Integration of Social Determinants in Breast Cancer Treatment for African American Women

Running head: SOCIAL DETERMINANTS IN BREAST CANCER CARE 1

Integration of Social Determinants in Breast Cancer Treatment for

African American Women

Daryl A. Mangosing

Berea College

SOCIAL DETERMINANTS IN BREAST CANCER CARE 2

Abstract

African American women within the United States continue to have

the highest breast cancer mortality rate despite higher incidence

in Caucasian women. This racial disparity is attributed to

unaddressed factors such as lower socioeconomic status, lesser

utilization of medical services, and lower screening rates. The

present study investigates social determinants (socioeconomic

status, cultural beliefs and attitudes, psychosocial perceptions,

and community/social support) influencing adherence and

effectiveness in ongoing treatment. The study utilizes a

randomized control trial design with a pre-test/post-test and

time series component. A pilot intervention consisting of four

phases is assigned to the experimental group in addition to

conventional biomedical treatment; the comparison group only

receives the latter. Subjects include African American women who

are 18 or older, diagnosed with invasive breast cancer within the

past six months, and are residing in minority, urban, and

socioeconomically disadvantaged areas; sampling is conducted via

probability multistage clustering. Health-related quality of life

(HR QoL) will be measured through the European Organization for


Research and Treatment of Quality of Life Questionnaire (EQRTC

QLQ-C30) and the Quality of Life in Adult Cancer Survivors

(QLACS) questionnaire. Correlations between type of intervention

and the biological stage of breast cancer, HR QoL and

survivorship will then be generated. Findings within this report

will be integrated into a theoretical social framework aimed

towards optimizing cancer care. Nursing implications entail

enhancing patient-physician communication, establishing the role

of “navigator” from oncology nurses, providing psychosocial

assessment and intervention, and encouraging engagement in breast

cancer support groups.


Integration of Social Determinants in Breast Cancer Treatment for

African American Women

Mortality rates of breast cancer among women living within

the United States have fallen due to increased awareness and

education, the ban of carcinogenic agents, and improved health

care delivery. However, “Unique circumstances evident within

different populations may confer risk or protection against poor

outcomes” (Shelby et al., 2008). Studies have determined that,

although Caucasian women have the highest incidence rate, African

American women continue to have the highest breast cancer

mortality rate (Conway-Phillips & Millon-Underwood, 2009;

Phillips & Cohen, 2011; Royak-Schaler et al., 2008; Underwood,

Richards, Bradley, & Robertson, 2008). Unaddressed factors

continue to influence the behavior of African American women in

regards to screening and treatment. These include, but are not

limited to, lower socioeconomic status, less utilization of

medical services, higher incidence of comorbidities, lower

screening rates, and unfavorable tumor biology (Royak-Schaler et

al., 2008).


This study will investigate the social determinants of

breast cancer treatment adherence and the effectiveness thereof

among African American women within the U.S. The exploration of

the relationship amongst these factors urgently call for

improving health outcomes, thus instating a significant objective

for this population as their higher mortality rates continue to

persist. In addition to socioeconomic status, social factors that

will be examined specifically comprise cultural beliefs and

attitudes, psychosocial perceptions, and community/social

support. The findings within existing literature along with this

prospective report may then serve as a transcultural and

psychosocial framework for addressing this health disparity by

individual and community interventions, ultimately optimizing

cancer care for vulnerable populations. Otherwise, “If we are not

providing cancer care to all of our community, we are not able to

offer clinical research advances and studies to all patients

equally” (Lally, 2008).

Initial Literature Search Process

Database Search Parameters for Study Selection


Journals were retrieved from Academic Search Premier, the

Cumulative Index to Nursing and Allied Health (CINAHL), PsycINFO,

and Education Research Complete. Searches within these databases

were based on the key terms: “breast cancer,” African American

women,” “screening,” and “treatment.” Studies were included based

on the following parameters: published between January 2008

through January 2013, peer-reviewed, subjects being of the female

sex, and the population identified as exclusively African

American women or inclusive thereof. After the conducting

searches with the aforementioned criteria, included for review

were eight quantitative studies, five qualitative studies, one

journal editorial, and one comprehensive review. Either the

exploration of significant factors or the outcomes of

interventions were reported in order to characterize or address

the screening behaviors or adherence to treatment.

Themes of Current Literature and Objective of Current Study

Four relevant themes emerged from the review of literature.

These included reports on the African American racial disparity

and the influence of socioeconomic status, cultural attitudes and

beliefs, psychosocial and emotional perceptions, and the role of


the community and social support. Although majority of these

studies focus specifically on either screening or treatment of

breast cancer, the interrelationship between the two is

underdeveloped despite the likelihood that they practically share

the same themes where one is secondary prevention and the other

is tertiary prevention. This connection will be the central in

understanding the merging of social determinants contributing to

screening behavior and, for the purpose of this study, treatment

adherence and effectiveness into one multi-factorial, contextual

framework that will abate this health inequity in our diverse

population based on evidence-based practice.

Research Question and Hypothesis

Although the survival rate of African American women (AAW)

is generally attributed to a later stage of breast cancer due to

delayed screening and therefore ineffective treatment, research

has revealed that worse outcomes continue to emerge among women

of color even when compared to whites with the same stage of the

disease (Kasper & Ferguson, 2000). In order to investigate this

finding further, the current study presents the following

question: “Does a breast cancer intervention program with an


integrated social-determinant framework increase the

effectiveness of treatment compared to a traditional biomedical-

model for AAW?” The intervention will be designed to address the

following social components and themes: socioeconomic status

(SES), cultural attitudes and beliefs, psychosocial perceptions,

and community/social support. The following hypothesis is that

the application of a pilot socially integrated intervention to

combat the progression of invasive breast cancer in AAW would

help promote positive outcomes that lead to a better prognosis,

quality of life, and survivorship. It will be the goal of this

study, consequently, to address the fact that “There are

insufficient studies to determine whether worse survival rates

reflect differences in medical care, environmental exposures,

genetics, or other characteristics” (Kasper & Ferguson, 2000).

Review of Literature

Similarities in Themes and General Findings

Kasper and Ferguson (2000) raise the issue of how social

inequality and the status of being female and a racial minority,

such as AAW, are more likely to lead to a lack of insurance or

being underinsured. One study examines the relationships between


SES and the variations of physical and mental health quality of

life (QOL) among breast cancer survivors (Ashing-Giwa & Lim,

2009). In their cross-sectional study, Ashing-Giwa and Lim (2009)

found a strong positive correlation between SES and health-

related QOL and that socioecologic stress was the most

influential variable for physical and mental health QOL. For

cultural attitudes and beliefs, Germino et al. (2011) conducted a

randomized clinical trial of an intervention that incorporated

culturally informed, population-specific recruitment and

retention strategies to engage younger African American breast

cancer survivors. Research findings emphasize the importance of

utilizing a multifaceted approach to address cultural and racial

barriers to research participation and connecting cultures and

communities (e.g. the role of faith and beliefs). Another aspect

of connecting to diverse cultures is examined by Royak-Schaler et

al.’s (2008) qualitative study of patient-physician communication

from the patient’s perspectives. With African American breast

cancer survivors as subjects, findings suggest that gaps lingered

in the information given to patients regarding diagnosis,

treatments, side effects, and guidelines for follow-up care.


Psychosocial perceptions, on the other hand, were found to

be significant in a meta-analysis that considers ethnic

differences in psychosocial factors that have been proven to

influence adherence to adjuvant treatment (Magai, Consedine,

Adjei, Hershman, & Neugut, 2008). The review indicates that

factors of cognition, emotion, emotion regulation, and social

networks likely contribute to breast cancer treatment adherence

(Magai et al., 2008). To complement this, a randomized controlled

clinical trial with a two-group design tested the effect of a

one-time psychoeducational intervention on treatment adherence

among AAW (Rosenzwelg et al., 2011). The study found that the

pilot Attitudes, Communication, Treatment, and Support intervention promoted

trends toward rapid initiation of chemotherapy as well as better

overall adherence to chemotherapy (Rosenzwelg et al., 2011). As

for community/social support, this factor was found to be a

moderator of the optimism-adjustment relationship, safeguarding

against the negative influence of low optimism on psychological

distress, well-being, and psychosocial functioning based on a

randomized clinical trial of a psychosocial intervention (Shelby

et al., 2008). Their data suggest that perceived social support


is an important resource for women with low optimism (Shelby et

al., 2008). In a cross-sectional design with AAW who have been

diagnosed with invasive/infiltrating ductal carcinoma, Heiney, et

al. (2011) described the theory of community connection (close

relationships with women and men who are members of a

neighborhood, church, etc.). Findings indicate that community

connection is particularly salient for AAW with breast cancer due

to the emotional, social, and practical support that comes with

being engaged in a supportive community environment (Heiney et

al., 2011).

Limitations and Gaps in Research

Ashing-Giwa and Lim (2009) pointed out the limitation of

self-reported data with possible influence by participant

reactivity to items involving SES, hence calling for more

research to understand cultural sensitivity in reporting SES

data. Furthermore, a longitudinal assessment of health-related

QOL would be more helpful compared to a cross-sectional design

(Ashing-Giwa & Lim, 2009). Although Germino et al.’s (2011)

multifaceted approach to recruitment and retention of African

American cancer survivors was based on the literature, their


culturally informed approach evolved over the time of the trial.

Their study did not utilize a comprehensive community based

participative research model (Germino et al., 2011). Magai et

al.’s (2008) meta-analysis on psychosocial influences on

suboptimal adjuvant treatment adherence suggests more research in

studying the influence of the full range of psychosocial

variables on treatment in order to design interventions that will

benefit from cultural competence. Heiney et al. (2011) proposes

that their study on community connection could serve as a model

for new research pursuing to understand connection in ethnic

groups and communities. Additionally, the majority of the studies

within this literature review call for larger representative

samples of the targeted population, which, in this case, is

African American women.

Overall Purpose and Significance of Literature Review

The purpose of the literature review is to focus on

intervention or exploratory studies that attempt to investigate

social determinants that influence the effectiveness and process

of treatment for breast cancer among AAW. Four relevant,

collective themes emerged from the review of literature. These


themes included the influence of SES, cultural attitudes and

beliefs, psychosocial perceptions, and community/social support.

Thus, the present study is aimed towards introducing an

integrated social-determinant framework for breast cancer

intervention rather than focusing only on physical/biomedical

aspects of treatment.

Inclusion of social, psychological, and public health

perspectives are needed for a more comprehensive research

base to also explore why poor women and women of color have

higher death rates from breast cancer…Research that relies

on biology alone and ignores socioeconomic factors will be

unlikely to uncover the best way to remove this survival

differential. (Kasper & Ferguson, 2000)

The importance of these themes based on current literature

drive the objective of the present study in attempting to

determine whether current treatment programs/protocols address

AAW’s social needs, which may very well be as equally significant

in determining not only the effectiveness of treatment but also

prognosis, survivorship, and quality of life.

Methods


Study Design and Setting

The present study will be based on a randomized control

trial design. The experimental group will be receiving the

social-integrated intervention coupled with standard biomedical

treatment. The comparison (control) group will only be receiving

the conventional biomedical treatment. Within the design, data

collection and intervention implementation will involve a

compounded pre-test/post-test and time series with a total of

three total intervention/collection points. Interventions will

start within the location of the subject’s hospital/clinic of

treatment and then subsequent follow-ups will be conducted as

time progresses during the study. This proposal will be submitted

to an Institutional Review Board for approval before the study

commences.

Implementation of a Pilot Intervention Based on Social-

Determinants

As mentioned in the research question, the pilot

intervention designated for the experimental group will consist

of four major components or social-determinants: socioeconomic

status (SES), cultural attitudes and beliefs, psychosocial


perceptions, and community/social support. Proper biomedical

intervention will initially be provided as a standard based on

the diagnosed stage and degree of invasive breast cancer. Upon

the completion of biomedical treatment, each social-determinant

will be addressed in a sequential manner. The overall

intervention will be initiated in the following chronological

sequence of four phases. Phases 1 and 2 will remain implemented

for at least one year with no minimum duration in order to

accommodate the variability of invasive breast cancer diagnoses

and their treatment thereof. Phases 3 and 4 will initiated as

soon as the subject has completed and participated in the

interventions of phases 1 and 2 and will last for a duration of

one year upon initiation.

Phases 1 and 2.

Phase 1 will consist of the involvement of two medical

professionals: the medical provider and a navigator (oncology

nurse). Providers will be given culture-sensitivity training

based on the Institute of Medicine’s guidelines for follow-up

planning development (Royak-Schaler et al., 2008). Oncology

nurses will be designated as navigators who will advocate for


patients throughout the duration in which the subject is under

the healthcare system (Lally, 2008). Based on the roles, phase 1

will be addressing cultural beliefs and attitudes.

Phase 2 will involve the nurse’s assessment for fear and

isolation through a one-on-one interview session before

discharge. The purpose is to address the patient’s fears and

concerns as well as the level of community support they

experience due to their effects on cancer stigma and community

connection (Heiney et al., 2011). The exploration of stress and

isolation levels will allow nurses to address those issues before

it escalates to cause psychological harm. Based on type of

assessment, this will primarily be addressing psychosocial

perceptions.

Phases 3 and 4.

Phase 3 will involve contacting and recruiting Breast Cancer

support groups within close proximity of the subjects’

hospital/clinical of treatment provision. Groups aiming for the

African American population and younger women will specifically

be included. Collaboration between the research team of the

present study and the organization will promote dialogue,


education, and social support among the subjects’ after

completion of their initial biomedical treatment, ensuring that

subjects are contacted within a week of discharge and met with

for a minimum of two sessions (Germino et al., 2011). Potential

referrals to churches for the development of partnerships with

congregations will serve as an asset for the organizations as

they follow-up regularly with the subjects. This phase will

provide a source of social support.

Phase 4 will serve as the final phase throughout the

intervention. Based on evaluation reports of the three previous

segments by the research team, supplementary education will be

provided on proper breast-cancer treatment follow-up, referrals

to healthcare providers will be made if necessary, and financial

assistance will be provided for transportation to clinics and the

organization groups if requested (Northington et al., 2011). The

basis for provision of education, referrals, and possible

financial assistance is their relevance to SES and theoretically

addresses the lack of such resources. Hence, this phase will

address the social-determinant of SES.

Subject Criteria


The inclusion criteria for the subjects are as follows:

African-American women 18 or older who are diagnosed with

invasive breast cancer within the past six months and are

residing in predominantly minority, urban, and socioeconomically

disadvantaged areas based on the Census Bureau’s most current

definition. The exclusion criteria are as follows: having

undergone surgical treatment or extensive chemotherapy lasting

more than six months, in-situ (non-invasive) breast cancer

diagnosis, and having lived in the United States for less than 20

years. Subjects will be asked to provide informed consent as

well.

The sampling method that is to be utilized for selecting

subjects for this study will be probability multistage

clustering. The most updated list of major accredited medical

institutions that have an oncology unit for treating breast

cancer patients within the U.S will serve as the sampling frame.

This preliminary list will then be narrowed down to a final list

that will only include those institutions that are within regions

that contain major clusters of African-American populations with

lower socioeconomic statuses as determined by the Census Bureau.


The first random selection will be applied to this final list.

Once a feasible number of institutions are selected, a list of

all of the patients who fit the subject criteria will be created.

Random selection will be executed within these patient lists for

a final number of subjects for the selected sample.

Measuring Instruments

Measuring instruments for this study will be derived from

Davies’ (2009) literature review on measuring health-related quality of

life (HR QoL) in cancer patients. In order to measure the

immediate and long-term changes of the pilot intervention, two

types of questionnaires related to HR QoL will be implemented. To

assess HR QoL in the breast cancer patients throughout the cancer

pathway and during or after a specific treatment regimen, the

European Organization for Research and Treatment of Cancer Quality of Life

Questionnaire (EQRTC QLQ-C30) will be utilized. The second

questionnaire to be given complements the former: “The Quality of

Life in Adult Cancer Survivors (QLACS) is one of the few instruments that

explores the longer-term effect of cancer, with its focus on

survivorship as opposed to illness” (Davies, 2009). The former

evaluates HR QoL whereas the latter assesses survivorship in


relation to the social-determinants in question. Both

questionnaires have been demonstrated to hold confirmed

reliability and validity (Davies, 2009).

Data Collection and Analysis

Biophysiological data regarding the subjects’ cancer

diagnosis and status will be retrieved from their medical chart

with permission from the patient and medical practitioner. This

information will be compared to the outcomes of both groups in

three data collection points: prior to the intervention-

implementation of both groups, upon discharge from the medical

institution, and finally six months after discharge. These

different time points may yield a potential correlation between

the implementation of a social-determinant based or a

conventional intervention and the biological stage of the breast

cancer. These correlations will then be compared to the responses

of the questionnaires to validate the truthful occurrence between

one’s perceived health (HR QoL and survivorship) and one’s actual

health status (prognosis). Administering the questionnaire and

utilizing biophysiological measuring instruments are intended to

strengthen validity and reliability so that generalizability may


be strengthened. Data collected from these instruments will

demonstrate whether statistically significant changes could be

observed. Descriptive analyses will be executed as well to

compare demographic and characteristic differences between the

experimental group and the comparison group.

Implications to Nursing Practice

The Impact of Racial Inequity in Oncology Care

The four social determinants in question entail collective

and progressive implications to nursing. Enhancing sensitivity to

cultural attitudes and perceptions call for comprehensive

guidance from healthcare providers, given that the IOM guidelines

for dissemination and use of care plans addressing QoL in cancer

patients have not been established for cancer patients (Royak-

Schaler et al., 2008). This is supplemented by the need for

oncology nurses to serve as “navigators” who identify patient

barriers to completing treatment due to social issues (Lally,

2008). As for psychosocial perceptions, nurses must be aware of

patient fear and isolation stemming from cancer stigma and

community connection, thus calling for assessment and mediation

of these concerns (Heiney et al., 2011). Lastly, the


incorporation of community/social support necessitates the

development and application of knowledge regarding cancer

survivors based on the diversity and representativeness of the

target population (Germino et al., 2011).

The Impact of the Proposed Study in Nursing

Descriptive statistics will categorize the selected sample,

which a lower SES according to the Census Bureau, into more SES

subgroups in order to identify any correlation between one’s

level of SES and HR QoL, survivorship, and prognosis based on the

type of intervention. These findings would then contribute to the

body of knowledge concerning participant reactivity to data

collection items involving SES as to whether cultural sensitivity

has been addressed (Ashing-Giwa & Lim, 2009). A duration of at

least two years for the present study also allows for a

longitudinal analysis of HR QoL (Ashing-Giwa & Lim, 2009). As for

a preliminary research model that aims to be community and

participative based in nature, the creation of a pilot

intervention that addresses the four social determinants in

question will contribute to such a design (Germino et al., 2011).

Lastly, the inclusion of an emphasized assessment for


psychosocial perceptions will provide more data on psychosocial

variables of cancer treatment that influence the design of

interventions supported by cultural competence (Heiney et al.,

2011).

Conclusion: Study Quality and Contribution to Knowledge in

Nursing Oncology Care

The gaps and limitations identified in the literature review

primarily drove construction of this hypothetical study as the

author progressed during the research process. The study design

was devised, moreover, based on the expectations of a scientific

quantitative study, particularly that of a randomized control

clinical trial. Due to the focus on these two components for the

research proposal – the attempt to address identified limitations

and to conduct a well-constructed quantitative design, the author

overall believes that the quality of this study remains

unprecedented. This is to say that the research study

demonstrates exceptional rigor and contribution to the body of

knowledge despite inherent issues with feasibility in the real

world.


Nevertheless, the early beginnings of research proved that

most studies displayed not as high as a priority for assessing

and evaluating treatment effectiveness for invasive breast cancer

among AAW compared to prevention or screening behavior. Although

such is justified in due to public health implications and social

inequities, the author surmised that those currently diagnosed or

have extreme risk for of breast cancer would be at a disadvantage

for taking preventative measures – they are already practically

subjected to the standard routine of biomedical treatment. This

subjection is clearly not acceptable. Therefore, the present

study was created in an attempt to undermine this gap, or so it

seems, in hopes of abating higher breast cancer mortality rates

in AAW through the field of nursing and evidence-based practice.

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Integration of Social Determinants in Breast Cancer Treatment for African American Women

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