Differences in psychosocial stressors between black and white cancer patients

The present study is the first of its kind to compare the individual stressors identified through psychosocial distress screening between black and white cancer patients. In our sample, 304 of 933 patients (32%) reported high distress, with a total score of ≥4. Previous research on overall distress difference across race/ethnicity is mixed. VanHoose and colleagues found no difference in overall distress between racial groups,¹⁵ Alcala and colleagues found higher overall distress in black patients with cancer compared with white patients with cancer,⁹ and Culver and colleagues found black women with breast cancer had lower overall distress compared with white women.¹¹ We found no difference in the presence of high distress between black and white patients at our cancer center in either crude or adjusted analysis. Differences in overall distress across studies may be owing to the timing of screening. Given that overall distress may vary across time^16,17 and there is no current information on whether temporal variations in distress differ by race, it is possible that the time of distress assessment may influence demonstrated differences between racial groups. For example, if different stressors affect black and white women differentially, and those stressors are associated with different points across the cancer continuum, then we might see that the magnitude of racial differences in overall stress are time dependent. Alcala and colleagues examined any cancer diagnosis across the lifespan, whereas Culver and colleagues examined multiple time points across treatment for a small group of breast cancer patients. Badr and colleagues, in a sample of head and neck cancer patients, found that distress increased across the course of treatment;¹⁸ however they did not examine variations in type of stressors related to overall distress, nor did they examine racial differences in distress. Differences in results may also be the result of differences in measurement of distress. Culver and colleagues did not examine distress using the NCCN distress thermometer, rather psychological distress was measured by a scale rating a series of “mood-descriptive adjectives” (p. 497).¹¹ Alcala used the K-6 as a measure of psychological distress;⁹ therefore, demonstrated differences in overall distress between white and black women may vary across studies because of differences in measurement of the underlying distress variable. The lack of racial differences in overall distress in our study is consistent with the findings of VanHoose and colleagues,¹⁵ who also examined distress near the start of treatment and also used the NCCN distress thermometer as the measure of psychosocial distress.

We did find differences in the individual stressors between racial groups, indicating that the source of distress does vary between black and white cancer patients. Black patients more frequently reported distress secondary to housing, loss of interest and their ability to have children than did white patients. By comparison, white patients more frequently reported distress secondary to nervousness and treatment decisions than black patients. Identified differences in individual stressors may be attributable to sociocultural differences or differences in external support. It is also possible that black patients are more likely to willingly report distress related to nonpsychological factors, whereas white patients are more willing to report factors, such as nervousness, that are related to psychological disorders. Although it has been suggested that black cancer patients have more concerns about finances and work than do white cancer patients,¹⁹ we did not identify a statistically significant difference in child care, insurance or financial issues, transportation, work, or school between these 2 cohorts. This may be because the psychosocial distress screening score included in this study was performed at the time of initial diagnosis, and not further into their prescribed treatment at which point the financial worries may be more realized. Psychosocial screening scores obtained at subsequent visits were not included in the analysis because they are not routinely collected as part of clinical care in the center where this study took place. Furthermore, it is impossible to identify where a specific patient is in their treatment regimen based on their demographic data or subsequent distress scores in our data extraction tool. Further investigation into the sources of distress at different time points along the continuum of care may shed more light on this topic.
 

Limitations

There are several limitations to this study. First, the method of data extraction from an electronic medical record report limited the capacity to explore possible differences between the patients in our sample, such as insurance status, level of education, available social support, current employment status, stage of disease, overall prognosis and prescribed treatment regimen.

Second, there were likely patients who either did not complete a psychosocial distress screening tool or whose data were not entered into the electronic medical record for inclusion in the analysis. The present study period took place during the implementation of the NCCN tool at the center. Although the policy was to screen all new patients as part of routine care; not all patients seen at the center received the NCCN screening tool at their first visit. Owing to the mechanisms for data entry and abstraction, only information from the patients who had a completed form was able to be accessed for this study, thus a statistical comparison between those who did and did not receive the NCCN tool cannot be made. During the timeframe for this study, the head and neck, breast, genitourinary, and hematologic services completed proportionally more NCCN screening of new patients than other services in the center. This is reflected in the distributional breakdown of cancer in the overall sample of this study. It is possible that the results are more representative of differences between black and white cancer patients in the services that were more likely to properly implement NCCN screening.

Third, our patient population was derived from an urban, academic medical center and the results may not be generalizable to other patient populations.

Fourth, the NCCN distress thermometer is a single-item rating of overall global distress that is not intended to be a diagnostic indicator of psychological comorbidity and, therefore, does not distinguish between common psychological diagnoses such as depression or anxiety. However, the usefulness of the tool is to provide an impetus for referral to services that may then encompass the evaluation and diagnosis of particular psychological conditions. Further, the distress thermometer tool is designed to identify stress relating to the social aspects of cancer diagnosis and treatment and is not limited to psychological distress alone.