Post-treatment symptoms among ethnic minority breast cancer survivors

Simulating the population impact of interventions to reduce racial gaps in breast cancer treatment

BACKGROUND

Inequities in guideline-concordant treatment receipt contribute to worse survival in Black patients with breast cancer. Inequity-reduction interventions (eg, navigation, bias training, tracking dashboards) can close such treatment gaps. We simulated the population-level impact of statewide implementation of inequity-reduction interventions on racial breast cancer inequities in North Carolina.

METHODS

Using registry-linked multipayer claims data, we calculated inequities between Black and White patients receiving endocrine therapy (n = 12 033) and chemotherapy (n = 1819). We then built cohort-stratified (endocrine therapy and chemotherapy) and race-stratified Markov models to simulate the potential increase in the proportion of patients receiving endocrine therapy or chemotherapy and subsequent improvements in breast cancer outcomes if inequity-reducing intervention were implemented statewide. We report uncertainty bounds representing 95% of simulation results.

RESULTS

In total, 75.6% and 72.1% of Black patients received endocrine therapy and chemotherapy, respectively, over the 2006-2015 and 2004-2015 periods (vs 79.3% and 78.9% of White patients, respectively). Inequity-reduction interventions could increase endocrine therapy and chemotherapy receipt among Black patients to 89.9% (85.3%, 94.6%) and 85.7% (80.7%, 90.9%). Such interventions could also decrease 5-year and 10-year breast cancer mortality gaps from 3.4 to 3.2 (3.0, 3.3) and from 6.7 to 6.1 (5.9, 6.4) percentage points in the endocrine therapy cohorts and from 8.6 to 8.1 (7.7, 8.4) and from 8.2 to 7.8 (7.3, 8.1) percentage points in the chemotherapy cohorts.

CONCLUSIONS

Inequity-focused interventions could improve cancer outcomes for Black patients, but they would not fully close the racial breast cancer mortality gap. Addressing other inequities along the cancer continuum (eg, screening, pre- and postdiagnosis risk factors) is required to achieve full equity in breast cancer outcomes.

Association between sleep-disordered breathing and post-stroke fatigue in patients with ischemic stroke

OBJECTIVES

Post-stroke fatigue (PSF) is common and often disabling. Sleep-disordered breathing (SDB) is highly prevalent among stroke survivors and can cause fatigue. We explored the relationship between SDB and PSF over time.

MATERIALS AND METHODS

Ischemic stroke (IS) patients within the BASIC project were offered SDB screening with a well-validated cardiopulmonary sleep apnea test at 0, 3-, 6-, and 12-months post-stroke. The primary exposure was the respiratory event index (REI; sum of apneas plus hypopneas per hour). The primary outcome was PSF, measured by the SF-36 vitality scale. Associations between REI and PSF were evaluated using linear regression including time-by-REI interactions, allowing the effect of REI to vary over time.

RESULTS

Of the 411 IS patients who completed at least one outcome interview, 44 % were female, 61 % Mexican American (MA), 26 % non-Hispanic white, with a mean age of 64 (SD 10). Averaged across timepoints, REI was not associated with PSF. In a time-varying model, higher REI was associated with greater PSF at 3-months (β = 1.75, CI = 0.08, 3.43), but not at 6- or 12-months. Across timepoints, female sex, depressive symptoms, and comorbidity burden were associated with greater PSF, whereas MA ethnicity was associated with less PSF.

CONCLUSIONS

Higher REI was associated with modestly greater PSF in the early post-stroke period, but no association was observed at 6 months and beyond. SDB may be a modest modifiable risk factor for early PSF, but its treatment is unlikely to have a substantial impact on long-term PSF. MA ethnicity seems to be protective against PSF.

Exploring Quality of Life Experiences and Concerns of Black Breast Cancer Survivors: a Narrative Approach

Black breast cancer survivors (BCS) in comparison with White BCS are more likely to experience suboptimal quality of life (QoL). QoL is a multi-dimensional concept that focuses on different aspects of well-being (e.g., emotional well-being). There is limited evidence on the perspectives and experiences of QoL (e.g., the influence of breast cancer on QoL) and the QoL concerns (e.g., negative perceptions of body appearance) among Black BCS. The purpose of this study was to explore the QoL experiences and QoL concerns of Black BCS. Primary data was collected in semi-structured interviews and analyzed using a thematic analysis. A narrative approach (detailed stories or life experiences of a small group of people) was used to better understand the research topic among the target group. Ferrell's Conceptual Framework on QoL in Breast Cancer was used to guide the development of the interview questions, codes, and themes. There were 10 Black BCS, averaging 58 years of age. Two coders achieved a moderate level of agreement (i.e., Kappa) of 0.77. Five major themes were identified: defining QoL (what QoL means to them), behavioral changes (e.g., altering behaviors due to cancer), phases of cancer (e.g., breast cancer diagnosis), QoL experiences and factors affecting QoL, and impactful statements from cancer survivors (other meaningful information shared by the participants). The survivors reported multiple QoL concerns and body image issues. The study findings warrant cancer education interventions or programs to address the relevant survivorship issues of Black BCS.

Evaluating the relationship between physical activity and quality of life in a racially diverse sample of breast cancer survivors

PURPOSE

Physical activity (PA) has been shown to improve quality of life (QoL) in predominantly White cancer survivors. Very few studies have examined the association between PA and QoL among Black breast cancer survivors (BCS). We investigated the association between PA and multiple QoL domains and the effects of race on the proposed association in a racially diverse group of BCS.

METHODS

This was an exploratory study using secondary data from a completed 12-month randomized controlled  trial (RCT). Mixed effects models were tested on a subset of participants in the control and exercise groups of the RCT. The primary outcomes were changes in the QoL domains (baseline to 12 months post baseline).

RESULTS

There were 173 participants included in this analysis, averaging 59 years of age; about 33% of the participants were Black women. There were no significant differences in the QoL outcomes between the control and exercise groups at 12 months post baseline. Race was not a significant moderator. Exercise improved emotional/mental wellbeing and body image as it relates to social barriers at 12 months post baseline in Black and White BCS, but the changes in these outcomes were only statistically significant in White BCS (p < 0.05).

CONCLUSIONS

Results show that exercise can improve multiple QoL domains over time in Black BCS. However, the significance of the effect on QoL was isolated to White BCS. The small sample size in Black women could constrain the statistical significance of observed effects. Future studies are warranted to assess associations between exercise and QoL in larger samples of Black women.

Postmastectomy Pain Syndrome: A Narrative Review

Postmastectomy pain syndrome is a very common disorder in breast cancer survivors. The impact on the quality of patients' lives is significantly adverse. The precise pathophysiology has not been determined as yet though various risk factors have been identified that make the patient vulnerable. Required preoperative work includes the identification and possible elimination of risk factors. Treatment is multidisciplinary involving surgical and non-surgical modalities. There is a great scope of research in this field.

Correlation and Level of Agreement between the Ocular Surface Disease Index and the Symptom Assessment in Dry Eye Questionnaires: A Survey-Based Study

PURPOSE

The Ocular Surface Disease Index (OSDI) is the most frequently used dry eye disease (DED) questionnaire, and the Symptom Assessment iN Dry Eye (SANDE) is the simplest and quickest to apply. We analyze the correlation and level of agreement between these two questionnaires in a large DED heterogeneous population to evaluate their performance and potential interchangeability.

METHODS

Prospective, multicenter longitudinal survey-based study performed on patients diagnosed with DED by 99 ophthalmologists from 20/32 Mexican states. Questionnaires were applied in two consecutive visits to analyze the correlation between OSDI and SANDE to evaluate patients with DED clinically. Level of agreement was evaluated with Bland-Altman analysis, and internal consistency of instruments was evaluated individually and combined with Cronbach's alpha index.

RESULTS

3421 patients studied: 1996 (58.3%) women and 1425 (41.7%) men, aged 49.5 ± 15.4 years; 995 (29.1%) patients had aqueous-deficient, 1086 (31.7%) evaporative, and 1340 (39.2%) mixed DED subtypes. Normalized baseline scores were 53.7 (OSDI) and 54.1 (SANDE). After 36.3 ± 24.4 days between visits, scores were reduced to 25.2 (OSDI) and 21.8 (SANDE) points (p < .001). A positive correlation between questionnaires was found at baseline (R = 0.592; p < .001), follow-up (R = 0.543; p < .001) and change between visits (R = 0.630; p < .001). Using both questionnaires together improved the overall reliability of symptom evaluation at baseline (α = 0.7), follow-up (α = 0.7), and both (α = 0.7), compared to individual application (OSDI α = 0.5, SANDE α = 0.6)-the same improvements applied to all DED subtypes. Bland-Altman analysis revealed a differential bias of -0.41% at baseline and +3.6% at follow-up visits between OSDI and SANDE.

CONCLUSIONS

We validated the correlation (high precision) between questionnaires in a large-scale population, demonstrating improved reliability (high accuracy) in evaluating DED when used together, challenging their interchangeable use. These results open a venue to improve recommendations toward a more precise and accurate diagnostic and therapeutic evaluation of DED by using OSDI and SANDE concurrently.

Identifying risk factors for chronic postsurgical pain and preventive measures: a comprehensive update

INTRODUCTION

Chronic postsurgical pain (CPSP) is a prevalent condition that can diminish health-related quality of life, cause functional deficits, and lead to patient distress. Rates of CPSP are higher for certain types of surgeries than others (thoracic, breast, or lower extremity amputations) but can occur after even uncomplicated minimally invasive procedures. CPSP has multiple mechanisms, but always starts as acute postsurgical pain, which involves inflammatory processes and may encompass direct or indirect neural injury. Risk factors for CPSP are largely known but many, such as female sex, younger age, or type of surgery, are not modifiable. The best strategy against CPSP is to quickly and effectively treat acute postoperative pain using a multimodal analgesic regimen that is safe, effective, and spares opioids.

AREAS COVERED

This is a narrative review of the literature.

EXPERT OPINION

Every surgical patient is at some risk for CPSP. Control of acute postoperative pain appears to be the most effective approach, but principles of good opioid stewardship should apply. The role of regional anesthetics as analgesics is gaining interest and may be appropriate for certain patients. Finally, patients should be better informed about their relative risk for CPSP.

Disparities in Pain Management

Health disparities in pain management remain a pervasive public health crisis. Racial and ethnic disparities have been identified in all aspects of pain management from acute, chronic, pediatric, obstetric, and advanced pain procedures. Disparities in pain management are not limited to race and ethnicity, and have been identified in multiple other vulnerable populations. This review targets health care disparities in the management of pain, focusing on steps health care providers and organizations can take to promote health care equity. A multifaceted plan of action with a focus on research, advocacy, policy changes, structural changes, and targeted interventions is recommended.

Treatment-related side effects among Hispanic and non-Hispanic white long-term breast cancer survivors by tamoxifen use and duration

PURPOSE

To determine the associations between ethnicity, age at diagnosis, obesity, multimorbidity, and odds of experiencing breast cancer (BC) treatment-related side effects among long-term Hispanic and non-Hispanic white (NHW) survivors from New Mexico and explore differences by tamoxifen use.

METHODS

Lifestyle and clinical information including self-reported tamoxifen use and presence of treatment- related side effects were collected at follow-up interviews (12-15 years) for 194 BC survivors. Multivariable logistic regression models were used to examine associations between predictors and odds of experiencing side effects overall and by tamoxifen use.

RESULTS

Women ranged in age at diagnosis (30-74, M = 49.3, SD = 9.37), most were NHW (65.4%) and had in-situ or localized BC (63.4%). Less than half reportedly used tamoxifen (44.3%), of which 59.3% reported using > 5 years. Overall, survivors who were overweight/obese at follow-up were 5.42 times more likely to experience treatment-related pain (95% CI 1.40-21.0) compared to normal weight survivors. Survivors with multimorbidity, compared to survivors without, were more likely to report treatment-related sexual health issues (aOR 6.90, 95% CI 1.43-33.2) and poorer mental health (aOR 4.51, 95% CI 1.06-19.1). The statistical interactions between ethnicity and overweight/obese with tamoxifen use were significant (p-interaction < 0.05) for treatment-related sexual health issues.

CONCLUSION

Our results demonstrate that survivors with overweightness/obesity or multimorbidity may be more likely to experience BC treatment-related side effects. Tamoxifen use modifies associations between ethnicity, being overweight/obese, and sexual health issues following treatment. The likelihood of experiencing treatment-related side effects were more favorable for those on tamoxifen or those who had used tamoxifen for longer durations. These findings highlight the importance of fostering side effect awareness and applying appropriate interventions to assist with disease management throughout BC survivorship care.

Prospective Study of Pain Outcomes Associated With Breast Surgery in Women With Nonhereditary Breast Cancer

OBJECTIVE

To assess pain severity and interference with life in women after different types of breast cancer surgery and the demographic, treatment-related, and psychosocial variables associated with these pain outcomes.

SUMMARY OF BACKGROUND DATA

Data are conflicting regarding pain outcomes and quality of life (QOL) among women who undergo different types of breast surgery.

METHODS

Women with nonhereditary breast cancer completed the brief pain inventory before surgery and at 1, 6, 12, and 18 months postsurgery. We assessed associations between pain outcomes and CPM status and mastectomy status using multivariable repeated measures models. We assessed associations between pain outcome and QOL and decision satisfaction.

RESULTS

Of 288 women (mean age 56 years, 58% non-Hispanic White), 50 had CPM, 75 had unilateral mastectomy, and 163 had BCS. Mean pain severity scores were higher at one (2.78 vs 1.9, P = 0.016) and 6 months (2.79 vs 1.96, P = 0.031) postsurgery in women who had CPM versus those who did not, but there was no difference at 12 and 18 months. Comparing mastectomy versus BCS, pain severity was higher at 1 and 12 months. There was a significant interaction between pain severity and time point for CPM ( P = 0.006), but not mastectomy status ( P = 0.069). Regardless of surgery type, Black women had higher pain severity ( P = 0.004) than White women. Higher pain interference was associated with lower QOL ( P < 0.001) and lower decision satisfaction ( P = 0.034).

CONCLUSIONS

Providers should counsel women considering mastectomy about the potential for greater acute pain and its impact on overall well-being. Racial/ethnic disparities in pain exist and influence pain management in breast surgical patients.

Family-based psychosocial interventions for adult Latino patients with cancer and their caregivers: A systematic review

Objective

This review aimed to systematically examine the characteristics and outcomes of family-based psychosocial interventions offered to adult Latino patients with cancer and their caregivers.

Methods

We searched six databases from their inception dates through June 2022. Studies were eligible for inclusion if they (1) targeted both adult Latino patients diagnosed with cancer and their adult caregivers or reported subgroup analyses of Latino patients and caregivers; (2) included family-based psychosocial interventions; (3) used randomized controlled trial (RCT) or quasi-experimental designs; and (4) were published in English, Spanish or Portuguese. Members of our multidisciplinary team assessed the risk of bias in the reviewed studies using the Cochrane Collaboration's Risk of Bias Tool.

Results

Our database searches yielded five studies. The studies were conducted in the U.S. and Brazil. Three studies were RCTs, and two used quasi-experimental designs. The sample sizes ranged from 18 to 230 patient-caregiver dyads. These studies culturally adapted the intervention contents and implementation methods and involved bilingual interventionists. The interventions had beneficial effects on multiple aspects of psychosocial outcomes for both patients and caregivers. We also identified methodological limitations in the reviewed studies.

Conclusions

Findings from this systematic review help deepen our understanding of family-based psychosocial interventions for Latinos affected by cancer. The small number of psychosocial interventions focused on adult Latino cancer patients and their caregivers is concerning, considering that Latino populations are disproportionally burdened by cancer. Future research needs to design and evaluate culturally-appropriate interventions to support Latino patients and families who cope with cancer.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=274993, identifier CRD42021274993.

Influence of social and behavioral determinants on health-related quality of life among cancer survivors in the USA

PURPOSE

Cancer survivors experience a worse health-related quality of life (HRQoL) than non-cancer survivors. However, it is not fully understood whether social determinants of health (SDOH) and health behaviors are significantly associated with HRQoL among cancer survivors. The purpose of this study was to investigate the influence of SDOH and health behaviors on HRQoL among cancer survivors.

METHODS

We identified adult (18 years or older) cancer survivors (n = 5784) in the 2017 and 2019 Behavioral Risk Factor Surveillance System. The primary outcome (HRQoL) was defined as whether cancer survivors reported having poor mental or physical health (e.g., 14 or more mentally or physically unhealthy days). Unadjusted and adjusted logistic regression was used to compute the odds ratios and 95% CIs of factors associated with poor HRQoL among the cancer survivors.

RESULTS

More than half of the cancer survivors were non-Hispanic White, female, and 65 years or older. In the adjusted multivariable logistic regression models, cancer survivors who were physically active and who did not avoid care because of costs had a lower risk of poor mental and physical health. Current smokers were more likely to report poor physical health. Homeowners were less likely to report poor mental health. Daily fruit and vegetable consumption and healthcare coverage were not associated with poor HRQoL.

CONCLUSIONS

Some SDOH (healthcare access, economic stability, and the neighborhood and built environment) and health behavior (physical activity) are associated with lower likelihood of experiencing poor mental and/or physical health in the cancer survivors. The study findings can be used to target survivors who experience suboptimal HRQoL and to inform research, public health policies, and/or programs.

Antiracist symptom science: A call to action and path forward

Nurse scientists recognize the experience of racism as a driving force behind health. However, symptom science, a pillar of nursing, has rarely considered contributions of racism. Our objective is to describe findings within symptom science research related to racial disparities and/or experiences of racism and to promote antiracist symptom science within nursing research. In this manuscript, we use an antiracist lens to review a predominant symptom science theory and literature in three areas of symptom science research-oncology, mental health, and perinatal health. Finally, we make recommendations for increasing antiracist research in symptom science by altering (a) research questions, (b) recruitment methods, (c) study design, (d) data analysis, and (e) dissemination of findings. Traditionally, symptom science focuses on individual level factors rather than broader contexts driving symptom experience and management. We urge symptom science researchers to embrace antiracism by designing research with the specific intent of dismantling racism at multiple levels.

Pain management practices for outpatients with breast cancer

Objectives

Methods

Results

Conclusions

•

One in four women office visits for breast cancer received pain medication prescriptions.

•

Among the patients receiving pain medications, one in seven women received opioids.

•

Both patient and provider characteristics contribute to variations in pain management in breast cancer patients.

Cancer Epidemiology in Hispanic Populations: What Have We Learned and Where Do We Need to Make Progress?

The Hispanic/Latino(x) population (H/L) in the United States of America is heterogeneous and fast growing. Cancer is the number one cause of death among H/Ls, accounting for 21% of deaths. Whereas for the most common cancers, incidence rates are lower in H/Ls compared with non-H/L White (NHW) individuals, H/Ls have a higher incidence of liver, stomach, cervical, penile, and gallbladder cancers. H/L patients tend to be diagnosed at more advanced stages for breast, colorectal, prostate, and lung cancers, and melanoma compared with NHW individuals. Etiologic and cancer outcomes research among H/Ls lags other populations. In this review, we provide a summary of challenges, opportunities, and research priorities related to cancer etiology, cancer outcomes, and survivorship to make progress in addressing scientific gaps. Briefly, we prioritize the need for more research on determinants of obesity, nonalcoholic fatty liver disease and its progression to liver cancer, stomach and gallbladder cancers, and pediatric acute lymphoblastic leukemia. We emphasize the need to improve cancer screening, early detection of cancer, and survivorship care. We highlight critical resources needed to make progress in cancer epidemiologic studies among H/L populations, including the importance of training the next generation of cancer epidemiologists conducting research in H/Ls.

Racial Differences in Pain, Nutrition, and Oxidative Stress

Investigating the disproportionate rates of chronic pain and their related comorbidities between Black and non-Hispanic White (White) individuals is a growing area of interest, both in the healthcare community and in general society. Researchers have identified racial differences in chronic pain prevalence and severity, but still very little is known about the mechanisms underlying them. Current explanations for these differences have primarily focused on socioeconomic status and unequal healthcare between races as causal factors. Whereas these factors are informative, a racial gap still exists between Black and White individuals when these factors are controlled for. One potential cause of this racial gap in chronic pain is the differences in nutrition and dietary intake between groups. Certain foods play a key role in the inflammatory and oxidative stress pathways in the human body and could potentially influence the severity of the pain experience. Here, we review the previous literature on the surrounding topics and propose a potential mechanism to explain racial differences in the chronic pain population, based on established racial differences in diet and oxidative stress.

A Cross-Sectional Study of Distress Levels in Patients with Newly Diagnosed Breast Cancer: The Impact of Race, Ethnicity, and Language Preference

PURPOSE

Our objective was to assess distress levels in female breast cancer patients as a function of race, ethnicity, and preferred language. We hypothesized minority patients and non-English screen-takers would report higher distress levels compared to English screen-takers and non-Hispanic whites.

METHODS

We conducted a retrospective observational study of female breast cancer patients at an NCI designated cancer center from 2009 to 2016 who were administered a validated biopsychosocial distress screening questionnaire. Self-reported data on race and ethnicity was collected.

RESULTS

A total of 3,156 patients were included in the analysis; mean age of 56.3 (SD 12.25) years. The racial/ethnic cohort distribution included 54% non-Hispanic white (NHW), 19% Hispanic, 16% Asian, 7% Black/African American, and 4% other. On multivariable analysis only Hispanic patients were significantly more likely to report overall distress compared to NHW (OR [1.39; CI [1.03-1.87; p=0.03). Asians were significantly less likely to report distress in the functional domain (OR 0.71, CI [0.58-0.88]; p=0.002), while Black patients were significantly more likely to report highest distress levels in the physical (OR 1.53, CI [1.11-2.12]; p=0.01) domain. Hispanic Spanish screen-takers reported significantly more distress compared to Hispanic English screen-takers across all four domains of distress (p<0.05 for all).

CONCLUSIONS

Top sources of distress in female breast cancer patients vary as a function of race, ethnicity, and preferred language. Future studies should focus on identifying effective, culturally appropriate targeted interventions to mitigate emotional distress levels in ethnic and racial minorities as well as non-English speaking patients with breast cancer.

Patient-reported symptom burden in routine oncology care: Examining racial and ethnic disparities

Background

Racial and ethnic disparities are well‐documented in cancer outcomes such as disease progression and survival, but less is known regarding potential disparities in symptom burden.

Aims

The goal of this retrospective study was to examine differences in symptom burden by race and ethnicity in a large sample of cancer patients. We hypothesized that racial and ethnic minority patients would report greater symptom burden than non‐Hispanic and White patients.

Methods and results

A total of 5798 cancer patients completed the Edmonton Symptom Assessment Scale—revised (ESAS‐r‐CSS) at least once as part of clinical care. Two indicators of symptom burden were evaluated: (1) total ESAS‐r‐CSS score (i.e., overall symptom burden) and (2) number of severe symptoms (i.e., severe symptomatology). For patients completing the ESAS‐r‐CSS on multiple occasions, the highest score for each indicator was used. Zero‐inflated negative binomial regression analyses were conducted, adjusting for other sociodemographic and clinical characteristics. Symptomology varied across race. Patients who self‐identified as Black reported higher symptom burden (p = .016) and were more likely to report severe symptoms (p < .001) than self‐identified White patients. Patients with “other” race were also more likely to report severe symptoms than White patients (p = .032), but reported similar total symptom burden (p = .315). Asian and Hispanic patients did not differ from White or non‐Hispanic patients on symptom burden (ps > .05).

Conclusion

This study describes racial disparities in patient‐reported symptom burden during routine oncology care, primarily observed in Black patients. Clinic‐based electronic symptom monitoring may be useful to detect high symptom burden, particularly in patients who self‐identify their race as Black or other. Future research is needed to reduce symptom burden in racially diverse cancer populations.

Characterization of Clinical Symptoms by Race Among Women With Early-Stage, Hormone Receptor-Positive Breast Cancer Before Starting Chemotherapy

IMPORTANCE

Race disparities persist in breast cancer mortality rates. One factor associated with these disparities may be differences in symptom burden, which may reduce chemotherapy tolerance and increase early treatment discontinuation.

OBJECTIVES

To compare symptom burden by race among women with early-stage breast cancer before starting chemotherapy and quantify symptom differences explained by baseline characteristics.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of symptom burden differences by race among Black and White women with a diagnosis of stage I to III, hormone receptor-positive breast cancer who had a symptom report collected before chemotherapy initiation in a large cancer center in the southern region of the US from January 1, 2007, through December 31, 2015. Analyses were conducted from November 1, 2019, to March 31, 2021. Blinder-Oaxaca decomposition was used, adjusting for baseline sociodemographic and clinical characteristics.

MAIN OUTCOMES AND MEASURES

Four symptom composite scores with a mean (SD) of 50 (10) were reported before starting chemotherapy (baseline) and were derived from symptom items: general physical symptoms (11 items), treatment adverse effects (8 items), acute distress (4 items), and despair (7 items). Patients rated the severity of each symptom they experienced in the past week on a scale of 0 to 10 (where 0 indicates not a problem and 10 indicates as bad as possible).

RESULTS

A total of 1338 women (mean [SD] age, 54.6 [11.6] years; 420 Black women [31.4%] and 918 White women [68.6%]) were included in the study. Before starting chemotherapy, Black women reported a statistically significantly higher (ie, worse) symptom composite score than White women for adverse effects (44.5 vs 43.8) but a lower acute distress score (48.5 vs 51.0). Decomposition analyses showed that Black patients' characteristics were associated with higher symptom burden across all 4 scores. However, these differences were offset by relatively greater, statistically significant, unexplained physical, distress, and despair symptom reporting by White patients.

CONCLUSIONS AND RELEVANCE

In this study, before starting chemotherapy, Black patients with early-stage breast cancer reported significantly higher burden for symptoms that may be exacerbated with chemotherapy and lower distress symptoms compared with White patients. Future studies should explore how symptoms change before and after treatment and differ by racial/ethnic groups and how they are associated with treatment adherence and mortality disparities.

"I never heard anything about it": Knowledge and psychosocial needs of Latina breast cancer survivors with lymphedema

Objective:

Breast cancer is the most commonly diagnosed form of cancer and the leading cause of cancer-related death among Latina women in the United States. One aspect of recovery that has been underrepresented in the English-language literature is the recovery of Latina women who have developed lymphedema, a debilitating condition characterized by persistent swelling of the arm, hand, chest, and/or breast. To fill this research gap, a study was conducted to examine the lived experiences of Latina women with breast cancer-related lymphedema.

Methods:

Given the limited scholarship on this topic, qualitative methods were used to obtain a foundational and nuanced understanding of Latina women’s experiences. Semi-structured interviews were conducted with a sample of 10 Latina survivors with breast cancer-related lymphedema. Data were analyzed through thematic analysis and constant comparison methodology.

Results:

The data analysis yielded three major themes: knowledge of lymphedema, impact of lymphedema diagnosis, and coping with lymphedema. Participants had limited knowledge of lymphedema and its risk factors upon diagnosis, in addition to barriers accessing quality care. They also noted psychological distress related to a significant financial burden as well as social anxiety related to interacting with others while wearing compression gloves or sleeves. A major coping strategy was receiving social support from friends, family, peers in structured support groups, and spiritual/religious groups or practices.

Conclusions:

Our findings bring to light contextual factors that may place Latina breast cancer survivors at increased risk for lymphedema and for experiencing a high burden managing their condition. Recommendations are provided for primary, secondary, and tertiary prevention.

Barriers to Psychosocial Services Use For Latina Versus Non-Latina White Breast Cancer Survivors

OBJECTIVE

The aims of this study were to compare barriers to use of psychosocial services by Latina versus non-Latina white women who had been diagnosed as having breast cancer and to examine associations between the barriers and use of psychosocial services.

METHODS

A sample of 265 Latina and non-Latina white women who had received treatment in a comprehensive cancer center in New York City completed a mailed questionnaire. The questionnaire measured quality of life, interest in receiving help for psychological distress, psychosocial services use, and barriers to use of psychosocial services. Bivariate and adjusted logistic regression models were used to analyze the data.

RESULTS

More than half of the sample reported preferring to return to their normal routines, felt they could take care of their emotional problems themselves, and preferred to seek support from their family or friends. Latinas were more likely to seek counseling from a spiritual leader, to report that there were no counselors who spoke their language and understood their values or background, and to report that mental health services were too expensive.

CONCLUSIONS

It is crucial to address the barriers that contribute to health disparities and discrepancies in patient access to and use of psychosocial health care. These findings highlight the need to educate providers about patients' psychosocial needs, provide patients with information about the benefits of psychosocial services, normalize mental health service use, diminish stigma surrounding use of these services, and provide culturally and linguistically sensitive services for Latina patients.

Factors Impacting Management of Breast Cancer-Related Lymphedema (BCRL) in Hispanic/Latina Breast Cancer Survivors: A Literature Review

INTRODUCTION

Breast cancer-related lymphedema (BCRL) is a treatment sequela with negative physical and psychological implications. BCRL is a lifetime concern for survivors and is currently incurable. With the increase in the Latino population in the United States, it is critical for the cancer care community to address factors that increase BCRL risk and negatively impact long-term quality of life. This literature review undertook to identify successful intervention strategies for BCRL among Latina survivors.

METHODS

Multiple databases were searched for published articles from 2006 to 2020. PRISMA guidelines were utilized. Data were extracted related to physical activity, diet, and psychosocial stress concerns of Latinas at risk for or living with BCRL.

RESULTS

Eleven interventions combined education and skill-building techniques to address physical activity, diet, and stress management for BCRL. Family involvement, peer-mentoring, culturally tailored education, and self-care skill development were identified as important for Latina survivors.

CONCLUSION

Latina survivors may benefit from culturally tailored BCRL education programs and self-management interventions. Health care professionals and researchers should consider cultural influences when developing clinical intervention strategies to enhance outcomes for Latinas at risk for living with BCRL. In addition, including family members and/or peers in such strategies may be helpful to Latina survivors.

Patterns of Use of Smartphone-Based Interventions Among Latina Breast Cancer Survivors: Secondary Analysis of a Pilot Randomized Controlled Trial

BACKGROUND

Latina breast cancer survivors experience poorer health-related quality of life (HRQoL), greater symptom burden, and more psychosocial needs compared to non-Latina breast cancer survivors. eHealth platforms such as smartphone apps are increasingly being used to deliver psychosocial interventions to cancer survivors. However, few psychosocial eHealth interventions have been developed specifically for Latina breast cancer survivors. Further, little is known about how Latinas, in general, engage with eHealth interventions and whether specific participant characteristics are associated with app use in this population. We evaluated the use of 2 culturally informed, evidence-based smartphone apps for Latina breast cancer survivors-one that was designed to improve HRQoL and reduce symptom burden (My Guide) and the other to promote healthy lifestyle behaviors (My Health).

OBJECTIVE

The objectives of our study were to explore the patterns of use of the My Guide intervention app and My Health attention-control app among Latina breast cancer survivors.

METHODS

Eighty Latina breast cancer survivors were randomized to use the My Guide or My Health app for 6 weeks. Assessments were collected at baseline (T1), immediately after the 6-week intervention (T2), and 2 weeks after T2 (T3). Specific study outcomes included subdomains of HRQoL, symptom burden, cancer-specific distress, cancer-relevant self-efficacy, and breast cancer knowledge.

RESULTS

On average, participants used their assigned app for more than 1 hour per week. Sociodemographic or psychological characteristics were not significantly associated with app use, except for employment status in the My Health group. Content related to common physical and emotional symptoms of breast cancer survivors as well as recommendations for nutrition and physical activity were most frequently accessed by My Guide and My Health participants, respectively. Lastly, clinically meaningful improvements were demonstrated in breast cancer well-being among low app users (ie, <60 minutes of use/week) of My Guide and social well-being among high app users (ie, ≥60 minutes of use/week) of My Health.

CONCLUSIONS

The favorable rates of participant use across both apps suggest that Latina breast cancer survivors are interested in the content delivered across both My Guide and My Health. Furthermore, since sociodemographic variables, excluding employment status, and baseline HRQoL (psychological variable) were not related to app use, My Guide and My Health may be accessible to diverse Latina breast cancer survivors.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03645005; https://clinicaltrials.gov/ct2/show/NCT03645005.

Symptom Profiles of Latina Breast Cancer Survivors: A Latent Class Analysis

BACKGROUND

Symptom research among Latinas with breast cancer is limited-especially as it relates to multiple co-occurring symptoms.

OBJECTIVE

The aim of the study was to identify subgroups (latent classes) of Latinas who have distinct symptom profiles while receiving radiation, chemotherapy, and/or hormonal therapy for breast cancer.

METHODS

This secondary analysis included intake data from three randomized trials of supportive care psychosocial interventions for Latinas treated for breast cancer (n = 290). Prevalence of 12 symptoms-measured using the General Symptom Distress Scale-was entered into the latent class analysis to identify classes of women with different symptom profiles.

RESULTS

Most of the participants had Stage II or III disease, and 81% reported receiving chemotherapy. On average, women reported 4.2 (standard deviation [SD] = 3) symptoms with an overall symptom distress score of 6.4 (SD = 2.5) on a 1-10 scale, with 10 being most distressing. Latent class analysis resulted in three classes that were labeled based on symptoms with the highest prevalence. Class 1 (n = 192) was "Disrupted Sleep and Tired," Class 2 (n = 74) was "Tired," and Class 3 (n = 24) was "Pain, Disrupted Sleep, and Tired." Depression, anxiety, and difficulty concentrating had moderate prevalence in each of the three classes.

DISCUSSION

Beyond the core six symptoms (depression, anxiety, fatigue, pain, disrupted sleep, difficulty concentration), the classes differed in the prevalence of other burdensome symptoms (e.g., nausea, vomiting, constipation), which provide implications for treatment. Thus, it is important to assess for the full range of symptoms so that supportive care interventions can be tailored for the distinct symptom profiles of Latinas with breast cancer.

Issues in Recruiting and Retaining Asian American Breast Cancer Survivors in a Technology-Based Intervention Study

BACKGROUND

Difficulties in recruiting and retaining Asian Americans in traditional research have been well documented. Despite an increasing number of technology-based cancer studies among racial/ethnic minorities, little is still known about potential issues in recruiting and retaining racial/ethnic minority cancer survivors for technology-based intervention research.

OBJECTIVE

This discussion article aims to examine issues in recruiting and retaining a group of racial/ethnic minorities-Asian American breast cancer survivors-for a technology-based intervention study.

METHODS

The parent study is an ongoing large-scale, national-scope, technology-based intervention study among a target number of 330 Asian American breast cancer survivors. During the recruitment and retention process, research diaries were written by research team members, and the written records of weekly research team meetings were kept. The written records were analyzed using a content analysis. Then, the themes were used to support the discussion points made in the article.

RESULTS

There existed subethnic differences in research participation; it was easier to recruit Chinese participants compared with other subethnic groups. The use of culturally matched research team members and multiple languages was essential. Gatekeepers were also elemental for recruitment and retention. Various motivation strategies were needed to retain the participants. Each subethnic group used different communication apps. Finally, trust building was essential to retain the participants in the intervention.

CONCLUSIONS

Researchers need to consider these practical issues in future technology-based intervention research.

IMPLICATIONS FOR PRACTICE

These issues need to be considered in future program/intervention development and implementation among racial/ethnic minority cancer survivors.

Knowledge and Attitudes About Genetic Testing Among Black and White Women with Breast Cancer

Prior to embarking on a large descriptive evaluation of genetic/racial variations in symptom phenotype, we sought foundational information to determine racial differences in (1) feasibility (consent) and acceptability of collecting genomic samples, (2) genetic literacy, and (3) concerns of genomic research during breast cancer (BC) chemotherapy. Women with early-stage BC undergoing chemotherapy were recruited from an academic, urban breast care center. Information was collected for consent to participate, genetic literacy, and concerns about genetic testing in Black and White women with BC. Fifty-six women were eligible, and 48 were consented (24 Black, 24 White). All participants consented to blood testing. This highly educated sample's mean age was 52.5 + 12.05 (years). Education (years) and genetic knowledge were positively correlated (p = .038). Genetic scores were high, and only one question significantly differed by race. On interview, most participants thought conducting genetic research helped to better understand hereditary disease and/or identify genes that cause disease and stated that they participated in the research to help other people. The majority of participants responded that friends/family would participate in genetic research without concerns, though three Black participants cited mistrust as a possible concern. Overall, there were high levels of genetic knowledge, slightly different between Black and White women. There were no high levels of personal concern regarding genetic testing. Black women reported more concern than White women that friends/family would have hesitations about participating in genetic research. There was general acceptability of blood collection for genetic testing among women with early-stage BC without racial difference.

Physical activity barriers and resources among black women with a history of breast and endometrial cancer: a systematic review

Physical inactivity is a significant public health problem among black women. However, there is limited evidence regarding barriers to physical activity and the availability of opportunities to engage in physical activity, specifically for posttreatment black women with a history of cancer.

PURPOSE

The purpose of this paper was to systematically review, summarize, and synthesize findings on physical activity-related research including barriers, facilitators, and resources for physical activity among posttreatment black women with a history of breast and endometrial cancer.

METHODS

We developed a comprehensive search strategy and conducted searches in the following databases: PsycINFO, Web of Science, Cochrane, PubMed, and Sociological Abstracts. Summary measures were described qualitatively (e.g., themes) and quantitatively (e.g., frequencies).

RESULTS

This review identified 35 eligible articles describing 12 intervention and 23 observational studies. We described intervention preferences (e.g., resistance activities), beliefs about physical activity, and benefits of physical activity for quality of life (e.g., improvements in social wellbeing) in black cancer survivors. In addition, very few studies identified barriers to physical activity (n = 7) and focused on increasing physical activity (n = 12) among black women with a history of cancer. The most common reported barriers among the target population were fatigue, lack of social support, weather, illness/health issues, cost, time constraints, living too far away, and inability/unwillingness to obtain physician clearance, whereas the most common facilitators were faith, other health concerns, and social support.

CONCLUSIONS/IMPLICATIONS

Future studies should target barriers, facilitators, and culturally adapted strategies for physical activity at all levels of influence to develop multi-level interventions to engage and improve physical activity among black women with a history of breast and endometrial cancer.

PROTOCOL REGISTRATION NUMBER

CRD42018110008.

Cancer-Relevant Self-Efficacy Is Related to Better Health-Related Quality of Life and Lower Cancer-Specific Distress and Symptom Burden Among Latina Breast Cancer Survivors

BACKGROUND

Latina breast cancer survivors (BCS) often report poorer health-related quality of life (HRQOL), higher symptom burden, and greater psychosocial needs compared to non-Latina BCS. However, Latinas are underrepresented in cancer survivorship research and more work is needed to examine the factors contributing to these psychosocial disparities. This study aimed to evaluate potentially modifiable patient characteristics associated with HRQOL, breast cancer concerns, and cancer-specific distress among Latina BCS.

METHODS

Baseline data was evaluated in 95 Latina BCS who participated in a smartphone-based psychosocial intervention designed to improve HRQOL. Hierarchical linear regression analyses were conducted to evaluate the associations between modifiable factors that have been shown to favorably impact outcomes in cancer populations (i.e., cancer-relevant self-efficacy, breast cancer knowledge) with overall and domain-specific HRQOL, breast cancer symptom burden, and cancer-specific distress, after controlling for sociodemographic and cancer-related characteristics.

RESULTS

Greater cancer-relevant self-efficacy was related to better overall HRQOL as well as better social, emotional, and functional well-being domains. Greater cancer-relevant self-efficacy was also related to less breast cancer symptom burden and less cancer-specific distress. Breast cancer knowledge was not associated with any of the study outcomes.

CONCLUSIONS

Results demonstrate that cancer-relevant self-efficacy is a significant correlate of general and domain-specific HRQOL, breast cancer symptom burden, and cancer-specific distress among Latina BCS. Future interventions in this population should target cancer-relevant self-efficacy as a possible mechanism to improve HRQOL outcomes and survivorship experiences for Latina BCS.

Cancer-related Fatigue in Breast Cancer Survivors: A Review

Fatigue has been the most distressing and frequent symptom in breast cancer (BC) survivors after treatment. Although fatigue can occur in other cancer survivors, women with a history of BC might share some distinctive features. The present study aimed to recapitulate the knowledge about risk factors and correlates of cancer-related fatigue (CRF) in BC survivors after oncologic therapy. An electronic data search was conducted in PubMed using the terms "fatigue," "breast," "cancer," and "survivors." Records were included if they were original articles, available in English, had used a quantitative scale, had > 100 participants, and had excluded women with BC relapse. BC survivors were required to have finished their treatments ≥ 2 months before, except for hormonal therapy. The physiopathology and other interventions were considered beyond the scope of our review. The correlates were subsequently classified into 7 main categories: (1) sociodemographic data, (2) physical variables, (3) tumor- and treatment-related variables, (4) comorbidities, (5) other symptoms, (6) psychological issues, and (7) lifestyle factors. Fatigue was consistently greater in younger, obese, and diabetic women. Women reporting fatigue often communicated symptoms such as pain, depression, insomnia, and cognitive dysfunction. Coping strategies such as catastrophizing could play an important role in the persistence of fatigue. However, tumor characteristics, previous treatments received, and physical activity were not consistently reported. CRF was a strong predictor of the quality of life of BC survivors after treatment. In conclusion, we found CRF was a frequent and serious symptom that severely affects the quality of life of BC survivors after treatment. Health practitioners require more awareness and information about CRF.

Symptom Experience, Management, and Outcomes According to Race and Social Determinants Including Genomics, Epigenomics, and Metabolomics (SEMOARS + GEM): an Explanatory Model for Breast Cancer Treatment Disparity

Even after controlling for stage, comorbidity, age, and insurance status, black women with breast cancer (BC) in the USA have the lowest 5-year survival as compared with all other races for stage-matched disease. One potential cause of this survival difference is the disparity in cancer treatment, evident in many population clinical trials. Specifically, during BC chemotherapy, black women receive less relative dose intensity with more dose reductions and early chemotherapy cessation compared with white women. Symptom incidence, cancer-related distress, and ineffective communication, including the disparity in patient-centeredness of care surrounding patient symptom reporting and clinician assessment, are important factors contributing to racial disparity in dose reduction and early therapy termination. We present an evidence-based overview and an explanatory model for racial disparity in the symptom experience during BC chemotherapy that may lead to a reduction in dose intensity and a subsequent disparity in outcomes. This explanatory model, the Symptom Experience, Management, Outcomes and Adherence according to Race and Social determinants + Genomics Epigenomics and Metabolomics (SEMOARS + GEM), considers essential factors such as social determinants of health, clinician communication, symptoms and symptom management, genomics, epigenomics, and pharmacologic metabolism as contributory factors.

Calidad de Vida: a systematic review of quality of life in Latino cancer survivors in the USA

BACKGROUND

Cancer is the leading cause of death among Hispanics/Latinos. Thus, understanding health-related quality of life (HRQOL) needs among this diverse racial/ethnic group is critical. Using Ferrell's multidimensional framework for measuring QOL, we synthesized evidence on HRQOL needs among Hispanic/Latino cancer survivors.

METHODS

We searched MEDLINE/PubMed, EMBASE, CINAHL, and PsycINFO, for English language articles published between 1995 and January 2020, reporting HRQOL among Hispanic/Latino cancer survivors in the USA.

RESULTS

Of the 648 articles reviewed, 176 met inclusion criteria, with 100 of these studies focusing exclusively on breast cancer patients and no studies examining end-of-life HRQOL issues. Compared with other racial/ethnic groups, Hispanics/Latinos reported lower HRQOL and a higher symptom burden across multiple HRQOL domains. Over 80% of studies examining racial/ethnic differences in psychological well-being (n = 45) reported worse outcomes among Hispanics/Latinos compared with other racial/ethnic groups. Hispanic/Latino cancer survivors were also more likely to report suboptimal physical well-being in 60% of studies assessing racial/ethnic differences (n = 27), and Hispanics/Latinos also reported lower social well-being relative to non-Hispanics/Latinos in 78% of studies reporting these outcomes (n = 32). In contrast, reports of spiritual well-being and spirituality-based coping were higher among Hispanics/Latinos cancer survivors in 50% of studies examining racial/ethnic differences (n = 15).

DISCUSSION

Findings from this review point to the need for more systematic and tailored interventions to address HRQOL needs among this growing cancer survivor population. Future HRQOL research on Hispanics/Latinos should evaluate variations in HRQOL needs across cancer types and Hispanic/Latino subgroups and assess HRQOL needs during metastatic and end-of-life disease phases.

Long-Term Effect of a Nonrandomized Psychosocial Mindfulness-Based Intervention in Hispanic/Latina Breast Cancer Survivors

Background: There is a paucity of research on the long-term impact of stress-reduction in Hispanic/Latina breast cancer (BC) survivors, a growing minority. In this article, we assess the long-term efficacy of an 8-week training program in mindfulness-based stress reduction (MBSR) on quality of life (QoL) in Hispanic BC survivors. Methods: Hispanic BC survivors, within the first 5 years of diagnosis, stages I to III BC, were recruited. Participants were enrolled in bilingual, 8-week intensive group training in MBSR and were asked to practice a- home, daily. They were also provided with audio recordings and a book on mindfulness practices. Patient-reported outcomes for QoL and distress were evaluated at baseline, and every 3 months, for 24 months. Results: Thirty-three self-identified Hispanic women with BC completed the MBSR program and were followed at 24 months. Statistically significant reduction was noted for the Generalized Anxiety Disorder measure (mean change −2.39, P=0.04); and Patient Health Questionnaire (mean change −2.27, P=0.04), at 24 months, compared with baseline. Improvement was noted in the Short-Form 36 Health-related QoL Mental Component Summary with an increase of 4.07 (95% confidence interval = 0.48-7.66, P=0.03). However, there was no significant change in the Physical Component Summary. Conclusions: Hispanic BC survivors who participated in an 8-week MBSR–based survivorship program reported persistent benefits with reduced anxiety, depression, and improved mental health QoL over 24 months of follow-up. Stress reduction programs are beneficial and can be implemented as part of a comprehensive survivorship care in BC patients.

Depressive complaints and utilization of mental health services: Comparison of adult cancer survivors of different ethnic origin

OBJECTIVE

To investigate depressive symptoms and mental health care utilization in adult cancer survivors (CS) of different ethnic origin.

METHODS

Mental health care utilization in dependence of depression (Patient Health Questionnaire, PHQ-9 ≥ 10) was analyzed in native German CS (GE) and in CS with Turkish (TR) or Polish (PL) migration background, recruited by a cancer registry. Frequencies and odds ratios (OR) were calculated.

RESULTS

135 native German and 50 CS belonging to the first migration generation (TR: n = 25 and PL: n = 25) participated. TR showed the highest rate of depression (36.0%), followed by PL (32.0%), while GE revealed the lowest frequency (20.9%). The frequency of the utilization of mental health services was 17.4% (TR), 4.5% (PL) and 8.1% (GE). After adjusting for sociodemographic and clinical variables, no significant differences between the migrants and German CS were detected for the risk of being depressed, however a tendency for an increased risk in the migrant group was observed (OR = 2.53, CI = 0.96-6.65, p = .061). Female gender (OR = 3.88, CI = 1.29-11.68, p = .016) and prior psychological/psychiatric treatment (OR = 4.35, CI = 1.86-10.18, p = .001) were significantly associated with a higher risk of being depressed.

CONCLUSION

Contrastingly to numerous surveys, our results indicate no substantial differences between migrants and native CS, when adjusted for important confounders. High levels of migrants´ acculturation (good language proficiency, German citizenship/unlimited residence permit, long duration of stay in Germany) may contribute to eliminate inequalities caused by migration status in depressive symptomatology and mental health care utilization in CS.

Lymphedema Signs, Symptoms, and Diagnosis in Women Who Are in Minority and Low-Income Groups and Have Survived Breast Cancer

BACKGROUND

Breast cancer-related lymphedema (BCRL) is a well-known side effect of cancer and its treatment with wide-ranging prevalence estimates.

OBJECTIVE

This study describes associations between breast cancer-related lymphedema (BCRL) signs, symptoms, and diagnosis for women who were African American, white, or had a low income and survived breast cancer.

DESIGN

This is a cross-sectional, observational study that used a computer-assisted telephone interview.

METHODS

Women who had survived breast cancer were queried on the presence of 5 lymphedema signs and symptoms (edema in the breast, axilla, arm, and/or hand; tissue fibrosis; pitting; hemosiderin staining; heaviness) and whether they had a diagnosis of BCRL. Relationships between signs/symptoms and diagnosis for each group were evaluated with kappa and chi-square statistics.

RESULTS

The study sample included 528 women who had survived breast cancer (266 white and 262 African American), with 514 reporting complete data on household income; 45% of the latter reported an annual household income of ≤$20,000. Women who were African American or had a low income were nearly twice as likely as women who were white to have any of 8 signs/symptoms of BCRL. Regardless of race and income, >50% of women with all BCRL signs and symptoms reported that they were not diagnosed with BCRL.

LIMITATIONS

The main limitations of our study are the lack of medical chart data and longitudinal design.

CONCLUSIONS

Women who were African American or had a low income and had survived breast cancer had a greater burden of BCRL signs and symptoms than women who were white. The lack of a strong association between BCRL signs, symptoms, and diagnosis suggests that BCRL may be underdiagnosed. These findings suggest that more rigorous screening and detection of BCRL-especially for women who are African American or have a low income-may be warranted. Cancer rehabilitation programs may be able to fill this gap.

The Effects of Melatonin on the Descending Pain Inhibitory System and Neural Plasticity Markers in Breast Cancer Patients Receiving Chemotherapy: Randomized, Double-Blinded, Placebo-Controlled Trial

Background: Adjuvant chemotherapy for breast cancer (ACBC) has been associated with fatigue, pain, depressive symptoms, and disturbed sleep. And, previous studies in non-cancer patients showed that melatonin could improve the descending pain modulatory system (DPMS). We tested the hypothesis that melatonin use before and during the first cycle of ACBC is better than placebo at improving the DPMS function assessed by changes in the 0–10 Numerical Pain Scale (NPS) during the conditioned pain modulating task (CPM-task) (primary outcome). The effects of melatonin were evaluated in the following secondary endpoints: heat pain threshold (HPT), heat pain tolerance (HPTo), and neuroplasticity state assessed by serum brain-derived neurotrophic factor (BDNF), tropomyosin kinase receptor B, and S100B-protein and whether melatonin’s effects on pain and neuroplasticity state are due more so to its impact on sleep quality.

Methods: Thirty-six women, ages 18 to 75 years old, scheduled for their first cycle of ACBC were randomized to receive 20mg of oral melatonin (n = 18) or placebo (n = 18). The effect of treatment on the outcomes was analyzed by delta (Δ)-values (from pre to treatment end).

Results: Multivariate analyses of covariance revealed that melatonin improved the function of the DPMS. The Δ-mean (SD) on the NPS (0–10) during the CPM-task in the placebo group was −1.91 [−1.81 (1.67) vs. −0.1 (1.61)], and in the melatonin group was −3.5 [−0.94 (1.61) vs. −2.29 (1.61)], and the mean difference (md) between treatment groups was 1.59 [(95% CI, 0.50 to 2.68). Melatonin’s effect increased the HPTo and HPT while reducing the (Δ)-means of the serum neuroplasticity marker in placebo vs. melatonin. The Δ-BDNF is 1.87 (7.17) vs. −20.44 (17.17), respectively, and the md = 22.31 [(95% CI = 13.40 to 31.22)]; TrKB md = 0.61 [0.46 (0.17) vs. −0.15 (0.18); 95% CI = 0.49 to 0.73)] and S00B-protein md = −8.27[(2.89 (11.18) vs. −11.16 (9.75); 95% CI = −15.38 to −1.16)]. However, melatonin’s effect on pain and the neuroplastic state are not due to its effect on sleep quality.

Conclusions: These results suggest that oral melatonin, together with the first ACBC counteracts the dysfunction in the inhibitory DPMS and improves pain perception measures. Also, it shows that changes in the neuroplasticity state mediate the impact of melatonin on pain.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier NCT03205033.

Meta-analysis of the prevalence of depression among breast cancer survivors in Iran: an urgent need for community supportive care programs

OBJECTIVES

Depression, which is the most common comorbidity in breast cancer (BC) patients, has adverse effects on patients' quality of life, disease progress, and survival.

METHODS

The protocol of this study was registered in PROSPERO (registration No. CRD42019121494). We electronically searched published studies through January 2019 with the aim of finding articles that investigated the prevalence of depression among BC survivors. Web of Science, Scopus, PubMed/MEDLINE, Science Direct, and Google Scholar were searched to obtain relevant published studies. This review included 14 cross-sectional and 4 cohort studies published from 2000 to 2018. We used a random-effects model to conduct the meta-analysis and generated a summary estimate for the pooled prevalence with 95% confidence intervals (CIs). A subgroup analysis was also conducted based on the depression assessment tool used and the study design.

RESULTS

The total sample size of the studies contained 2,799 women with BC, including 1,228 women who were diagnosed with depression. The pooled prevalence of depression among Iranian women with BC was 46.83% (95% CI, 33.77 to 59.88) with significant heterogeneity (I2 =98.5%; p<0.001). The prevalence of depression ranged from 14.00% (95% CI, 4.91 to 23.09) to 95.90% (95% CI, 91.97 to 99.83). The results of the subgroup analyses suggested that the depression assessment tool, year of publication, and study design were sources of heterogeneity.

CONCLUSIONS

Our findings indicate a high prevalence of depression among BC patients, underscoring the urgent need for clinicians and health authorities to provide well-defined social and psychological supportive care programs for these patients.

Telehealth intervention for Latina breast cancer survivors: A pilot

Aim:

This study was a pilot test of the Latina Breast Cancer Survivorship Intervention, a survivorship self-management intervention delivered via telephone.

Materials and methods:

This study used a wait-list control design with random assignment to either (1) support and early education or (2) support and delayed education. Latina breast cancer survivors were recruited through the Florida Cancer Data System Registry. Latinas with stage I–III breast cancer who completed primary cancer treatment 3 years prior to study enrollment were eligible. The Latina Breast Cancer Survivorship Intervention consisted of three education sessions delivered weekly via telephone and six telephone support calls, both delivered by a native Spanish speaker. Primary outcome variables included physical well-being, emotional well-being, fatigue, pain, and depressive symptoms. Data collection occurred at baseline, 3 months, and 6 months.

Results:

In total, 40 Latina breast cancer survivors who were middle-aged to older, married, with health insurance, and Spanish as preferred language enrolled in the Latina Breast Cancer Survivorship Intervention. Data were analyzed using mean change scores. Overall, physical and emotional well-being remained similar over time with well-being scores poorer compared with the general population. Pain levels improved over 6 months and showed a high effect size. Fatigue scores improved at 3 months and showed a moderate effect size. Depressive symptoms remained elevated but were not clinically significant.

Conclusion:

Telephone-based Latina Breast Cancer Survivorship Intervention reached Latina breast cancer survivors for survivorship education and support. Self-management of pain and fatigue showed improvement over time.

Risk factors for postoperative opioid use after elective shoulder arthroplasty

BACKGROUND

The opioid epidemic remains a serious issue in the United States with significant impact to the medical and socioeconomic welfare of communities. We sought to determine baseline opioid use in patients undergoing shoulder arthroplasty (SA) and identify patient characteristics, comorbidities, and surgical risk factors associated with postoperative opioid use.

METHODS

A Shoulder Arthroplasty Registry identified the number of dispensed opioid medication prescriptions (Rxs) in the first postoperative year in patients who underwent elective primary SA from 2008 to 2014. We used Poisson regression to study the effect of preoperative risks factors on number of dispensed opioid Rxs in the first postoperative year, evaluated quarterly (Q1: days 0-90, Q2: days 91-180, Q3: days 181-270, Q4: days 271-360).

RESULTS

Included were 4243 SAs from 3996 patients, and 75% used opioids in the 1-year preoperative period. The factors associated with increased opioid use in all postoperative quarters (Q4 incident rate ratio [IRR] shown) were age <60 years (IRR, 1.40; 95% confidence interval [CI], 1.29-1.51), preoperative opioid use (1-4 Rxs: IRR, 2.15; 95% CI, 1.85-2.51; ≥5 Rxs: IRR, 9.83; 95% CI , 8.53-11.32), anxiety (IRR, 1.11; 95% CI, 1.03-1.20), opioid dependence (IRR, 1.23; 95% CI, 1.05-1.43), substance abuse (IRR, 1.17; 95% CI, 1.07-1.28), and general chronic pain (IRR, 1.38; 95% CI, 1.28-1.50).

CONCLUSION

Opioid usage in patients undergoing SA is widespread at 1 year, with three-fourths of patients having been dispensed at least one Rx. These findings emphasize the need for surgeon and patient awareness as well as education in the management of postoperative opioid usage associated with the indicated conditions. Surgeons may consider these risk factors for preoperative risk stratification and targeted deployment of preventative strategies.

Differences in the Severity, Distress, Interference, and Frequency on Cancer-Related Symptoms Between Island Hispanic Puerto Ricans and Mainland Non-Hispanic Whites

The knowledge base of cancer-related symptoms is increasing; yet, limited attention has been given to provide evidence on differences in the perception of cancer symptoms between ethnic groups, especially in the Hispanic Puerto Rican (PR) population. To examine whether there are significant differences in the severity, distress, interference, and frequency of cancer symptoms between island Hispanic PR and mainland non-Hispanic whites. In this secondary data analysis, data from 109 Hispanic PR was matched by age, gender and cancer diagnosis with data from non-Hispanic whites. Cancer symptoms were assessed using the Cancer Symptom Scale (CSS). Mann-Whitney statistical test was used to evaluate pairwise differences between Hispanic PR and non-Hispanic whites on symptoms from the CSS. There were significant differences on some symptoms including PR reporting: (a) more intense itching, swelling, taste change, difficulty sleeping, bloating, depression, sadness, worry, and nervousness; (b) significantly greater distress about taste change, appetite, anxiety, depression, worry, and feeling nervous; (c) rash, anxiety, depression, sadness, and nervousness interfered the most with their daily lives; and, (d) that the frequency of occurrence of the symptoms of pain, itching, dizziness, taste change, anxiety, sadness, and nervousness was higher compared to non-Hispanic whites. PR cancer patients are at increased risk for experiencing greater severity of cancer symptoms compared to non-Hispanic whites. But because the Hispanic oncology population does not always report symptoms, risking under-assessment and under-management, this suggests there may be a greater need for symptoms surveillance for this population.

Examining the role of social support and spirituality on the general health perceptions of Hispanic cancer survivors

OBJECTIVE

Although cancer survival rates continue to improve, overall disparities persist for ethnic minority survivors, who have a disproportionately high risk of experiencing poor quality of life, despite documented higher levels of self-reported spirituality. Yet little is known about the relationship between spirituality and social support and health outcomes among Hispanic survivors. This study examined (1) differences between Hispanic and non-Hispanic white survivors on health, social support, and spirituality and (2) the potential mediating roles of mental health and emotional distress on general health perceptions.

METHODS

We analyzed data (N = 7778) from the American Cancer Society's Study of Cancer Survivors-II, a national cross-sectional study of adult cancer survivors. Preliminary analysis compared sociodemographic and medical characteristics between the 2 groups to identify significant covariates. Structural equation modeling assessed whether mental health and emotional distress mediate the impact of social support and spirituality on Hispanics' general health perceptions.

RESULTS

Overall, 693 survivors were Hispanic and 7085 were non-Hispanic whites. Hispanics reported poorer health and were more likely to have comorbid conditions such as diabetes and depression compared with non-Hispanic whites. Structural equation modeling indicated that the impact of spirituality on general health perceptions was fully mediated through mental health. Emotional distress did not have a direct effect on general health perceptions nor did it mediate effects of spirituality and social support and on general health perceptions. There was a mediated effect of social support on general health perceptions.

CONCLUSIONS

Spirituality is an important factor in the health of Hispanic survivors. Future studies should explore the impact and effectiveness of spiritual interventions and the beneficial effect for mental health on general health perceptions.

Exploring Racial Differences in Patient Centeredness of Care (PCC) During Breast Cancer (BC) Chemotherapy Clinical Visits

OBJECTIVES

The communication patterns between clinician and patient, described as the patient centeredness of care (PCC), may be a critically important etiology of breast cancer (BC) racial disparity. The purpose of this prospective, comparative pilot study was to qualitatively explore and code for PCC during the clinical visit of women undergoing BC chemotherapy and compare by race.

METHODS

Age-matched Black and White women were recruited. Audio recordings of clinical visits conducted prior to any cycle (except first) chemotherapy infusion were obtained and transcribed. Transcripts were blindly reviewed by three independent coders assigning PCC scores, ranging from 1 to 5, with lower scores indicating better PCC. Consensus was reached among reviewers via discussion.

RESULTS

Dyads consisted of five Black (mean age 47) and five White (mean age 45) women undergoing BC chemotherapy. Twenty-four recordings were analyzed, 13 White and 11 Black. For all 22 PCC items, the mean scores were worse for Black women with significant differences (compared by chi-square analysis) noted for 6/22 items (27%).

CONCLUSIONS

Qualitatively exploring clinician and patient communication patterns during the chemotherapy clinical visits informs the understanding of racial differences for symptom assessment, reporting, and management. These pilot findings inform future research exploring racial disparity in cancer treatment dose intensity.

Persistent Post-Mastectomy Pain: Risk Factors and Current Approaches to Treatment

Persistent Post-Mastectomy Pain (PPMP) is a common condition that can follow surgeries for breast cancer, the most common cancer in women. Because of the frequency of PPMP and its potential severity, it has received increasing research attention. This manuscript reviews the recent research literature, beginning with a brief history and then relevant medical, surgical, demographic, and psychosocial risk factors. Subsequently, social, psychological, and functional sequelae that have been linked to PPMPS are considered, as is research on current pharmacological, psychological, and rehabilitative approaches to treatment. The review concludes with a discussion of directions for future research and treatment that might reduce the incidence and impact of PPMP on breast cancer survivors. PERSPECTIVE: This article describes current research literature involving mechanisms, risks, and treatments related to persistent post-mastectomy pain. Implications of research findings also are discussed for pre- and post-surgical approaches to pain management, current treatments, and promising research directions.

Racial differences in symptom management experiences during breast cancer treatment

PURPOSE

Racial disparities in cancer treatment-related symptom burden are well documented and linked to worse treatment outcomes. Yet, little is known about racial differences in patients' treatment-related symptom management experiences. Such understanding can help identify modifiable drivers of symptom burden inequities. As part of the Cancer Health Accountability for Managing Pain and Symptoms (CHAMPS) study, we examined racial differences in symptom management experiences among Black and White breast cancer survivors (BCS).

METHODS

We conducted six focus groups (n = 3 Black BCS groups; n = 3 White BCS groups) with 22 stages I-IV BCS at two cancer centers. Focus groups were audio-recorded and transcribed verbatim. Based on key community-based participatory research principles, our community/academic/medical partner team facilitated focus groups and conducted qualitative analyses.

RESULTS

All BCS described positive symptom management experiences, including clinician attentiveness to symptom concerns and clinician recommendations for pre-emptively managing symptoms. Black BCS commonly reported having to advocate for themselves to get information about treatment-related symptoms, and indicated dissatisfaction regarding clinicians' failure to disclose potential treatment-related symptoms or provide medications to address symptoms. White BCS often described dissatisfaction regarding inadequate information on symptom origins and clinicians' failure to offer reassurance.

CONCLUSIONS

This study elucidates opportunities for future research aimed at improving equity for cancer treatment-related symptom management. For Black women, warnings about anticipated symptoms and treatment for ongoing symptoms were particular areas of concern. Routine symptom assessment for all women, as well as clinicians' management of symptoms for racially diverse cancer patients, need to be more thoroughly studied and addressed.

A Community-Based Approach to Assessing the Physical, Emotional, and Health Status of Hispanic Breast Cancer Survivors

INTRODUCTION

Latina breast cancer survivors in the United States face disproportionate risk for poorer quality of life and physical health, as well as greater emotional distress.

METHOD

A cross-sectional survey was conducted to describe the physical, emotional, and general health status of 135 Latina breast cancer survivors served by a community-based program.

RESULTS

Of the 135 surveys sent, 48 survivors responded. Of those who responded, time since diagnosis ranged from 0 to 24 years ( M = 4.37; SD = 5.54); and 45.9% of the women rated physical health as poor or fair. Fatigue prevalence was high, with 60.5% reporting fatigue as moderate or severe. Nearly 80% reported having pain (score >0); 38.3% reported pain was moderate or severe. The women reported mild levels of anxiety and depression but high levels of stress ( M = 4.14; SD = 3.02).

CONCLUSIONS

Latina breast cancer survivors could benefit from interventions focused on commonly shared problems while tailoring specific interventions for subsets with more severe symptoms.

Interventions to Improve Quality of Life, Well-Being, and Care in Latino Cancer Survivors: A Systematic Literature Review

PROBLEM IDENTIFICATION

Hispanic/Latino cancer survivors are at risk for increased psychosocial burden, in part, because of lower survival rates and lower quality of life (QOL) when compared with other populations. Despite this, very few interventional studies have been conducted in this population. This review synthesizes research on supportive care interventions to improve QOL, well-being, and cancer care in Hispanic/Latino cancer survivors.
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LITERATURE SEARCH

Data sources included MEDLINE®, CINAHL®, and PsycINFO®. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guideline was employed.
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DATA EVALUATION

This review includes studies conducted with cancer survivors from diagnosis to survivorship and addresses any type of intervention for Hispanic/Latino survivors of all cancer types and sites. Studies were written in English and had a sample of at least 25% Hispanics/Latinos. Key study attributes were extracted and tabled.
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SYNTHESIS

Of the 15 studies reviewed, types of interventions included were psychosocial (n = 6), educational (n = 4), exercise/diet (n = 4), and navigational (n = 1). Most studies were pilot and feasibility studies, and nine were randomized, controlled trials (RCTs).
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CONCLUSIONS

Interventional studies for Hispanic/Latino cancer survivors are at the very early stages of scientific development and are feasible and accepted by the Hispanic/Latino population. Culturally relevant psychosocial support and educational, exercise, and navigational interventions are beneficial for this population.
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IMPLICATIONS FOR RESEARCH

To advance the science, as the Hispanic/Latino population rapidly increases, a great need exists for additional research in this area. A theoretical basis for interventions is needed for development of additional research. Efficacy of culturally relevant supportive care interventions needs to be tested through RCTs, replication, and multisite studies. A need exists for these developing interventions to be translated into practice to improve QOL and well-being for Hispanic/Latino cancer survivors.

Occupational Engagement in Low-Income Latina Breast Cancer Survivors

OBJECTIVE

This qualitative study examined the experience of occupational engagement in low-income Latina breast cancer survivors and suggests the potential for occupational therapy practitioners to improve health outcomes in this vulnerable and underserved population.

METHOD

Semistructured interviews were conducted with 9 participants. Inductive analysis was used to code for themes and patterns related to occupational engagement and quality of life (QOL).

RESULTS

Lack of occupational engagement negatively affected QOL, but participation in occupations such as religious activity and caregiving promoted well-being. Financial concerns and communication barriers decreased QOL.

CONCLUSION

Breast cancer can have a negative impact on occupational engagement in low-income Latina breast cancer survivors; however, some occupations may increase QOL. Socioeconomic status and cultural values influence occupational engagement and QOL. Occupational therapy practitioners can improve health outcomes in this population through awareness of relevant sociocultural factors and attention to appropriate patient communication.