Black women who survive breast cancer face greater psychological distress

June 7, 2021
Negative mental health symptoms such as stress and intrusive thoughts may may affect Black breast cancer survivors more than others. (Unsplash/Vonecia Carswell)

Negative mental health symptoms such as stress and intrusive thoughts may may affect Black breast cancer survivors more than others. (Unsplash/Vonecia Carswell)

Compared with white women, the psychological distress incurred from having breast cancer disproportionately affects Black women who are considered early survivors of the disease, according to new research from The Ohio State University that is the first to compare distress-related trajectories across these groups from diagnosis to early survivorship. If this disparity is left unaddressed, Black female cancer survivors could experience worsening physical health and quality of life over the course of their recovery, the authors suggest.

Levels of negative mental health symptoms, such as stress and intrusive thoughts, were consistently high in Black women from the time of diagnosis until 18 months after completing treatment, while symptoms for white women gradually improved, the researchers explained in their paper, published May 27 in Psychoneuroendocrinology. This remained true even though Black patients did not report higher levels of pain or physical fatigue than the white patients in the sample. 

Annelise A. Madison, first author of the paper and a clinical psychology researcher at The Ohio State University, told The Academic Times that stress and depression symptoms correlate with our physiology, which creates a strong relationship between our physical and mental health. And studies have established that Black women who have survived breast cancer have greater morbidity rates than white women, as well as mortality rates that are up to 41% higher.

"Prior literature suggested that Black survivors have worse physical health outcomes than their white peers, but the literature was mixed as to whether they experienced more psychological distress throughout early survivorship," Madison said. "We wanted to add some clarity to these mixed findings."

Some studies have found that Black women showed worse mental health symptoms after surviving cancer, potentially due to "unmet supportive care needs, greater financial distress, and lower physical function," the authors noted in the paper. But other research has concluded that Black female cancer survivors have better mental health and quality of life than white women, driven by factors such as community support and religion.

These contradictory findings could be a result of issues with the studies' methods and data collection, Madison said, such as developing and testing psychological symptom measures only among white people and not adjusting for socioeconomic status when analyzing the data.

Madison and her co-researchers sought to address these problems by examining the psychological distress trajectories of both white and Black women who were diagnosed with breast cancer and underwent treatment. The study assessed the patients right after they were diagnosed, and then followed them through their treatment for a total of roughly two years. The researchers did so in order to "see change within an individual throughout early survivorship," Madison said.

"Distress comprises both psychological and physical symptoms, so we used a wide variety of self-report measures, including perceived stress, anxiety and depressive symptoms, cancer-related distress, fatigue and pain," the authors said in the paper.

The sample consisted of 163 white women and 32 Black women recruited from The Ohio State University cancer clinics. The research team performed secondary analyses of the data, which originated from a study run by Madison's colleague that investigated fatigue during early breast cancer survivorship. 

Just after being diagnosed, and prior to their cancer treatment, both groups of women expressed similar levels of cancer-related distress and intrusive cancer-related thoughts. But when they were assessed in the months following their treatment, mental health symptoms in white women had improved, while in Black women they had not. 

Madison said she and her colleagues found that Black breast cancer patients generally had "persistently elevated psychological distress compared to their white peers even 18 months after successful treatment."

Overall, Black women reported higher levels of anxiety and depressive symptoms, as well as mental fatigue, general fatigue, physical fatigue and pain, but the authors said these differences disappeared once they adjusted for socioeconomic and health-related factors. Yet the same was not true for higher levels of cancer-related distress, intrusive thoughts, avoidance, perceived stress, emotional fatigue and vigor among Black patients. The racial disparity persisted even after the team adjusted for factors such as health status, income and education.

"Of note, these differences emerged even though, in adjusted models, Black survivors did not report higher levels of pain or physical fatigue across time compared to white survivors, suggesting that the observed differences in psychological distress and emotional fatigue trajectories do not simply reflect disproportionate physical burden," the authors reported in the paper. 

While the research team acknowledged the need for larger samples of Black patients in future research, they also noted their study's strengths. These included the fact that all participants received treatment at the same cancer clinic, which the authors said may have helped to reduce treatment differences. And the present study established that greater disease severity or worse physical symptoms did not explain their findings regarding mental health symptoms.

"Although oncology clinics routinely screen for anxiety and depression, our results point to the need for administering more sensitive assessments of distress, which may be elevated even after treatment has ended — especially among Black survivors," Madison said. "Clinicians cannot assume that patients' distress will return to baseline after successful completion of treatment. Adequate assessment is critical to identify those in need of intervention, and timely intervention may improve not only psychological outcomes, but also potentially physical outcomes."

The authors recommended that cancer clinics screen for more symptoms of distress beyond anxiety and depression. They said that clinics should also continue to conduct these screenings after treatments have ended, which is not currently universally mandated. And to address high levels of distress among cancer patients, Madison suggested intervention strategies such as cognitive-behavioral therapy and mindfulness-based stress reduction.

"In sum, a cancer diagnosis and treatment are universally stressful, but may be even more so for women from a historically marginalized group who may experience a lack of control, fewer resources and discrimination throughout treatment and early survivorship," the authors said in the paper.

The study, "Distress trajectories in Black and white breast cancer survivors: from diagnosis to survivorship," published May 27 in Psychoneuroendocrinology, was authored by Annelise A. Madison, Juan Peng, M. Rosie Shrout, Megan E. Renna, Stephen P. Povoski, Adele M. Lipari, Doreen M. Agnese, William E. Carson, William B. Malarkey, and Janice K. Kiecolt-Glaser, The Ohio State University; and Catherine M. Alfano, Northwell Health Cancer Institute.

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