Understanding racial/ethnic differences in breast cancer-related physical well-being: the role of patient-provider interactions

Racial equity in and through medical interaction scholarship: A scoping review

OBJECTIVE

We conducted a systematic scoping review to characterize the landscape of communication scholarship within racial health equity in and through the patient-provider interaction.

METHODS

We employed three waves of data collection to identify relevant articles (N = 454) about racial equity within provider-patient interactions. We iteratively developed a codebook concerning article characteristics, coding for journal names, data source, descriptive characteristics for the study samples, and presence of theory and equity in sections of the manuscripts.

RESULTS

This search identified studies (N = 206) that were published in 76 peer-reviewed scientific journals. The majority of studies reported primary data analyses and used survey and interview methodology. Many studies examined participants as patients generally rather than in reference to particular health conditions. Among those with a specific health condition, the largest proportion focused on cancer control. Very few studies included samples with Native American and Pacific Island heritage. Most studies included cisgender men and/or women, but none included transgender men or women. The vast majority of research focused on the patient experience; few centered on providers' and caregivers' experiences. The body of scholarship was largely atheoretical; the most frequently noted constructs were patient-provider communication (including patient-centered communication and patient-centered care), implicit/explicit racial bias, shared decision-making. There was wide variation in the extent to which equity was woven through the manuscripts. Equity is typically mentioned in the literature review, and racial identity in the sample may serve as a marker of racialized experiences.

CONCLUSION

This study demonstrates the need for the development of theory that elevates the centrality of health equity to attend to the bi- or multi-directional flow of communication that shapes the quality of these interactions.

PRACTICE IMPLICATIONS

These insights can serve as a strong foundation for the development of interventions to address equity in clinical interactions.

Culturally appropriate patient-provider communication methods for Black women with breast cancer: a scoping review

PURPOSE

Black women with breast cancer experience a 40% higher mortality rate compared to white women, and this disparity may be influenced by suboptimal patient-provider communication. Evidence has suggested that Black patients with breast cancer have unique informational needs, yet few studies focus on patient-provider communication for this community. The aim of this scoping review was to identify best practices for communicating breast cancer diagnosis and treatment options with Black women.

METHODS

Following PRISMA-ScR, a search strategy was developed and implemented in 4 databases and grey literature. Coders achieved reliability and independently screened articles by title and abstract, then full-text. Articles were included if they studied Black patients with breast cancer and reported on patient-provider communication. Outcomes of interest included patients' appraisals of their communication, and associated health outcomes.

RESULTS

A final sample of 27 studies were included. Black patients' positive appraisal of their providers was based on their interactions, rather than providers' perceived expertise. Patients had negative appraisal of communication when they received limited information regarding their treatment plan, side-effects, or possibility of disease recurrence. High-quality communication was associated with adherence to adjuvant therapy; low-quality communication was associated with treatment discontinuation or delay, and lower self-rating of physical well-being.

CONCLUSION

Patients' perceptions of their quality of communication with their healthcare providers was associated with their treatment decisions and health outcomes. Future research is needed to test interventions that optimize communication between Black breast cancer patients and their providers, including discussing navigating barriers to care.

Shared decision making in routine oncology appointments with Black patients with lung cancer

PURPOSE

Poor clinician-patient communication may contribute to racialized inequities in cancer symptom burden. Shared decision-making (SDM) enhances clinician-patient communication, and could contribute to health equity for Black patients with cancer. However, research on SDM is limited for Black patients with cancer.

METHODS

This multi-method longitudinal observational study examined SDM during routine oncology follow-ups for patients with advanced lung cancer. We analyzed SDM reported by clinicians (n = 6), self-identified Black patients with lung cancer (n = 30), and coded from patient visit recordings (n = 20). We described the symptom management conversations, and examined how SDM related to patient satisfaction and symptom severity with two-sided correlations.

RESULTS

Most patients (85.0%) asked questions during appointments and discussed cancer-related symptoms (95.0%), most commonly pain/neuropathy (65.0%). Though coded SDM during symptom discussions was low, providers and patients reported high levels of SDM. Coded SDM did not statistically significantly correlate with post-appointment satisfaction (r = -.01, p > .10) or symptom burden (r = .04, p > .10). However, patient-reported SDM did relate to post-appointment satisfaction (r = .72, p = .08) and symptom burden (r = .35, p = .08) one month later.

CONCLUSIONS

Through detailed multi-method analysis, we found that coded SDM did not correspond to patient and physician-reported SDM during routine oncology appointments. Patient-reported SDM correlated to several better physical and mental health outcomes as well as overall satisfaction a month later. Our findings highlight the complexities of clinician-patient communication and the importance of studying these processes for Black patients with cancer. Future research should develop culturally-relevant methods of assessing SDM with Black patients and understand Black patients' communication needs.

Race and ethnicity and self-reported racial/ethnic discrimination in breast cancer patient interactions with providers in the Pathways Study

PURPOSE

To examine the association of race and ethnicity groups with self-reported racial/ethnic discrimination in patient-provider interactions during the diagnosis and treatment for breast cancer.

METHODS

We analyzed data from the Pathways Study, a prospective cohort of women diagnosed with breast cancer from 2006-2013 in the Kaiser Permanente Northern California Health Care System. Racial/ethnic discrimination in patient-provider interactions was assessed with two questions from the Interpersonal Processes of Care survey at baseline and 6-months and 24-months post-diagnosis. Logistic regression was performed to compare women who self-identified as racial or ethnic minorities with Non-Hispanic White (NHW) women. Covariates included age at diagnosis, country of origin, education level, income, marital status, and medical provider's race/ethnicity.

RESULTS

Our sample included 1836 participants: 1350 NHW women and 486 women (87 Black, 208 Asian American, 153 Hispanic, 38 American Indian/Alaskan Native/Pacific Islander [AIANPI]) from racial or ethnic minority groups. In multivariate analysis, minority women were more likely to report racial/ethnic discrimination in patient-provider interactions than NHW women (adjusted odds ratio [aOR]: 4.73; 95% confidence interval [CI] 3.45-6.50). Specifically, Black women were most likely to self-report racial/ethnic discrimination in patient-provider interactions (aOR: 9.65; 95% CI 5.92-15.70), followed by Asian (aOR: 5.39; 95% CI 3.46-8.40), Hispanic (aOR: 2.55; 95% CI 1.54-4.14), and AIANPI (aOR: 1.74; 95% CI 0.58-4.25) women, compared with NHW women.

CONCLUSION

Racial/ethnic discrimination was more likely self-reported from minority women diagnosed with breast cancer. Additional studies are needed to understand the mechanisms and impact of racial/ethnic discrimination in patient-provider interactions on disparities.

Examining recollections of Black women with breast cancer who participated in clinical trials: A grounded practical theory study of patient-provider communication

The presence of strong barriers to research participation for Black women is indisputable. However, existing evidence supports the possibility of equal levels of participation among members of minoritized populations in past breast cancer (BC) clinical trials (CTs), demonstrating that while these participation barriers undoubtedly exist but are not insurmountable. This work aims to investigate patient-provider conversations to try to illuminate how providers can better engage Black women in communication that will positively influence their perceptions of breast cancer clinical trial participation. Fourteen women (N = 14) who self-identified as Black, Black American, or African American and who had previously or were currently involved in a BC CT participated in the grounded theory-guided study. These women were recruited through emails and social media platforms and interviewed regarding their communication with their medical providers and their pathway to CT participation. Findings revealed three primary categories: 1) participants reported the following provider types as most effective communicators: attentive, matter-of-fact, warm, or above-and beyond; 2) participants frequently received no information about CTs from their providers; and 3) cultural constructs including faith, word of mouth, and storytelling are important to the recruitment of these Black women to BC CTs. Our findings demonstrate the importance of healthcare providers adjusting their communication to meet one of the preferred provider archetypes of communication styles, understanding and incorporating cultural constructs in their communication, and providing information about BC CTs to Black women. Through improved patient-provider communication, healthcare providers may positively influence Black women's perceptions of and participation in BC CTs.

How Do Patients and Otolaryngologists Define Dizziness?

OBJECTIVE

To assess for differences in how patients and otolaryngologists define the term dizziness.

METHODS

Between June 2020 and December 2022, otolaryngology clinicians and consecutive patients at 5 academic otolaryngology institutions across the United States were asked to define the term "dizziness" by completing a semantics-based questionnaire containing 20 common descriptors of the term within 5 symptom domains (imbalance-related, lightheadedness-related, motion-related, vision-related, and pain-related). The primary outcome was differences between patient and clinician perceptions of dizzy-related symptoms. Secondary outcomes included differences among patient populations by geographic location.

RESULTS

Responses were obtained from 271 patients and 31 otolaryngologists. Patients and otolaryngologists selected 7.7 ± 3.5 and 7.1 ± 4.3 symptoms, respectively. Most patients (266, 98.2%) selected from more than 1 domain and 17 (6.3%) patients identified symptoms from all 5 domains. Patients and clinicians were equally likely to define dizziness using terms from the imbalance (difference, -2.3%; 95% CI, -13.2%, 8.6%), lightheadedness (-14.1%; -29.2%, 1.0%), and motion-related (9.4; -0.3, 19.1) domains. Patients were more likely to include terms from the vision-related (23.6%; 10.5, 36.8) and pain-related (18.2%; 10.3%, 26.1%) domains. There were minor variations in how patients defined dizziness based on geographic location.

CONCLUSIONS

Patients and otolaryngologists commonly described dizziness using symptoms related to imbalance, lightheadedness, and motion. Patients were more likely to use vision or pain-related terms. Understanding of these semantic differences may enable more effective patient-clinician communication.

Are you congested? A comparison of definitions between otolaryngologists and their patients

OBJECTIVE

To assess for differences of intended meaning in the description of congestion-related symptoms among otolaryngology patients and clinicians.

MATERIALS AND METHODS

Between June 2020 and October 2022, a questionnaire consisting of 16 common descriptors of congestion-related symptoms within four domains (obstructive-related, pressure-related, mucus-related, and other symptoms) was completed by patients and otolaryngologists at five tertiary otolaryngology practices. The primary outcome was to assess differences in patient and clinician perceptions of congestion-related symptoms. Differences based on geographic location was a secondary outcome.

RESULTS

A total of 349 patients and 40 otolaryngologists participated. Patients selected a median of 6.8 (standard deviation [SD] 3.0) terms compared with 4.0 (SD 1.6) terms for otolaryngologists (p < 0.001). Otolaryngologists were more likely to select obstruction-related symptoms (difference 6.3%; 95% confidence interval [CI] 3.8%, 8.9%). Patients were more likely to describe congestion using pressure-related (-43.7%; -58.9%, -28.5%), mucus-related (-43.5%; -59.3%, -27.8%), and other symptoms (-44.2; -51.3%, -37.1%) compared with otolaryngologists. There were no significant differences identified based on geographic location with regard to symptom domains on multivariate analysis.

CONCLUSIONS

There are differences between otolaryngologists and their patients in the interpretation of the symptoms of congestion. Clinicians tended to have a narrower interpretation of congestion that was limited to the obstruction-related symptom domain, while patients defined congestion more broadly. This has important counseling and communication implications for the clinician.

Mediational roles of stress-coping factors in the relationship between patient-perceived communication quality and physical functioning: racial difference between Chinese and Non-Hispanic White American breast cancer survivors

PURPOSE

The assumption that patient-provider communication may mediate patients' sense of control over cancer to affect health outcomes has limited evidence. This study examines whether patient-perceived cancer care communication quality (PPCQ) mediates stress appraisal and coping behavior, affecting physical functioning across different racial groups.

METHODS

Two hundred and twenty Chinese American and 216 non-Hispanic White (NHW) women (ages 28-80) with stage 0-III breast cancer, 1-5 years post-diagnosis, and without recurrence, enrolled and completed a cross-sectional telephone survey. Physical functioning was measured by the NIH-PROMIS short form. Validated measures of PPCQ, patients' evaluation of their socioeconomic well-being, stress appraisal (perceived severity and control), use of coping strategies, treatment-related symptoms, and comorbidities were also assessed. Path analyses were used to examine the mediation for each racial group.

RESULTS

Regardless of race, treatment-related symptoms, comorbidities, and socioeconomic well-being were all directly related to physical functioning (p < 0.05). The impact of PPCQ on physical functioning was mediated by perceived control in the Chinese American group (p < 0.05), but not in the NHW group. Perceived severity and coping were not mediators of physical functioning in either group.

CONCLUSIONS

The mediational pathway from PPCQ to perceived control to physical functioning in Chinese American survivors may be partially explained by their lower socioeconomic well-being and culturally valued conformity to physicians as a medical authority. These sociocultural dynamics reinforce the importance of cancer care communication. For NHW survivors, the impact of treatment-related symptoms and socioeconomic well-being on physical functioning outweighed their PPCQ and perceived control.

Associations between race/ethnicity and SEER-CAHPS patient care experiences among female Medicare beneficiaries with breast cancer

INTRODUCTION

We aimed to determine if racial/ethnic disparities exist in survivorship care patient experiences among older breast cancer survivors.

MATERIALS AND METHODS

Nineteen thousand seventeen female breast cancer survivors aged ≥65 at post-diagnosis survey contributed data via the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) and Centers for Medicare and Medicaid Services Consumer Assessment of Healthcare Providers & Systems (CAHPS) data linkage (2000-2019). Multivariable linear regression models were used to estimate adjusted beta (β) coefficients and standard error (SE) estimates for associations between race/ethnicity and survivorship care patient experiences.

RESULTS

Most women were non-Hispanic (NH)-White (78.1%; NH-Black [8.1%], NH-Asian [6.5%], Hispanic [6.2%]). On average, women reported 76.3 years (standard deviation [SD] = 7.14) at CAHPS survey and 6.10 years since primary diagnosis (SD = 3.51). Compared with NH-White survivors, NH-Black survivors reported lower mean scores for Getting Care Quickly (β = -5.17, SE = 0.69, p ≤0.001), Getting Needed Care (β = -1.72, SE = 0.63, p = 0.006), and Overall Care Ratings (β = -2.72, SE = 0.48, p ≤0.001), mirroring the results for NH-Asian survivors (Getting Care Quickly [β = -7.06, SE = 0.77, p ≤0.001], Getting Needed Care [β = -4.43, SE = 0.70, p ≤0.001], Physician Communication [β = -1.15, SE = 0.54, p = 0.03], Overall Care Rating [β = -2.32, SE = 0.53, p ≤0.001]). Findings among Hispanic survivors varied, where mean scores were lower for Getting Care Quickly (β = -2.83, SE = 0.79, p ≤0.001), Getting Needed Care (β = -2.43, SE = 0.70, p = 0.001), and Getting Needed Prescription Drug(s) (β = -1.47, SE = 0.64, p = 0.02), but were higher for Health Plan Rating (β = 2.66, SE = 0.55, p ≤0.001). Education, Medicare plan, and multimorbidity significantly modified various associations among NH-Black survivors, and education was a significant modifier among NH-Asian and Hispanic survivors.

DISCUSSION

We observed racial/ethnic disparities in the associations with survivorship care patient experience among NH-Black, Hispanic, and NH-Asian breast cancer survivors. Future research should examine the impact of education, Medicare plans, and multimorbidity on these associations.

Layperson Perception of Reflux-Related Symptoms

Objective

To assess for differences of intended meaning in the description of reflux-related symptoms among otolaryngology patients and clinicians.

Study Design

Cross-sectional survey-based study.

Setting

Five tertiary, academic otolaryngology practices.

Methods

Between June 2020 and July 2022, a questionnaire consisting of 20 common descriptors of reflux-related symptoms within four domains (throat-, chest-, stomach-, and sensory-related symptoms) was completed by patients. Attending otolaryngologists at five academic medical centers then completed the same survey. The primary outcome was to assess differences in patient and clinician perceptions of reflux-related symptoms. Differences based on geographic location was a secondary outcome.

Results

A total of 324 patients and 27 otolaryngologists participated. Patients selected a median of six terms compared with 10.5 for otolaryngologists (p < .001). Otolaryngologists were more likely to select sensory symptoms (difference: 35.8%; 95% confidence interval [CI]: 19.2%, 52.4%), throat-related symptoms (32.4%; 21.2, 43.6%), and chest-related symptoms (12.4%; 8.8, 15.9). Otolaryngologists and patients were equally likely to consider stomach symptoms as related to reflux (4.0%, -3.7%, 11.7%). No significant differences were identified based on geographic location.

Conclusion

There are differences between otolaryngologists and their patients in the interpretation of the symptoms of reflux. Patients tended to have a narrower interpretation of reflux with symptoms primarily limited to classic stomach-related symptoms, while clinicians tended to have a broader definition of reflux that included extra-esophageal manifestations of disease. This has important counseling implications for the clinician, as patients presenting with reflux symptoms may not comprehend the relationship of those symptoms to reflux disease.

Race Differences in Patient-Reported Symptoms during Chemotherapy among Women with Early-Stage Hormone Receptor-Positive Breast Cancer

BACKGROUND

Symptom burden differences may contribute to racial disparities in breast cancer survival. We compared symptom changes from before to during chemotherapy among women with breast cancer.

METHODS

This observational study followed a cohort of Black and White women diagnosed with Stage I-III, hormone receptor-positive breast cancer from a large cancer center in 2007 to 2015, and reported symptoms before and during chemotherapy. We identified patients who experienced a one-standard deviation (SD) increase in symptom burden after starting chemotherapy using four validated composite scores (General Physical Symptoms, Treatment Side Effects, Acute Distress, and Despair). Kitagawa-Blinder-Oaxaca decomposition was used to quantify race differences in symptom changes explained by baseline characteristics (sociodemographic, baseline scores, cancer stage) and first-line chemotherapy regimens.

RESULTS

Among 1,273 patients, Black women (n = 405, 31.8%) were more likely to report one-SD increase in General Physical Symptoms (55.6% vs. 48.2%, P = 0.015), Treatment Side Effects (74.0% vs. 63.4%, P < 0.001), and Acute Distress (27.4% vs. 20.0%, P = 0.010) than White women. Baseline characteristics and first-line chemotherapy regimens explained a large and significant proportion of the difference in Acute Distress changes (93.7%, P = 0.001), but not General Physical Symptoms (25.7%, P = 0.25) or Treatment Side Effects (16.4%, P = 0.28).

CONCLUSIONS

Black women with early-stage breast cancer were more likely to experience significant increases in physical and psychological symptom burden during chemotherapy. Most of the difference in physical symptom changes remained unexplained by baseline characteristics, which suggests inadequate symptom management among Black women.

IMPACT

Future studies should identify strategies to improve symptom management among Black women and reduce differences in symptom burden. See related commentary by Rosenzweig and Mazanec, p. 157.

What do we mean when we have a "sinus infection?"

INTRODUCTION

Sinus infections are a common reason patients seek medical care. However, the intended meaning of the term sinus infection among patients and otolaryngologists is incompletely understood.

METHODS

In this multi-institutional cross-sectional study, a semantics-based questionnaire was provided to consecutive patients presenting to otolaryngology clinics at six academic centers from June 2020 until May 2021. The primary outcome was respondent definitions for sinus infection from a list of 28 proposed terms covering six general categories. Secondary outcome measures included differences between geographic regions.

RESULTS

Responses were obtained from 560 patients (54% female, mean age 48.9 years) and 29 otolaryngologists (42% female, mean age 37.4 years). Patients and otolaryngologists selected a median of 10 and 11 terms, respectively, to define a sinus infection. Among patients the most frequently selected symptom categories were mucus (500, 89.3%), pressure/pain (480, 85.7%), and airflow (468, 83.6%). Compared to patients, clinicians selected with greater frequency the symptom categories of pressure/pain (14.3% difference; 95% CI, 7.6% to 22.5%), mucus (10.7% difference; 95% CI, 4.7% to 18.3%) and airflow (13.0% difference; 95% CI, 4.8% to 21.7%). Multiple categories were selected by 96% of patients and 100% of providers.

CONCLUSION

The definition of sinus infection appears variable for both patients and otolaryngologists, though patients appear to apply a broader range of symptoms to the term sinus infection. There were no pronounced geographic differences in the description of a sinus infection in this US sample population. Patients commonly described sinus infection in the context of pain-related symptoms. Appreciation of these semantic differences may enable more effective patient-clinician communication.

Multisite Quality Improvement Initiative to Identify and Address Racial Disparities and Deficiencies in Delivering Equitable, Patient-Centered Care for Multiple Myeloma-Exploring the Differences between Academic and Community Oncology Centers

Treatment of multiple myeloma (MM) is complex; however, with equal access to care, clinical outcomes for Black patients match those in other patient groups. To reveal and begin to address clinical practice barriers to equitable, patient-centered MM care, this quality improvement (QI) initiative assessed patient electronic medical records (EMRs) and surveyed patients and providers at two large hospital systems and four community-based practices. For the educational intervention, providers participated in feedback-focused grand rounds sessions to reflect on system barriers and develop action plans to improve MM care. EMR reviews revealed infrequent documentation of cytogenetics and disease staging at community-based practices compared to large hospital systems. In surveys, providers from each care setting reported different challenges in MM care. Notably, the goals of treatment for patients and providers aligned at community clinics while providers and patients from large hospital systems had discordant perspectives. However, providers in community settings underreported race-associated barriers to care and identified different factors impacting treatment decision-making than Black patients. Relative to pre-session responses, providers were more likely to report high confidence after the educational sessions in aligning treatment decisions with guidelines and clinical evidence and shared decision-making (SDM). This QI study identified discordant perceptions among providers at large hospital systems and community-based practices in providing quality MM care. Provider education yielded increased confidence in and commitment to patient-centered care.

The influence of racial-ethnic discrimination on women's health care outcomes: A mixed methods systematic review

BACKGROUND

In the U.S, a wide body of evidence has documented significant racial-ethnic disparities in women's health, and growing attention has focused on discrimination in health care as an underlying cause. Yet, there are knowledge gaps on how experiences of racial-ethnic health care discrimination across the life course influence the health of women of color. Our objective was to summarize existing literature on the impact of racial-ethnic health care discrimination on health care outcomes for women of color to examine multiple health care areas encountered across the life course.

METHODS

We systematically searched three databases and conducted study screening, data extraction, and quality assessment. We included quantitative and qualitative peer-reviewed literature on racial-ethnic health care discrimination towards women of color, focusing on studies that measured patient-perceived discrimination or differential treatment resulting from implicit provider bias. Results were summarized through narrative synthesis.

RESULTS

In total, 84 articles were included spanning different health care domains, such as perinatal and cancer care. Qualitative studies demonstrated the existence of racial-ethnic discrimination across care domains. Most quantitative studies reported a mix of positive and null associations between discrimination and adverse health care outcomes, with variation by the type of health care outcome. For instance, over three-quarters of the studies exploring associations between discrimination/bias and health care-related behaviors or beliefs found significant associations, whereas around two-thirds of the studies on clinical interventions found no significant associations.

CONCLUSIONS

This review shows substantial evidence on the existence of racial-ethnic discrimination in health care and its impact on women of color in the U.S. However, the evidence on how this phenomenon influences health care outcomes varies in strength by the type of outcome investigated. High-quality, targeted research using validated measures that is grounded in theoretical frameworks on racism is needed. This systematic review was registered [PROSPERO ID: CRD42018105448].

Barriers and facilitators to the engagement of physical activity among Black and African American cancer survivors during and after treatments

PURPOSE

To identify physical activity (PA) barriers and facilitators among Black and African American (Black/AA) cancer survivors that should be considered in future PA intervention development for this population.

METHODS

A community advisory board (CAB) of Black/AA cancer survivors and patient advocates guided in-depth qualitative interviews (n = 19) that were completed via telephone using a semi-structured interview guide. Interviews were transcribed verbatim, and data were analyzed using directed content analysis to detail a report of PA barriers and facilitators during and after cancer treatment. The CAB reviewed and interpreted these barriers and facilitators to identify the final results.

RESULTS

Survivors (n = 19) of nine different types of cancer completed interviews. PA barriers during cancer treatments included physical and psychological suffering. PA barriers after cancer treatments included social and environmental constraints (e.g., lack of access needed for PA, safety concerns, and competing priorities). PA facilitators both during and after cancer treatments included family support, faith, and support from other survivors. PA facilitators during treatment also included feeling better after doing PA, setting realistic and flexible goals, and gaining a sense of control of one's health by striving for PA goals.

CONCLUSIONS

To increase PA among Black/AA cancer survivors, PA interventions are needed that address structural barriers, include the role of faith, leverage family support, highlight the psychological benefits of PA, and use goal setting.

Racial Differences in Patient-Reported Symptoms and Adherence to Adjuvant Endocrine Therapy Among Women With Early-Stage, Hormone Receptor-Positive Breast Cancer

IMPORTANCE

Adjuvant endocrine therapy (AET) reduces breast cancer recurrence, but symptom burden is a key barrier to adherence. Black women have lower AET adherence and worse health outcomes than White women.

OBJECTIVE

To investigate the association between symptom burden and AET adherence differences by race.

DESIGN, SETTING, AND PARTICIPANTS

A retrospective cohort study using electronic health records with patient-reported data from a large cancer center in the US. Patients included Black and White women initiating AET therapy for early-stage breast cancer from August 2007 to December 2015 who were followed for 1 year from AET initiation. Sixty symptoms classified into 7 physical and 2 psychological symptom clusters were evaluated. For each cluster, the number of symptoms with moderate severity at baseline, and symptoms with 3-point or greater increases during AET were counted. Adherence was measured as the proportion of days covered by AET during the first-year follow-up. Multivariable regressions for patients' adherence adjusting for race, symptom measures, sociodemographic characteristics, and clinical characteristics were conducted. Kitagawa-Blinder-Oaxaca decomposition was used to quantify racial differences in adherence explained by symptoms and patient characteristics. Analyses were conducted from July 2021 to January 2022.

EXPOSURES

Physical and psychological symptoms at baseline and changes during AET.

RESULTS

Among 559 patients (168 [30.1%] Black and 391 [69.9%] White; mean [SD] age 65.5 [12.1] years), Black women received diagnoses younger (mean [SD] age at diagnosis, 58.7 [13.7] vs 68.5 [10.0] years old) than White women, with more advanced stages (30 Black participants [17.9%] vs 31 White participants [7.9%] had stage III disease at diagnosis), and lived in areas with fewer adults attaining high school education (mean [SD], 78.8% [7.8%] vs 84.0% [9.3%]). AET adherence in the first year was 78.8% for Black and 82.3% for White women. Black women reported higher severity in most symptom clusters than White women. Neuropsychological, vasomotor, musculoskeletal, cardiorespiratory, distress, and despair symptoms at baseline and increases during the follow-up were associated with 1.2 to 2.6 percentage points decreases in adherence, which corresponds to 4 to 9 missed days receiving AET in the first year. After adjusting for psychological symptoms, being Black was associated with 6.5 percentage points higher adherence than being White.

CONCLUSIONS AND RELEVANCE

In this cohort study, severe symptoms were associated with lower AET adherence. Black women had lower adherence rates that were explained by their higher symptom burden and baseline characteristics. These findings suggest that better symptom management with a focus on psychological symptoms could improve AET adherence and reduce racial disparities in cancer outcomes.

Developing an Education Pathway for Breast Cancer Patients Receiving Rapid Diagnostic Testing: Investigating Informational and Supportive Care Needs

Several studies have examined the informational needs of patients undergoing the breast diagnostic process where needs are highest during testing and prior to receiving a diagnosis. To aid in the development of an education pathway, we identified patient information needs. A multi-method approach to identify areas of need and to understand when and how information should be provided to patients was undertaken. The methods included an environmental scan of consumer health information, ethnographic observation of the patient clinical experience, key informant interviews, and a needs assessment survey. The data collected from the environmental scan, ethnography, and interviews were used to develop the items in the survey. The survey was developed around four domains: (1) Medical Procedures and Tests, (2) Understanding the Rapid Diagnostic Process, (3) Breast Cancer and Other Breast Conditions, and (4) Support and Coping. A total of 101 patients completed the survey. Mean importance scores were significantly different between domains of information need (p < .0001) and significantly higher for the 'Medical Procedures and Tests' domain compared with all others. Multivariate analysis suggested that participants with higher levels of education (p = .02) and a preference to speak English at home (p = .009) tended to rate the importance of 'Support and Coping' information lower than other participants. Information about medical procedures and tests are most important for the patients undergoing rapid diagnostic testing in our sample. Education materials that are tailored to patient needs should be provided to patients during this stage of the cancer journey to help meet informational needs.

Association between aspects of social support and health-related quality of life domains among African American and White breast cancer survivors

PURPOSE

Social support is associated with breast cancer survivors' health-related quality of life (HRQoL). More nuanced information is needed regarding aspects of social support associated with different HRQoL domains among diverse populations. We assessed the association between emotional/informational and tangible support and five HRQoL domains and evaluated race as an effect modifier.

METHODS

African American and White women (n = 545) diagnosed with hormone-receptor-positive breast cancer completed a survey that assessed sociodemographic, clinical, and psychosocial factors. We assessed bivariate relationships between emotional/informational and tangible support along with overall HRQoL and each HRQoL domain.We tested interactions between race and emotional/informational and tangible social support using linear regression.

RESULTS

The sample included African American (29%) and White (71%) breast cancer survivors. Emotional/informational social support had a statistically significant positive association with emotional well-being (β = .08, p = 0.005), social well-being (β = 0.36, p < 0.001), functional well-being (β = .22, p < .001), breast cancer concerns (β = .16, p = 0.002), and overall HRQoL (β = .83, p < .001). Similarly, tangible social support had a statistically significant positive association with emotional well-being (β = .14, p = 0.004), social well-being (β = .51, p < .001), functional well-being (β = .39, p < .001), and overall HRQoL (β = 1.27, p < .001). The interactions between race and social support were not statistically significant (p > 0.05).

CONCLUSIONS

Results underscore the importance of the different social support types among breast cancer survivors, regardless of survivors' race.

IMPLICATIONS FOR CANCER SURVIVORS

Population-based interventions can be standardized and disseminated to provide guidance on how to increase emotional/information and tangible support for all breast cancer survivors by caregivers, health providers, and communities.

"Nobody Will Tell You. You've Got to Ask!": An Examination of Patient-Provider Communication Needs and Preferences among Black and White Women with Early-Stage Breast Cancer

Patient-provider communication is a critical component of healthcare and is associated with treatment quality and outcomes for women with breast cancer. This qualitative study examines similarities and differences in patient perspectives of communication needs between Black and White breast cancer survivors. We conducted four focus groups (N = 28) involving women with early-stage breast cancer on adjuvant endocrine therapy (AET), stratified by race and length of time on AET (< 6 months and >6 months). Each group was moderated by a race-concordant moderator and analyzed by emergent themes. Participants expressed common patient-provider communication needs, namely increased sensitivity from oncologists during the initial cancer diagnosis, personalized information to facilitate treatment decisions, emotional support during the transition from active treatment to maintenance, and rapid provider responses to mobile app-based queries. Communication differences by race also emerged. Black women were less likely than White women to describe having their informational needs met. White women praised longstanding relationships with providers, while Black women shared personal stories of disempowered interactions and noted the importance of patient advocates. White women more often reported privacy concerns about technology use. Unlike White women, Black women reported willingness to discuss sensitive topics, both online and offline, but believed those discussions made their providers feel uncomfortable. Early-stage breast cancer patients on AET, regardless of race, have similar needs for patient-centered communication with their oncologists. However, Black women were more likely to report experiencing poorer communication with providers than White women, which may be improved by technology and advocates.

Brief Report: Hispanic Patients' Trajectory of Cancer Symptom Burden, Depression, Anxiety, and Quality of Life

Background: Anxiety and depression symptoms are known to increase cancer symptom burden, yet little is known about the longitudinal integrations of these among Hispanic/Latinx patients. The goal of this study was to explore the trajectory and longitudinal interactions among anxiety and depression, cancer symptom burden, and health-related quality of life in Hispanic/Latinx cancer patients undergoing chemotherapy. Methods: Baseline behavioral assessments were performed before starting chemotherapy. Follow-up behavioral assessments were performed at 3, 6, and 9 months after starting chemotherapy. Descriptive statistics, chi-square tests, Fisher’s exact tests, and Mann–Whitney tests explored associations among outcome variables. Adjusted multilevel mixed-effects linear regression models were also used to evaluate the association between HADS scores, follow-up visits, FACT—G scale, MDASI scale, and sociodemographic variables. Results: Increased cancer symptom burden was significantly related to changes in anxiety symptoms’ scores (adjusted β^ = 0.11 [95% CI: 0.02, 0.19]. Increased quality of life was significantly associated with decreased depression and anxiety symptoms (adjusted β^ = −0.33; 95% CI: −0.47, −0.18, and 0.38 adjusted β^= −0.38; 95% CI: −0.55, −0.20, respectively). Conclusions: Findings highlight the need to conduct periodic mental health screenings among cancer patients initiating cancer treatment.

Assessing Perceived Discrimination as Reported by Black and White Women Diagnosed with Breast Cancer

OBJECTIVE

Although a number of factors contribute to racial disparities in breast cancer outcomes, perceived discrimination in healthcare may be a key factor that hinders positive interactions and negatively impacts patient outcomes. The goals of our study were to (1) assess the prevalence of perceived discrimination as reported by breast cancer patients and (2) identify factors related to discrimination in women overall as well as by race.

DESIGN

This study is a secondary analysis of a larger study, "Narrowing the Gaps in Adjuvant Therapy," where a convenience sample of 359 women completed one telephone survey assessing sociodemographics, and attitudes and beliefs concerning breast cancer treatments and care. Chi-square analysis was used to assess the relationship of categorical variables with perceived discrimination, while the F-test was employed for continuous variables. Logistic regression determined predictors of perceived discrimination, a dichotomous variable (none vs. any).

RESULTS

A majority of women were Black (58%), privately insured (85%), and had at least a Bachelor's degree (48%). Discrimination was reported by 32.4% of women, with significantly more Black women reporting discrimination than White women. Insurance status, attitudes toward treatment, and distress factors were significantly related to perceived discrimination. In the logistic model, women who were less trusting of their providers (OR = 0.863 [0.751, 0.993], p = .021) and Black women (OR = 7.241 [0.751, 0.993], p = .039) were more likely to report incidences of discrimination.

CONCLUSIONS

Our findings suggest a need to understand Black survivor's experiences with healthcare. Similarly, future work must focus on identifying ways to improve provider trust amongst breast cancer survivors.

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.

Racial/Ethnic Disparities in All-Cause Mortality among Patients Diagnosed with Triple-Negative Breast Cancer

It is unclear whether racial/ethnic disparities in triple-negative breast cancer (TNBC) mortality remain after accounting for clinical characteristics, treatment, and access-to-care-related factors. In this study, women with a primary diagnosis of TNBC during 2010-2014 were identified from the National Cancer Database. Hazard ratios (HR) and 95% confidence intervals (CI) for 3- and 5-year all-cause mortality associated with race/ethnicity were estimated using Cox proportional hazards models with stepwise adjustments for age, clinical characteristics, treatment, and access-to-care-related factors. Of 78,708 patients, non-Hispanic (NH) black women had the lowest 3-year overall survival rates (79.4%), followed by NH-whites (83.1%), Hispanics (86.0%), and Asians (87.1%). After adjustment for clinical characteristics, NH-blacks had a 12% higher risk of dying 3 years post-diagnosis (HR, 1.12; 95% CI, 1.07-1.17), whereas Hispanics and Asians had a 24% (HR, 0.76; 95% CI, 0.70-0.83) and 17% (HR, 0.83; 95% CI, 0.73-0.94) lower risk than their NH-white counterparts. The black-white disparity became non-significant after combined adjustment for treatment and access-to-care-related factors (HR, 1.04; 95% CI, 0.99-1.09), whereas the white-Hispanic and white-Asian differences remained. Stratified analyses revealed that among women aged less than or equal to 50 with stage III cancer, the elevated risk among NH-blacks persisted (HR, 1.20; 95% CI, 1.04-1.39) after full adjustments. Similar results were seen for 5-year mortality. Overall, clinical characteristics, treatment, and access-to-care-related factors accounted for most of the white-black differences in all-cause mortality of TNBC but explained little about Hispanic- and Asian-white differences. SIGNIFICANCE: These findings highlight the need for equal healthcare to mitigate the black-white disparity and for investigations of contributors beyond healthcare for lower mortality among Asians and Hispanics.

Characterizing Pain Experiences: African American Patients With Multiple Myeloma Taking Around-the-Clock Opioids

BACKGROUND

Despite known disparities by race, studies to date have not focused on pain characterization among African American patients with multiple myeloma.

OBJECTIVES

This study aimed to characterize the pain experience, beliefs about pain and pain control, and additional symptoms among African American patients with multiple myeloma taking around-the-clock opioids.

METHODS

This study employed secondary analysis of baseline data from a completed longitudinal study of opioid adherence. Descriptive statistics were used to characterize the sample, pain experience, beliefs regarding pain and pain control, and related symptoms.

FINDINGS

Participants (N = 34) experienced everyday pain and additional symptoms, and half experienced depression. Pain management barriers included dislike of pills, fear of addiction, and bothersome side effects from pain and medication. Additional larger studies can incorporate multilevel factors contributing to high symptom burden.

Differences in the Intended Meaning of Congestion Between Patients and Clinicians

Importance

Disagreement in the presumed meaning of common medical terms may impair communication between patients and caregivers.

Objective

To clarify the intended meaning of the term congestion among otolaryngology clinic patients and to identify discrepancies in definitions between patients and otolaryngologists.

Design, Setting, and Participants

In this cross-sectional survey study from an otolaryngology clinic at an academic center, a semantics-based questionnaire was provided to consecutive new patients during intake for a clinical encounter from December 2016 through February 2017, and to 31 otolaryngologists and 28 nonotolaryngologist physicians in February 2018. Respondent definitions for congestion were selected from a list of 16 proposed terms covering 4 general categories.

Main Outcome and Measures

Symptom categories for term used to describe congestion by patients and clinicians.

Results

Among 226 patient respondents (133 female [58.8%]; mean [SD] age, 54 [15.6] years), the most commonly selected definitions for congestion were from the obstructive (199; 88.1%) and mucus-related (196; 86.7%) symptom categories. More than 1 general category was selected by 208 patients (92.0%), whereas 11 patients (4.9%) described congestion only in terms of mucus-related symptoms. Definitions were limited to upper respiratory tract symptoms by 83 (36.7%) patients and lower respiratory tract symptoms by 2 (0.9%) patients. Among 31 otolaryngologists, congestion was most frequently defined in terms of obstructive symptoms (difference, 11.9%; 95% CI, 7.4%-16.5%). In contrast, patients more often described congestion in terms of pressure-related (difference, 38.8%; 95% CI, 7.5%-70.1%) or mucus-related (difference, 51.2%; 95% CI, 22.6%-79.9%) symptoms. A total of 22 otolaryngologists (71.0%) defined congestion using 1 to 4 symptoms, compared with only 69 patients (30.5%).

Conclusions and Relevance

The definition of congestion appears to be highly variable and ambiguous for many patients. Moreover, the findings suggest that patients and otolaryngologists generally do not describe congestion using the same terms.

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.

Congruence of patient- and clinician-reported toxicity in women receiving chemotherapy for early breast cancer

BACKGROUND

The National Cancer Institute's Patient-Reported Outcomes Version of the Common Terminology Criteria for Adverse Events, collected alongside the clinician-reported Common Terminology Criteria for Adverse Events, enables comparisons of patient and clinician reports on treatment toxicity.

METHODS

In a multisite study of women receiving chemotherapy for early-stage breast cancer, symptom reports were collected on the same day from patients and their clinicians for 17 symptoms; their data were not shared with each other. The proportions of moderate, severe, or very severe patient-reported symptom severity were compared with the proportions of clinician-rated grade 2, 3, or 4 toxicity. Patient-clinician agreement was assessed via κ statistics. Chi-square tests investigated whether patient characteristics were associated with patient-clinician agreement.

RESULTS

Among 267 women, the median age was 58 years (range, 24-83 years), and 26% were nonwhite. There was moderate scoring agreement (κ = 0.413-0.570) for 53% of symptoms, fair agreement for 41% (κ = 0.220-0.378), and slight agreement for 6% (κ = 0.188). For example, patient-reported and clinician-rated percentages were 22% and 8% for severe or very severe fatigue, 41% and 46% for moderate fatigue, 32% and 39% for mild fatigue, and 6% and 7% for none. Clinician severity scores were lower for nonwhite patients in comparison with white patients for peripheral neuropathy, nausea, arthralgia, and dyspnea.

CONCLUSIONS

Although clinician reporting of symptoms is common practice in oncology, there is suboptimal agreement with the gold standard of patient self-reporting. These data provide further evidence supporting the integration of patient-reported outcomes into oncological clinical research and clinical practice to improve monitoring of symptoms as well as timely interventions for symptoms.

Opportunities to Improve Detection and Treatment of Depression Among Patients With Breast Cancer Treated in an Integrated Delivery System

CONTEXT

Patients with cancer commonly experience depression. If not addressed, depression can lead to reduced quality of life and survival.

OBJECTIVE

Given the introduction of national initiatives to improve management of psychiatric symptoms among patients with cancer, we examined patterns of depression detection and treatment over time, and with respect to patient characteristics.

METHODS

This cross-sectional study linked data from the Pathways Study, a prospective cohort study of women diagnosed with breast cancer at Kaiser Permanente Northern California between 2005 and 2013, with data from Kaiser Permanente Northern California's electronic medical record. Pathways participants eligible for this analysis had no known prior depression but reported depressive symptoms at baseline. We used modified Poisson regression to assess the association of cancer diagnosis year and other patient characteristics with receipt of a documented clinician response to depressive symptoms (depression diagnosis, mental health referral, or antidepressant prescription).

RESULTS

Of the 725 women in our sample, 34% received a clinician response to depression. We observed no statistically significant association of breast cancer diagnosis year with clinician response. Characteristics associated with clinician response included Asian race (adjusted risk ratio, Asian vs. white: 0.44, 95% CI: 0.29-0.68) and depression severity (adjusted risk ratio, mild-moderate vs. severe depression: 1.45, 95% CI: 1.11-1.88).

CONCLUSION

Most patients in our sample did not receive a clinician response to their study-reported depression, and rates of response do not appear to have improved over time. Asian women, and those with less severe depression, appeared to be at increased risk of having unmet mental health care needs.

Information visualizations of symptom information for patients and providers: a systematic review

Objective

To systematically synthesize the literature on information visualizations of symptoms included as National Institute of Nursing Research common data elements and designed for use by patients and/or healthcare providers.

Methods

We searched CINAHL, Engineering Village, PsycINFO, PubMed, ACM Digital Library, and IEEE Explore Digital Library to identify peer-reviewed studies published between 2007 and 2017. We evaluated the studies using the Mixed Methods Appraisal Tool (MMAT) and a visualization quality score, and organized evaluation findings according to the Health Information Technology Usability Evaluation Model.

Results

Eighteen studies met inclusion criteria. Ten of these addressed all MMAT items; 13 addressed all visualization quality items. Symptom visualizations focused on pain, fatigue, and sleep and were represented as graphs (n = 14), icons (n = 4), and virtual body maps (n = 2). Studies evaluated perceived ease of use (n = 13), perceived usefulness (n = 12), efficiency (n = 9), effectiveness (n = 5), preference (n = 6), and intent to use (n = 3). Few studies reported race/ethnicity or education level.

Conclusion

The small number of studies for each type of information visualization limit generalizable conclusions about optimal visualization approaches. User-centered participatory approaches for information visualization design and more sophisticated evaluation designs are needed to assess which visualization elements work best for which populations in which contexts.

A conceptual model of social networks and mechanisms of cancer mortality, and potential strategies to improve survival: an invited commentary

In this article, the importance of social factors for cancer survivorship has been theoretically considered and empirically studied. This commentary and Kroenke's narrative review highlight how social network theory and methods may innovatively expand this substantive body of work. First, we add to a new understanding of cancer survivorship through: (a) discussing the delineation and differences between multiple social factors of interest across existing conceptual models; (b) characterizing their relationships to each other and to cancer survivorship through a social network lens; and (c) overall, sharing terminology and strengthening connections within this diverse body of literature. Second, we note opportunities for future research in terms of (a) simultaneous measurement of multiple social factors at different levels and (b) adaptation of designs to leverage and measure the theorized mechanisms. This commentary describes how incorporation of social network research can optimize research, practice, and policy contributions regarding cancer survival and survivorship.