Anxiety and Depression in Metastatic Cancer: A Critical Review of Negative Impacts on Advance Care Planning and End-of-Life Decision Making With Practical Recommendations

PURPOSE

Providers treating adults with advanced cancer increasingly seek to engage patients and surrogates in advance care planning (ACP) and end-of-life (EOL) decision making; however, anxiety and depression may interfere with engagement. The intersection of these two key phenomena is examined among patients with metastatic cancer and their surrogates: the need to prepare for and engage in ACP and EOL decision making and the high prevalence of anxiety and depression.

METHODS

Using a critical review framework, we examine the specific ways that anxiety and depression are likely to affect both ACP and EOL decision making.

RESULTS

The review indicates that depression is associated with reduced compliance with treatment recommendations, and high anxiety may result in avoidance of difficult discussions involved in ACP and EOL decision making. Depression and anxiety are associated with increased decisional regret in the context of cancer treatment decision making, as well as a preference for passive (not active) decision making in an intensive care unit setting. Anxiety about death in patients with advanced cancer is associated with lower rates of completion of an advance directive or discussion of EOL wishes with the oncologist. Patients with advanced cancer and elevated anxiety report higher discordance between wanted versus received life-sustaining treatments, less trust in their physicians, and less comprehension of the information communicated by their physicians.

CONCLUSION

Anxiety and depression are commonly elevated among adults with advanced cancer and health care surrogates, and can result in less engagement and satisfaction with ACP, cancer treatment, and EOL decisions. We offer practical strategies and sample scripts for oncology care providers to use to reduce the effects of anxiety and depression in these contexts.

Health Promotion and Black Elders

This article profiles three subgroups of African American elders that are at risk in terms of health. Major barriers to optimum health for older rural Blacks are a lack of confidence in the formal health care system, greater rates of poverty than urban elders, geographic isolation, and lack of access to health care and to social supports; for older Black women, barriers include attitudes that reflect an overestimation of health, health pessimism, a lack of confidence in the health care system, lower economic resources, and major family responsibilities that affect the availability of money for, and time to seek, health care; and for older-aged Blacks, barriers are lack of confidence in the formal health care system, dependence on informal supports for health care and an underutilization of formal supports, and lower socioeconomic levels due to this cohort’s education and occupational status. Implications for theory, policy, and practice are discussed.

Clarifying the positive association between education and prostate cancer: a Monte Carlo simulation approach

Using the 1993-2011 data from the Wisconsin Longitudinal Study (N = 5,218), we examine prostate cancer screening, mortality after the diagnosis, and health behaviors as potential mechanisms explaining the paradoxical association between men's higher education and higher prostate cancer risk. Our study combines within-cohort longitudinal hazard models predicting a prostate cancer diagnosis with Monte Carlo simulations estimating the joint effects of socioeconomic differences in prostate cancer screening and mortality after the diagnosis. Our findings strongly suggest that higher utilization of prostate cancer screening and lower mortality after the diagnosis are important explanations for higher prostate rates among more educated men. In addition to applying an innovative method to the issues of prostate cancer incidence and survival, our results have potentially important implications for the current debate about the utility of prostate cancer screening as well as for accurate predictions of future mortality and morbidity trends in the expanding older population.

Predictors of screening mammography among Asian Indian American women: a cross-sectional study in the Baltimore-Washington metropolitan area

OBJECTIVE

To assess adherence to screening mammography guidelines and examine predictors of having a mammogram in the past 2 years among immigrant Asian Indian women (AIW) aged > or = 40 years.

METHODS

Face-to-face surveys of 418 AIW in the Baltimore-Washington metropolitan area were conducted. Subjects were recruited through Asian Indian (AI) religious and other community-based organizations.

RESULTS

Of the 418 AIW surveyed, 83% had ever had a mammogram, and 70% had obtained a mammogram within the past 2 years. AIW who had lived in the United States for > 10 years had a higher rate of obtaining a mammogram (75.4%) within the past 2 years than did those who had lived in the United States for < or = 10 years (24.6%). In multiple logistic regression analysis, length of stay in the United States, marital status, knowledge of mammogram guidelines, age, having health insurance, physician recommendations, and number of relatives who had a mammogram were positively associated with having a mammogram within the past 2 years. Physician ethnicity and not having a healthcare provider were negatively associated with having a mammogram within the past 2 years.

CONCLUSIONS

This study lays a foundation for designing guidelines for interventions to improve mammography screening behaviors among AIW women. Increasing the use of mammogram to the levels recommended by guidelines will require a two-pronged approach directed at both AIW and AI physicians.

Black women and breast health: a review of the literature

AIM

In the UK, it is known that screening inequalities exist involving ethnic minority groups such as Black women (Patnick, 2009). To date, there is limited UK data on Black British women and breast health awareness. Black British women appear to be an underrepresented group in breast cancer studies (Breast Cancer Care, 2004, 2005). This literature review aimed to explore Black women's perceptions of breast health and factors that influence breast cancer screening practices.

METHODS

A literature search for the period 1994 to September 2009 was undertaken using BNI, CINAHL, PubMed, OSH-ROM, PsyInfo, Google scholar, and Scopus databases. Key words used included: breast cancer, breast health, African American women, Black British women, black women, breast cancer screening, qualitative studies. Hand-searching was also done, and reference lists of papers were examined for relevant studies.

RESULTS

Black women hold a variety of views and perceptions on the risk that breast cancer poses. These perceptions are strongly related to existing knowledge, related stigmatization, spiritual and religious beliefs, all of which can adversely influence motivation to engage in self-breast examination and breast cancer screening.

CONCLUSION

US based studies identified several influential factors: religion, educational awareness of breast cancer screening, breast health awareness. Breast health interventions and research are needed to increase breast health awareness in Black British women.

Beauty salon health intervention increases fruit and vegetable consumption in African-American women

African Americans, especially women, have low fruit and vegetable consumption, which is related to higher rates of obesity, morbidity, and mortality in comparison to whites. Community-based approaches are recommended to address this problem, including beauty salons, which are conducive environments for health information dissemination. The purpose of this pilot study, conducted in 2007, was to determine the effectiveness of a 6-week beauty salon-based health intervention, Steps for a New You, in improving diet, physical activity, and water consumption behaviors in African-American women using a quasiexperimental design. A random sample of 20 African-American women was selected from a list of regular clients at two beauty salons (n=10 each for treatment and comparison salons) located in a Southern rural community. The intervention included scripted motivational sessions between the cosmetologist and clients, information packets, and a starter kit of sample items. Data were collected using pre- and posttest questionnaires. The results showed that mean intake of fruit and vegetables was significantly higher at posttest for the treatment group but not for the comparison group. These findings suggest that the intervention may have had a positive effect on fruit and vegetable consumption by treatment group participants. However, further work is needed to refine the methodology, especially strengthening the intervention to increase physical activity and water consumption.

Family matters in mammography screening among African-American women age > 40

PURPOSE

To examine how family history of cancer influences the mammography screening behaviors of asymptomatic African-American women.

METHODS

Using the National Health Interview Survey's 2000 Cancer Control Module, the authors performed bivariate analyses and multivariate logistic regressions with SAS/SUDAAN due to the complex sampling design.

RESULTS

Of the 1,531 African-American women in the final sample, 38% had a family history of cancer. Women with a family history of cancer were 39% more likely to have a recent mammogram compared to women with no family history of cancer (OR = 1.39; 95% CI: 1.06-1.81; p < 0.05). Eighty-five percent of African-American women aged > 40 with a family history of cancer indicated having a mammogram in the past compared to nearly 70% of African-American women without a family history of cancer.

CONCLUSION

Family history of any cancer independently and positively predicted mammography screening behaviors among asymptomatic African-American women. This suggests that African-American women with a history of cancer in their family are more likely (and perhaps more motivated) to engage in early cancer detection practices.

Psychosocial influences on suboptimal adjuvant breast cancer treatment adherence among African American women: implications for education and intervention

Despite lower incidence, African American women are at increased risk of dying from breast cancer relative to their European American counterparts. Although there are key differences in both screening behavior and tumor characteristics, an additional part of this mortality difference may lie in the fact that African American women receive suboptimal adjuvant chemotherapy and may receive suboptimal hormonal therapy, therapies that are known to increase survival. The authors consider ethnic differences in the psychosocial factors that have been shown to relate to poor screening adherence and consider how they may influence adherence to breast cancer adjuvant treatment, thus the receipt of suboptimal adjuvant chemo or hormonal therapy. To this end, they review ethnic differences in cognitive, emotional, and social network variables. Psychosocial variables should be included in research designed to understand cancer disparities as well interventions that can be tailored to culturally diverse populations to improve treatment adherence.

Common psychosocial factors underlying breast cancer screening and breast cancer treatment adherence: a conceptual review and synthesis

In this paper, we review the literature on psychosocial influences on breast cancer screening and treatment adherence with an eye to identifying common cognitive, emotional, and social network factors that may lead to poor screening adherence and suboptimal treatment in the case of diagnosed breast cancer. Nonadherence to breast cancer screening and treatment guidelines can significantly and negatively impact the prospects for prevention and control of breast cancer. Psychosocial factors are an especially important focus for research, inasmuch as belief structures and psychosocial characteristics (such as patterns of emotion regulation and the quality of social relations) are modifiable and are, thus, eminently suitable to intervention.

Time spent in the united states and breast cancer screening behaviors among ethnically diverse immigrant women: Evidence for acculturation?

The current study was designed to investigate the relations between time spent in the United States and breast cancer screening in a large sample (N=915) of ethnically diverse immigrant women living in New York City. Previous research among Hispanic women has suggested that acculturation positively influences health beliefs and preventive health behaviors. However, research has not yet extended to other growing immigrant groups, including women from Haiti and the English-speaking Caribbean, and has not tested whether time spent in the United States differentially impacts breast screening across groups that are known to vary in their health beliefs. As expected, time spent in the United States was associated with a greater number of mammograms and clinical breast exams. Importantly, these relations held even when controlling for (a) age, income, education, marital status; (b) morbidity, health insurance, physician's recommendation, physical exams; and (c) ethnicity. Moreover, time spent in the United States interacted with being Haitian to predict the number of clinical breast exams. Even though Haitians were less likely to utilize breast cancer screening overall, time spent in the United States had a stronger effect on the number of clinical breast exams for Haitian women. Results are discussed in terms of the ethnic-specificity of health beliefs, how they may change over time and their implications for preventive health behaviors.

Factors associated with mammographic decisions of Chinese-Australian women

BreastScreen (a free breast cancer screening service) has been implemented in Australia since 1991. Surveys conducted overseas consistently report that women of Chinese ancestry have low participation rates in breast cancer screening. Although Chinese women's use of breast cancer screening services has been investigated abroad, to date there are few studies of mammographic screening behavior among Chinese-Australian women. The purpose of this study is to explore and investigate the factors associated with mammographic decisions of Chinese-Australian women. Using a qualitative approach, in-depth interviews were conducted with 20 Chinese-Australian women. These were augmented by additional data from ethnographic observations. The findings show two facilitators: organizational factors (an invitation letter from BreastScreen and seniors' clubs arrangements) and the influence of 'significant others'. Barriers identified were fear perceptions of mammography, modesty and fear of stigmatization. This study provides a useful framework for designing and implementing mammographic screening services for Chinese-Australian women that may improve their participation rates.

Fear, Anxiety, Worry, and Breast Cancer Screening Behavior: A Critical Review

Anxiety, fear, and worry are variously described as facilitators and barriers of breast cancer screening. However, several contradictions are evident in this research. A review article described the literature regarding the relations among fear, anxiety, and worry, along with emotion regulatory styles, and breast cancer screening behaviors before critiquing it in an attempt to uncover preliminary explanations for these discrepancies. Three main conclusions are drawn. First, it is suggested that researchers need to clearly define the components of cancer and the screening process that women are afraid of as each may bear a different relation to screening behavior. Second, greater care needs to be taken to employ psychometrically valid and reliable measures of fear and anxiety. Third, studies need to more systematically test findings across the minority and ethnic groups at greatest risk. A framework is presented and suggestions regarding the continued development of this promising area of research are made.

Diversity matters: Unique populations of women and breast cancer screening

BACKGROUND

Ethnic differences in breast cancer screening behaviors are well established. However, there is a lack of understanding regarding exactly what causes these differences and which characteristics in low-screening populations should be targeted in an effort to modify screening behavior.

METHODS

Stratified cluster sampling was used to recruit 1364 women (ages 50-70 years) from 6 ethnic groups: African-American women; U.S.-born white women; English-speaking Caribbean, Haitian, and Dominican women; and immigrant Eastern-European women. In interviews, respondents provided information concerning demographic and structural variables related to mammogram utilization (age, education, income, marital status, physician recommendation, access, and insurance) and a set of cognitive variables (fatalism, perception of personal risk, health beliefs concerning cancer) and socioemotional variables (stress, cancer worry, embarrassment, and pain).

RESULTS

For data analysis, the authors used a 2-step logistic regression with frequency of mammograms over a 10-year period (< or = 4 mammograms over 10 years or > or = 5 mammograms over 10 years) as a dependent variable. U.S.-born African-American women and Dominican women were screened as frequently as European-American women, but the remaining minority groups were screened with less frequency. With one exception, ethnicity ceased to predict screening frequency once cognitive and emotional variables were controlled.

CONCLUSIONS

Although women from clearly operationalized ethnic groups continue to screen at rates substantially below those of the majority groups, these differences appear to be explained substantially by differences in psychologic variables. This is encouraging because, rather than targeting culture for intervention, variables can be targeted that are amenable to change, such as emotions and beliefs.

Predictors of breast cancer screening in a panel study of African American women

PURPOSE

This study examines the predictors of breast cancer screening participation in a panel study of African American women over age 40. We examine the effect of depression, age, beliefs and concerns about breast cancer and its risk, communication with social networks regarding screening, marital status, participation in religious organizations, breast cancer family history, and participation in a breast cancer education program.

METHODS

Participants were recruited from 30 African American churches, two low-income housing projects, and from a health fair at a historically African American University (N = 364). Participants were interviewed upon recruitment, and three months later. Multinomial logistic regression models are estimated to assess the relative impact of covariates on the odds of getting a mammogram while controlling for other factors. We also assess predicted probabilities of screening at specific levels of covariates.

RESULTS

We find that age, marriage, an educational intervention, talking with friends, and believing that early detection can lead to cure had a positive impact on getting a mammogram between T1 and T2. In contrast, depression significantly reduces the odds of getting a mammogram. Family histories of breast cancer and church participation have no effect on rates of mammography net of other factors.