabetes, as well as reporting disabilities related to vision and cognition and difficulty with activities of daily living, including walking, dressing, and running errands. Waters and colleagues expand on previous work by providing estimates separately for sexual orientation and gender identity. Their results for lesbian, gay, and bisexual survivors were similar to those for LGBTQ+ survivors overall. In novel findings, they report much stronger associations between identifying as transgender or gender nonconforming and nearly all comorbidities compared with cisgender survivors, including those who identify as lesbian, gay, or bisexual. This commentary advocates for the importance of future work considering the drivers of disparities in cancer outcomes based on sexual orientation and gender identity. See related article by Waters et al., p. 1405.

Assessing Narrative Patterns in Health Access, Outcomes, and Behaviors Across Three Data Sets From England, the United States, and California for Sexual Minority Adults

We examined peer-reviewed publications analyzing data from the English GP Patient Survey (GPPS), U.S. National Health Interview Survey (NHIS), and California Health Interview Survey (CHIS) to explore how the health of sexual minority populations varies across settings and subgroups. We searched for English language articles published 2011-2022, screening abstracts (n = 112), reviewing full text (n = 97), and extracting data (n = 85). We conducted a content analysis to identify patterns across settings for sexual minority people compared with heterosexual counterparts and each other. Across all settings, sexual minority adults had poorer health care access, worse health outcomes and patient experiences, more detrimental health behaviors, and greater health care services utilization (reflecting risk awareness and need). When subgroup data were reported, differences were greater among women, except for HIV and related cancers, which were most prevalent among sexual minority men. Sexual minority people generally reported significantly worse health access, outcomes, and behaviors in all three settings.

From Invisibility to Inclusion: A Call to Action to Address COPD Disparities in the Lesbian, Gay, Bisexual, Transgender, and Queer+ Community

COPD is a significant cause of morbidity and mortality both in the United States and worldwide. Lesbian, gay, bisexual, transgender, or queer + (LGBTQ+) individuals (the plus sign indicates inclusion of people who are questioning, intersex, asexual, or who hold other gender/sex/romantic identities not specifically identified) have a higher rate of tobacco smoking, predisposing them to an increased risk of developing COPD. Despite this risk, the burden of COPD in LGBTQ+ individuals is not known. Moreover, there is limited focus on efforts to identify and reduce disease risk in this population. In this perspective, we present the results of a focused literature review of COPD in LGBTQ+ populations. We found only 8 studies that reported the prevalence of COPD in different subgroups of the LGBTQ+ population. All studies found an increased prevalence of COPD in the studied LGBTQ+ sub-groups compared to their heterosexual and/or cisgender counterparts. We propose a 3-pronged call to action to improve the care of LGBTQ+ people with COPD. First, we must improve awareness and education about COPD in the LGBTQ+ community through the effective development and dissemination of educational resources to LGBTQ+ people and their health care providers. Second, we call for prevention and intervention efforts through targeted tobacco cessation initiatives and case-finding via screening spirometry among symptomatic LGBTQ+ smokers. Finally, well-designed cohort studies are required to better characterize the COPD burden among LGBTQ+ populations. With targeted approaches in these 3 areas, we can improve the health of this vulnerable population, historically marginalized by current COPD research efforts.

Scoping review of experiences of sexual minority women treated for breast cancer

PURPOSE

To summarize and critique research on the experiences and outcomes of sexual minority women (SMW) treated with surgery for breast cancer through systematic literature review.

METHODS

A comprehensive literature search identified studies from the last 20 years addressing surgical experiences and outcomes of SMW breast cancer survivors. Authors performed a quality assessment and thematic content analysis to identify emergent themes.

RESULTS

The search yielded 121 records; eight qualitative studies were included in the final critical appraisal. Quality scores for included studies ranged 6-8 out of 10. Experiences and outcomes of SMW breast cancer survivors were organized by major themes: 1) Individual, 2) Interpersonal, 3) Healthcare System, and 4) Sociocultural and Discursive.

CONCLUSIONS

SMW breast cancer survivors have unique experiences of treatment access, decision-making, and quality of life in survivorship. SMW breast cancer survivors' personal values, preferences, and support network are critical considerations for researchers and clinicians.

Food Insecurity, Neighborhood Food Environment, and Health Disparities: State of the Science, Research Gaps and Opportunities

Food insecurity and the lack of access to affordable, nutritious food are associated with poor dietary quality and an increased risk of diet-related diseases, including cardiovascular disease, diabetes, and certain types of cancer. Those of lower socioeconomic status and racial and ethnic minority groups experience higher rates of food insecurity, are more likely to live in under-resourced food environments, and continue to bear the greatest burden of diet-related chronic diseases in the United States. Despite the growing body of literature in this area, there are still significant gaps in our understanding of the various pathways that link food insecurity and neighborhood food environments to racial/ethnic and socioeconomic disparities in health and the most effective intervention strategies to address these disparities. To better understand the science in this area, the National Institutes of Health, in collaboration with the Centers for Disease Control (CDC) and Prevention and the United States Department of Agriculture (USDA), convened a virtual 3-d workshop 21-23 September 2021: Food Insecurity, Neighborhood Food Environment, and Nutrition Health Disparities: State of the Science. The workshop brought together a diverse group of researchers, practitioners, policymakers, and federal partners with expertise in nutrition, the food environment, health and social policy, and behavioral and social sciences. The workshop had the following 3 research objectives: 1) summarize the state of the science and knowledge gaps related to food insecurity, neighborhood food environments, and nutrition health disparities, 2) identify research opportunities and strategies to address research gaps, and 3) examine evidence-based interventions and implementation approaches to address food insecurity and neighborhood food environments to promote health equity. This article summarizes workshop proceedings and describes research gaps and future opportunities that emerged from discussions.

Risk of chronic health conditions in lesbian, gay, and bisexual survivors of adolescent and young adult cancers

BACKGROUND

In the general population, individuals with minoritized sexual orientation and gender identity have a higher burden of chronic health conditions than heterosexual individuals. However, the extent to which sexual orientation is associated with excess burden of chronic conditions in adolescent and young adult cancer survivors (AYACS) is unknown.

METHODS

Lesbian, gay, and bisexual (LGB) AYACSs, LGB individuals without a history of cancer, and heterosexual AYACSs were identified by self-reported data from the cross-sectional National Health Interview Survey (2013-2020). Socioeconomic factors and the prevalence of chronic health conditions were compared between groups using χ2 tests. Logistic regression methods were used to determine the odds of chronic conditions by socioeconomic factors within and between survivor and comparison groups.

RESULTS

One hundred seventy LGB cancer survivors, 1700 LGB individuals without a history of cancer, and 1700 heterosexual cancer survivors were included. Compared with heterosexual survivors, LGB survivors were less likely to be married (p = .001) and more likely to have never been married (p < .001). LGB survivors were more likely to have incomes between 100% and 200% of the federal poverty level than LGB individuals without a history of cancer (p = .012) and heterosexual survivors (p = .021) and were less likely to report incomes >200% the federal poverty level. LGB survivors had higher odds of chronic health conditions than LGB individuals without a history of cancer (odds ratio, 2.45; p < .001) and heterosexual survivors (odds ratio, 2.16; p = .003).

CONCLUSIONS

LGB AYACSs are at increased risk of having chronic health conditions compared with both LGB individuals without a history of cancer and heterosexual AYACSs.

"Queer people are excellent caregivers, but we're stretched so very thin": Psychosocial wellbeing and impacts of caregiving among LGBTQI cancer carers

BACKGROUND

LGBTQI (lesbian, gay, bisexual, transgender, queer and/or intersex) communities are increasingly recognized as a vulnerable and high-risk population in oncology. LGBTQI cancer carers, including carers who are LGBTQI and other carers of LGBTQI people, experience many of the same stressors as LGBTQI patients but their support needs are often overlooked in the cancer literature.

METHOD

This mixed-methods study examined distress and quality of life in LGBTQI cancer carers. Online surveys were completed by 129 carers and 31 carers took part in a one-to-one semi-structured interview. Analyses of variance (ANOVAs) tested for differences in psychosocial outcomes and carer experiences by gender, sexuality, age, carer relationship and carer/patient LGBTQI status. Reflexive thematic analysis of interviews and open-ended survey responses facilitated in-depth examination of subjective experiences.

RESULTS

42.6% of participants reported high or very high distress. Distress was significantly positively correlated with discrimination in cancer care, health impact, financial impact and lack of family support; it was negatively correlated with comfort in LGBTQI sexuality and gender identity, social support and quality of life. Four themes were identified in thematic analysis of qualitative data: (1) Identity on the sidelines: LGBTQI sexuality and gender pushed aside during cancer caregiving; (2) Fear of being shut-out: rejection and exclusion of LGBTQI cancer carers; (3) Lack of support for LGBTQI caregivers; and (4) Closer and stronger relationships due to a culture of mutual caregiving.

CONCLUSIONS

LGBTQI cancer carers must contend with typical caregiving demands whilst also managing additional minority stressors, including discrimination, rejection from family, isolation from LGBTQI communities, and invisibility in healthcare and support services. Despite this, LGBTQI carers showed resilience in building their own mutually supportive networks to rally around the person with cancer, which were reported to ameliorate psychosocial vulnerabilities. Service providers need to recognize the needs of LGBTQI cancer carers through inclusive and reflective practices. This will facilitate trust and patient and carer sexuality and gender identity disclosure, with positive consequences for wellbeing and satisfaction with cancer care.

Disrupted identities, invisibility and precarious support: a mixed methods study of LGBTQI adolescents and young adults with cancer

BACKGROUND

Lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) adolescents and young adults (AYAs) with cancer report higher levels of depression and anxiety and lower health related quality of life than non-LGBTQI AYAs with cancer, and LGBTQI adults with cancer. This mixed methods study examined LGBTQI AYAs' experiences of cancer and cancer care, to understand these health disparities.

METHODS

Online surveys were completed by 95 LGBTQI AYAs with cancer (age 16-39 years); 19 AYAs took part in a one-to-one semi structured interview. Reflexive thematic analysis of interviews and open-ended survey responses facilitated in-depth examination of subjective experiences; descriptive statistics performed on individual closed-ended survey items identified the percentage of AYAs reporting experiences identified in the qualitative analysis.

RESULTS

63% of AYAs reported high or very high distress on the K10. Three themes were identified in the qualitative analysis: 1) "Identities in flux", included subthemes "Cancer disrupts developing identities, and involvement with LGBTQI communities"; "Internalized prejudice impacts identities"; and "Cancer facilitates identities and embodiment". 2) "Invisibility in cancer care", included subthemes "Navigating disclosure amongst cis-heteronormative assumptions", "Discrimination and paternalistic cancer care" and " Cis-heteronormativity within cancer information". 3) "Precarious social support for LGBTQI AYAs with cancer", included subthemes " Social support during cancer is helpful for LGBTQI AYAs", "LGBTQI AYAs navigate limited support", and" Finding cancer peer support networks is difficult for LGBTQI AYAs".

CONCLUSIONS

LGBTQI AYAs with cancer experience psychosocial vulnerabilities related to identity development, experiences of care, and social support networks. These factors likely contribute to their previously evidenced elevated risk of distress, relative to both non-LGBTQI AYAs and LGBTQI older adults. AYAs affected by cancer may require additional, tailored supportive care, including targeted information resources, LGBTQI AYA specific cancer support groups, or partnerships and referrals to LGBTQI community organisations. Additionally, it is evident that health care professionals and cancer services have much work to do in ensuring LGBTQI AYAs receive affirming and appropriate care across paediatric and adult clinical settings. They must move beyond assuming all patients are cisgender, heterosexual and do not have intersex variations unless otherwise stated; work to signal inclusivity and facilitate disclosure; and be able to respond appropriately with tailored information and care, which is inclusive of LGBTQI partners, chosen family, and support systems.

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.

Almost invisible: A review of inclusion of LGBTQI people with cancer in online patient information resources

OBJECTIVE

This review assessed the inclusion of lesbian, gay, bisexual, trans, queer and/or intersex (LGBTQI) people in online cancer information.

METHODS

The websites of Australian cancer organizations were reviewed to identify if they included LGBTQI people and the extent and nature of this inclusion. Websites that did not include LGBTQI people were then reviewed to identify if information was implicitly LGBTQI inclusive. International LGBTQI cancer information resources were reviewed to identify key content.

RESULTS

Of sixty-one Australian cancer organization websites reviewed, eight (13%) mentioned LGBTQI people, including 13 information resources targeted to LGBTQI people and 19 general cancer information resources that mentioned LGBTQI people. For Australian cancer websites that did not mention LGBTQI people, 88% used gender neutral language to refer to partners, 69% included a range of sexual behaviours, 13% used gender neutral language when referring to hormones or reproductive anatomy but none acknowledged diverse relationship types. Internationally, 38 LGBTQI-specific cancer information resources were identified.

CONCLUSIONS

Cancer patient information resources need to be LGBTQI inclusive. LGBTQI-targeted resources are required to address this population's unique needs and improve cultural safety and cancer outcomes.

PRACTICE IMPLICATIONS

Recommendations are provided for LGBTQI inclusive cancer patient information resources.

Disparities in health-related quality of life among lesbian, gay, and bisexual cancer survivors

OBJECTIVE

This study compared health-related quality of life (HRQOL) among lesbian, gay, and bisexual (LGB) cancer survivors and their heterosexual counterparts in a US population-based sample of cancer survivors.

METHODS

The study utilized data from the All of Us research program. LGB survivors (n = 885) were matched for age, gender identity, marital status, income, education, and cancer site with heterosexual survivors (n = 885) using 1:1 propensity matching. Physical, mental, and social HRQOL were assessed with items from the Patient-Reported Outcomes Measurement Information System (PROMIS).

RESULTS

Relative to heterosexuals, LGB cancer survivors reported lower HRQOL in mental and social domains, but not in physical HRQOL. Older age was associated with higher HRQOL across domains. LGB survivors identifying as Black/African American were more likely to experience lower social HRQOL than White survivors.

CONCLUSIONS

This study highlights several disparities in HRQOL that exist between LGB and heterosexual cancer survivors.

Clinical, psychosocial, and sociodemographic factors of sexual and gender minority groups with cancer: A systematic review

PURPOSE

Psychosocial health varies depending on demographic and clinical factors and the social context in which individuals grow and live. Sexual and gender minority (SGM) populations experience health disparities due to systemic factors that privilege cisgender and heterosexual identities. We reviewed the literature on the psychosocial, sociodemographic, and clinical factors in SGM groups with cancer and described the associations among these factors.

METHODS

We conducted a systematic review according to Fink's methodology and the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines in the PubMed, PsycInfo, Cumulative Index of Nursing and Allied Health Literature, and LGBTQ+ Life databases. Quantitative articles published in English or Spanish were included. Grey literature and studies with participants in hospice care were excluded. The quality of the publications was assessed with the Joanna Briggs Institute criticalappraisal tools.

RESULTS

The review included 25 publications. In SGM groups, systemic cancer treatment was associated with worse psychosocial outcomes; and older age, employment, and higher income were associated with better psychosocial outcomes.

CONCLUSIONS

SGM groups with cancer are different from their heterosexual cisgender peers in sociodemographic, psychosocial, and clinical factors. Clinical and sociodemographic factors are associated with psychosocial outcomes among SGM individuals with cancer.

Sexual Orientation and Food Hardship: National Survey of Family Growth, 2011-2019

OBJECTIVE

Given the high rates of poverty observed among sexual minority groups and their social vulnerability, we examined the prevalence and correlation of food hardship, measured as food insecurity, receipt of free or reduced-cost food, and Supplemental Nutrition Assistance Program (SNAP) participation among low-income sexual minority and heterosexual adults using population-level health surveillance data.

METHODS

We used 4 waves of pooled data (2011-2019) from the National Survey of Family Growth for adults aged 18-44 years. We compared the sexual orientation subgroups and used logistic regression to predict the likelihood of food hardship.

RESULTS

Among men, gay and bisexual men had higher odds of experiencing food insecurity than their heterosexual counterparts (adjusted odds ratio [aOR] = 1.97 and 1.83, respectively). Compared with heterosexual men, bisexual men had significantly higher odds of receiving free or reduced-cost food, but gay men did not. The odds of participating in SNAP did not differ significantly among gay, bisexual, and heterosexual men. Among women, only bisexual women were more prone to experiencing food insecurity than their heterosexual counterparts (aOR = 1.81). The odds of receiving free or reduced-cost food did not differ significantly among heterosexual, bisexual, and lesbian women. However, compared with heterosexual women, lesbian women had significantly lower odds (aOR = 0.62) and bisexual women had significantly higher odds (aOR = 1.24) of participating in SNAP.

CONCLUSION

Our findings contribute to the limited literature examining trends in food hardship among sexual minority groups and suggest potentially different patterns of food insecurity, food assistance, and SNAP participation among sexual orientation subgroups, which may call for group-specific, nuanced approaches for lessening food hardship.

Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update

PURPOSE

To update the American Society of Clinical Oncology guideline on the management of anxiety and depression in adult cancer survivors.

METHODS

A multidisciplinary expert panel convened to update the guideline. A systematic review of evidence published from 2013-2021 was conducted.

RESULTS

The evidence base consisted of 17 systematic reviews ± meta analyses (nine for psychosocial interventions, four for physical exercise, three for mindfulness-based stress reduction [MBSR], and one for pharmacologic interventions), and an additional 44 randomized controlled trials. Psychological, educational, and psychosocial interventions led to improvements in depression and anxiety. Evidence for pharmacologic management of depression and anxiety in cancer survivors was inconsistent. The lack of inclusion of survivors from minoritized groups was noted and identified as an important consideration to provide high-quality care for ethnic minority populations.

RECOMMENDATIONS

It is recommended to use a stepped-care model, that is, provide the most effective and least resource-intensive intervention based on symptom severity. All oncology patients should be offered education regarding depression and anxiety. For patients with moderate symptoms of depression, clinicians should offer cognitive behavior therapy (CBT), behavioral activation (BA), MBSR, structured physical activity, or empirically supported psychosocial interventions. For patients with moderate symptoms of anxiety, clinicians should offer CBT, BA, structured physical activity, acceptance and commitment therapy, or psychosocial interventions. For patients with severe symptoms of depression or anxiety, clinicians should offer cognitive therapy, BA, CBT, MBSR, or interpersonal therapy. Treating clinicians may offer a pharmacologic regimen for depression or anxiety for patients who do not have access to first-line treatment, prefer pharmacotherapy, have previously responded well to pharmacotherapy, or have not improved following first-line psychological or behavioral management.Additional information is available at www.asco.org/survivorship-guidelines.

Identity affirmation is associated with adaptive cardiovascular flexibility in response to stress among sexual and gender minority people of color

BACKGROUND

Research with sexual and gender minority (e.g., lesbian, gay, bisexual, queer, asexual, trans, non-binary) people of Color (SGM-PoC) has largely focused on risk and negative health outcomes. The existing strengths-based mental health research suggests that identity affirmation may be associated with psychological resilience and good mental health among SGM-PoC, but little is known about predictors of physiological resilience and biomarkers of physical health in this population. Adaptive cardiovascular flexibility is an indicator of physiological resilience and physical health in that it enables the body to mobilize resources to adapt to challenges. This study explored the association between identity affirmation and physiological resilience, observed through cardiovascular flexibility in response to stress among SGM-PoC.

METHODS

Participants were 95 SGM-PoC of varying ethnoracial backgrounds, sexual orientations, and gender identities, residing in Canada. Participants completed questionnaires on sociodemographic and psychosocial variables, including a measure of identity affirmation, the Queer People of Color Identity Affirmation Scale (QPIAS). In a laboratory setting, we induced stress using the Trier Social Stress Test and measured heart rate variability (HRV) over time using wearable electrocardiogram devices.

RESULTS

Results from multilevel modeling analyses revealed that high QPIAS scores were associated with adaptive cardiovascular flexibility, as evidenced by reduced HRV during stress exposure, followed by HRV increase during recovery. As QPIAS scores increased, the shape of HRV trajectory increasingly reflected our predicted pattern of adaptive cardiovascular flexibility. Meanwhile, low QPIAS scores were not associated with this pattern and appeared to predict a more flatlined HRV activity during the experiment.

CONCLUSIONS

Findings indicate that Queer People of Color identity affirmation may be related to physiological resilience, observed through a more adaptive cardiovascular profile when responding to stress. Identity affirmation may thus be a protective factor for SGM-PoC, pointing to the critical importance of affirming resources and strengths-based health research.

Comprehensive systematic review and meta-analysis on physical health conditions in lesbian- and bisexual-identified women compared with heterosexual-identified women

BACKGROUND

Sexual minority individuals experience discrimination, leading to mental health disparities. Physical health disparities have not been examined to the same extent in systematic reviews so far.

OBJECTIVES

To provide a systematic review and, where possible, meta-analyses on the prevalence of physical health conditions in sexual minority women (i.e. lesbian- and bisexual-identified women) compared to heterosexual-identified women.

DESIGN

The study design is a systematic review with meta-analyses.

DATA SOURCES AND METHODS

A systematic literature search in MEDLINE, EMBASE, CENTRAL, CINAHL, and Web of Science databases was conducted on epidemiologic studies on physical health conditions, classified in the Global Burden of Disease project, published between 2000 and 2021. Meta-analyses pooling odds ratios were calculated.

RESULTS

In total, 23,649 abstracts were screened and 44 studies were included in the systematic review. Meta-analyses were run for arthritis, asthma, back pain, cancer, chronic kidney diseases, diabetes, headache disorders, heart attacks, hepatitis, hypertension, and stroke. Most significant differences in prevalence by sexual identity were found for chronic respiratory conditions, especially asthma. Overall, sexual minority women were significantly 1.5-2 times more likely to have asthma than heterosexual women. Furthermore, evidence of higher prevalence in sexual minority compared to heterosexual women was found for back pain, headaches/migraines, hepatitis B/C, periodontitis, urinary tract infections, and acne. In contrast, bisexual women had lower cancer rates. Overall, sexual minority women had lower odds of heart attacks, diabetes, and hypertension than heterosexual women (in terms of diabetes and hypertension possibly due to non-consideration of pregnancy-related conditions).

CONCLUSION

We found evidence for physical health disparities by sexual identity. Since some of these findings rely on few comparisons only, this review emphasizes the need for routinely including sexual identity assessment in health research and clinical practice. Providing a more detailed picture of the prevalence of physical health conditions in sexual minority women may ultimately contribute to reducing health disparities.

Sexual minority-specific experiences of colorectal cancer survivors

OBJECTIVE

To examine how sexual minority-specific factors relate to colorectal cancer survivors' health-related quality of life, psychological adjustment, and quality of care.

METHOD

One hundred twenty-seven sexual minority survivors diagnosed with stage I, II, or III colorectal cancer were recruited from four cancer registries. An average of 3 years after diagnosis, eligible survivors participated in a telephone survey, which measured survivors' outcomes, consisting of physical and mental quality of life, anxiety, depression, self-rated fair or poor health, and quality of care. We considered sexual minority-specific factors (e.g., outness, discrimination) as correlates for each survivorship outcome using forward selection with generalized linear or logistic regression models.

RESULTS

After adjusting for confounders, accumulation of lifetime discrimination experiences had negative associations with survivors' physical and mental quality of life, anxiety, and depression. Sexual minority-specific discrimination experiences were negatively associated with perceived quality of care after adjusting for confounders. Sexual minority survivors' self-rated fair or poor health and their rating of care as excellent were independent of sexual minority-specific factors.

CONCLUSION

Addressing and counteracting sexual minority-specific and other lifetime discrimination experiences may be a pathway to improving sexual minority cancer survivors' quality of care, quality of life, and psychological adjustment. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

LGBTQI cancer patients' quality of life and distress: A comparison by gender, sexuality, age, cancer type and geographical remoteness

Background

There is growing acknowledgement of the psycho-social vulnerability of lesbian, gay, bisexual, transgender, queer and/or intersex (LGBTQI) people with cancer. The majority of research to date has focused on cisgender adults with breast or prostate cancer.

Study Aim

This study examined psycho-social factors associated with distress and quality of life for LGBTQI cancer patients and survivors, across a range of sexualities and gender identities, intersex status, tumor types, ages and urban/rural/remote location using an intersectional theoretical framework.

Method

430 LGBTQI people with cancer completed an online survey, measuring distress, quality of life (QOL), and a range of psycho-social variables. Participants included 216 (50.2%) cisgender women, 145 (33.7%) cisgender men, and 63 (14.7%) transgender and gender diverse (TGD) people. Thirty-one (7.2%) participants reported intersex variation and 90 (20%) were adolescents or young adults (AYA), aged 15-39. The majority lived in urban areas (54.4%) and identified as lesbian, gay or bisexual (73.7%), with 10.9% identifying as bisexual, and 10.5% as queer, including reproductive (32.4%) and non-reproductive (67.6%) cancers.

Results

Forty-one percent of participants reported high or very high distress levels, 3-6 times higher than previous non-LGBTQI cancer studies. Higher rates of distress and lower QOL were identified in TGD compared to cisgender people, AYAs compared to older people, those who identify as bisexual or queer, compared to those who identify as lesbian, gay or homosexual, and those who live in rural or regional areas, compared to urban areas. Elevated distress and lower QOL was associated with greater minority stress (discrimination in life and in cancer care, discomfort being LGBTQI, lower outness) and lower social support, in these subgroups. There were no differences between reproductive and non-reproductive cancers. For the whole sample, distress and poor QOL were associated with physical and sexual concerns, the impact of cancer on gender and LGBTQI identities, minority stress, and lack of social support.

Conclusion

LGBTQI people with cancer are at high risk of distress and impaired QOL. Research and oncology healthcare practice needs to recognize the diversity of LGBTQI communities, and the ways in which minority stress and lack of social support may affect wellbeing.

Reproductive Organ Pathology of Individuals Undergoing Gender-Affirming Surgery

As gender-affirming surgeries become more routine, it is increasingly important for pathologists to recognize the expected histologic changes seen in various tissues secondary to gender-affirming hormone therapy. For example, exogenous testosterone-related squamous atrophy or transitional cell metaplasia of the cervix may be confused for high-grade squamous intraepithelial lesion. In addition to distinguishing between benign and dysplastic/malignant features, pathologists should be mindful of the phrasing of their reports and aim to use objective, nongendered language.

Improving Sexual and Gender Minority Cancer Care: Patient and Caregiver Perspectives From a Multi-Methods Pilot Study

Purpose

Up to 1 million lesbian, gay, bisexual, and transgender (i.e., sexual and gender minority, SGM) individuals in the United States have histories of cancer. This medically underserved population is diverse, with complex sexualities and gender identities, and distinct health concerns. SGM persons experience disproportionate risks for, and rates of, anal, breast, cervical, colorectal, endometrial, lung, and prostate cancers, in addition to cancers affecting transgender persons who have undergone sex-reassignment. SGM individuals are linked by shared experiences of stigmatization as a minority population for which little cancer research has been conducted. SGM cancer patients frequently report reluctance to seek healthcare, have poorer outcomes following diagnosis, engage in elevated risk behaviors (i.e. smoking and alcohol use) even after cancer diagnosis, have difficulty making emotional adjustment to illness, and experience higher rates of psychological distress. They report less satisfaction with cancer care, deficiencies in patient-centeredness and shared decision-making, gaps in care, and social isolation. Minority stress resulting from experiences of anti-SGM sentiment and discrimination affects cancer patients and their informal cancer caregivers. Our paper presents findings from a pilot study to identify gaps and opportunities to improve cancer care for SGM patients and caregivers at the University of New Mexico Comprehensive Cancer Center.

Methods

Between June 2020 and July 2021, we used a multi-methods research design informed by ecological theory to collect qualitative and quantitative data regarding cancer patient and caregiver quality of life (QoL) and experiences of cancer and survivorship care. We used PROMIS measures distributed via REDCap to assess QoL (i.e., fatigue, pain interference, pain intensity, anxiety, depression, emotional support, social isolation, and companionship), and conducted in-depth semi-structured interviews. We recruited 10 SGM cancer patients and 8 heterosexual, cisgender (H/C) patient matches, and their self-identified informal cancer caregivers (n=36, dyad total n=18). Interviews ranged from 1 to 2 hours, were audio-recorded and transcribed for analysis. The study was approved by the University of New Mexico Human Research Protections Office Institutional Review Board.

Results

Results of the PROMIS QoL assessments indicated that SGM patients reported greater anxiety [mean (SD) = 54.5 (8.8)] and depression [mean (SD) = 49.3 (4.8)] than H/C patients [mean (SD)=51.6 (7.5) and 45.4 (6.8) respectively], while heterosexual, cisgender (H/C) patients reported higher fatigue [mean (SD) =52.04 (8.18)] and stronger pain intensity than SGM patients [mean (SD)=48.3 (9.1) and 37.8 (9.1) respectively]. SGM patients reported higher levels of social isolation [mean (SD) = 48.3 (7.3) vs. 42.1 (7.4) for H/C patients, whereas H/C patients reported more emotional support (mean (SD) =57.5 (9.3) vs. 53.0 (6.9)] and companionship [mean (SD) = 55.2 (8.6) vs. 51.5 (11.0)]. SGM and H/C differences in caregiver QoL were most notable with regards to higher levels of fatigue [mean (SD) = 47.1 (6.0) for SGM, and 42.4 (11.5) for H/C] and companionship [mean (SD) = 55.3 (6.0) for SGM, and 50.9 (5.5) for H/C]. Qualitative interviews supported our quantitative results. SGM patients and caregivers articulated experiences of anti-SGM stigma and discrimination contributing to minority stress that influenced their initial cancer care encounters. SGM dyads had more trepidation and/or medical mistrust during initial cancer care encounters when compared to H/C patients and caregivers. SGM patients questioned care that was not culturally responsive to SGM preferences, while H/C patients were more apt to identify gaps in communication and perceived lack of clarity regarding cancer care delivery. Although SGM patients experienced high satisfaction with their cancer care once they developed trust with their providers, they discussed desires to have more direct conversations with their oncologists about their sexual orientation and gender identities and sexual health. All patients and providers in the study (SGM and H/C) appreciated their oncology care teams. All patients and caregivers relied on social networks comprised of friends and family, although SGM patients and caregivers had smaller social networks and relied less on biological family, and single SGM individuals experienced challenges accessing cancer care and struggled with social isolation. We discovered too, that all caregivers, regardless of Sexual Orientation and Gender Identity (SOGI), perceived a lack of support and information pertaining to their loved one’s treatment, side effects and best way to provide care.

Conclusions

This study demonstrates that prior stigmatizing experiences contribute to minority stress and medical mistrust for SGM cancer patients and their informal caregivers across the cancer care experience. Findings point to specific gaps in SGM cancer patient care, including lack of conversation about patient SOGI, inadequate staff and oncology provider SGM specific knowledge and cultural competence/cultural humility training, and insufficient patient supports for those who lack social support during cancer care treatment. Further, this study reveals inadequacies in SGM specific support, and overall support services for informal cancer caregivers. Additional research is required to develop targeted interventions to address minority stress and clinic environment concerns to improve cancer care for SGM patients. Importantly, while there were differences between SGM and H/C experiences of cancer treatment, significant similarities also emerged. Caregiver expressed consensus about the current lack of support and guidance for informal caregivers of cancer patients. Future work should focus on providing caregiver-specific resources in the clinic setting and facilitating support groups for caregivers to network with one another, as well as for tailoring SGM specific caregiver support services. Our findings highlight areas for improving cancer care for the SGM community, as well as a broader population of patients and caregivers.

Barriers in care pathways and unmet mental health needs in LGBTIQ + communities

Lesbian, gay, bisexual, transgender, intersex, queer people and minority gender identities and sexualities (LGBTIQ+) are often stigmatized and experience discrimination in health care settings, leading to poorer mental health outcomes and unmet needs compared to heterosexual and cisgendered peers. It is thus imperative that mental health providers consider and address structural challenges in order to reduce mental health inequalities of this population. This narrative review assessed the barriers that may prevent access to care and the pathways for care in LGBTIQ + communities. PubMed, PsycInfo, Embase, and Scopus were searched for papers published between December 2021 and February 2022. A total of 107 papers were included with studies reflecting five themes: (1) Unmet mental health needs; (2) Young people; (3) Substance abuse and addiction; (4) Barriers and pathways to care; and (5) Interventions. Findings demonstrate that LGBTIQ + people experience stigmatization and higher rates of substance misuse and mental ill health, which may lead to barriers in accessing health care services, and fewer tailored interventions being provided. These findings have implications for policy, health care screening, and how specialist services are structured. Substantial gaps in the evidence-base exist, and future research should examine how mental health care providers can challenge social issues that maintain discriminatory and stigmatizing practices, and support LGBTIQ + individuals to sustain their resilience.

Rapid, application-based survey to characterise the impacts of COVID-19 on LGBTQ+ communities around the world: an observational study

INTRODUCTION

Emerging evidence indicates that the COVID-19 pandemic, and the responses it has generated, have had disproportionate impacts on lesbian, gay, bisexual, transgender and queer (LGBTQ+) communities. This study seeks to build on existing information and provide regional insight.

METHODS

In response, a cross-sectional survey was administered to a global sample of LGBTQ+ individuals (n=13 358) between 16 April and 20 May 2020 via the social networking application Hornet. The survey contained questions that characterise the impact of COVID-19 and associated mitigation strategies on economics, employment, mental health and access to healthcare.

RESULTS

5191 (43.9%) individuals indicated they were somewhat, slightly or unable to meet basic needs with their current income, while 2827 (24.1%) and 4710 (40.1%) felt physically or emotionally unsafe in their living environment, respectively. 2202 individuals (24.7%) stated they are at risk for losing health insurance coverage. 2685 (22.7%) persons reported having skipped or cut meals as there was not enough money.

CONCLUSION

Many LGBTQ+persons who responded reported adverse consequences to mental health, economics, interruptions to care and lack of support from their government. This data is part of ongoing analyses but accentuates the unique needs of LGBTQ+ communities that will require targeted, ameliorative approaches.

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.

Health outcomes of sexual and gender minorities after cancer: a systematic review

PURPOSE

Cancer research on sexual and gender minority (SGM) populations is gaining momentum. The purpose of this systematic review was to examine what is currently known in the research literature regarding patient-reported health outcomes after cancer treatment among SGM populations.

METHODS

In March 2021, a medical librarian conducted a systematic keyword search on PubMed, Embase, Scopus, Web of Science, PsycINFO, ClinicalTrials.gov , and the Cochrane Central Register of Controlled Trials. The primary inclusion criterion was assessment of at least one physical, psychosocial, emotional, or functional patient-reported health outcome related to the impacts of cancer diagnosis and/or treatment. Articles that met inclusion criteria were reviewed in their entirety, charted in a Word Table, and assessed for quality. Quality considerations included study design, sampling approach, diversity of sample, measures used, and analytic procedures. Studies were synthesized based on type of cancer study participants experienced.

RESULTS

Sixty-four studies were included in the final analysis: most were quantitative, secondary analyses or cross-sectional studies with convenience samples, and focused on people with a history of breast or prostate cancer. Differences between sexual minority men and women in terms of coping and resilience were noted. Few studies reported on experiences of transgender persons and none reported on experiences of intersex persons.

CONCLUSIONS

A growing literature describes the patient-reported health outcomes of SGM people with a history of cancer. This study summarizes important between-group differences among SGM and heterosexual, cisgender counterparts that are critical for clinicians to consider when providing care.

IMPLICATIONS FOR CANCER SURVIVORS

Sexual orientation and gender identity are relevant to cancer survivors' health outcomes. Subgroups of SGM people have differential experiences and outcomes related to cancer and its impacts.

Health outcomes of sexual and gender minorities after cancer: a systematic review

PURPOSE

Cancer research on sexual and gender minority (SGM) populations is gaining momentum. The purpose of this systematic review was to examine what is currently known in the research literature regarding patient-reported health outcomes after cancer treatment among SGM populations.

METHODS

In March 2021, a medical librarian conducted a systematic keyword search on PubMed, Embase, Scopus, Web of Science, PsycINFO, ClinicalTrials.gov , and the Cochrane Central Register of Controlled Trials. The primary inclusion criterion was assessment of at least one physical, psychosocial, emotional, or functional patient-reported health outcome related to the impacts of cancer diagnosis and/or treatment. Articles that met inclusion criteria were reviewed in their entirety, charted in a Word Table, and assessed for quality. Quality considerations included study design, sampling approach, diversity of sample, measures used, and analytic procedures. Studies were synthesized based on type of cancer study participants experienced.

RESULTS

Sixty-four studies were included in the final analysis: most were quantitative, secondary analyses or cross-sectional studies with convenience samples, and focused on people with a history of breast or prostate cancer. Differences between sexual minority men and women in terms of coping and resilience were noted. Few studies reported on experiences of transgender persons and none reported on experiences of intersex persons.

CONCLUSIONS

A growing literature describes the patient-reported health outcomes of SGM people with a history of cancer. This study summarizes important between-group differences among SGM and heterosexual, cisgender counterparts that are critical for clinicians to consider when providing care.

IMPLICATIONS FOR CANCER SURVIVORS

Sexual orientation and gender identity are relevant to cancer survivors' health outcomes. Subgroups of SGM people have differential experiences and outcomes related to cancer and its impacts.

Cross-sectional study of psychosocial well-being among lesbian, gay, bisexual, and heterosexual gynecologic cancer survivors

Background

Delays in care and increased risk for mental health diagnoses put individuals identifying as a sexual minority with cancer at risk for decreased quality of life.

Aim

To assess psychosocial health among sexual minority gynecologic cancer survivors, we compared self‐reported quality of life and psychosocial measures between individuals diagnosed with gynecologic cancers identifying as lesbian/gay/bisexual (LGB) and heterosexual.

Methods and Results

English‐speaking adults with gynecologic cancers were invited to participate in an ongoing cohort survey study. Quality of life and psychosocial measures included the Functional Assessment of Cancer Therapy‐General, Distress Thermometer (distress), Patient Health Questionnaire‐8 (depression), General Anxiety Disorder‐7 (anxiety), and Post‐traumatic Stress Disorder Checklist for DSM‐5 (post‐traumatic stress disorder; PTSD). Measures were compared by self‐reported sexual orientation (heterosexual vs. LGB) using descriptive statistics (frequencies and means) and linear and logistic regression models, adjusting for college education.

Of 814 patients invited, 457 enrolled (56.1%) and 401 (92.6%) completed the survey and provided information on their sexuality. All but one self‐identified as cisgender women and 22 (5.5%) as LGB. LGB participants were more likely to have completed college (68.2% vs. 40.1%, p = .009) but were otherwise similar across demographic and clinical characteristics. Quality of life and distress scores were similar between groups. LGB participants, compared to heterosexual, reported higher rates of depression (31.8% vs. 10.6%, adjusted odds ratio [OR] = 4.1 [95% confidence interval [CI]: 1.6–11.0], p = .004), anxiety (25.0% vs. 7.1%, adjusted OR = 5.4 [95% CI: 1.7–16.7], p= .004), and PTSD (13.6% vs. 3.5%, adjusted OR = 4.2 [95% CI: 1.1–16.3], p = .04).

Conclusion

LGB participants reported poorer emotional health following a gynecologic cancer diagnosis than heterosexual participants. Our data suggest this population may need additional resources and support during and after their cancer diagnosis. Future work is needed to identify additional risk factors and the underlying sources of these disparities in order to improve patient care and wellness in this population.