The objectives of this study were to characterize differences in the experience of traumatic stress for African American and non-African American men with prostate cancer enrolled in a study of supportive-expressive group psychotherapy. We are unaware of any previous study that has compared African American men to other men with prostate cancer in this important aspect of psychological functioning. As hypothesized, African American men reported significantly greater levels of traumatic stress, including both avoidant coping and intrusive thoughts, compared to non-African American men across all time points. Racial differences in traumatic stress remained significant across time, even after accounting for mood disturbance, impact of illness, income and disease stage. African American men also had a consistently higher prevalence of clinically significant traumatic stress symptoms with the exception of the 6-month follow-up. These findings are consistent with previous reports of poorer emotional functioning and greater health-related distress in African American men compared to whites [5
]. They are also consistent with recent evidence that blacks in the United Stated are more likely than non-Hispanic whites to meet criteria for the diagnosis of posttraumatic stress disorder (PTSD) and are more impaired by the effects of mental illness [23
]. However, this is the first study to show a racial disparity in traumatic stress specifically as an aspect of overall psychological adjustment to prostate cancer.
Several factors may explain the greater burden of traumatic stress for African American men with prostate cancer in this sample. African American men are at higher risk for many of the factors related to traumatic stress responses to cancer, including disproportionately low income, lower educational attainment, and history of other negative life stressors [8
]. The main effect of income was not significant in the final model, and because education was similar for African Americans and non-African Americans in this sample, this variable was not tested. Given the role of previous trauma in the risk of cancer-related traumatic stress, the higher prevalence of PTSD among blacks in the general population also may predispose African American men to traumatic stress responses to cancer. Despite lower rates for most anxiety disorders, the higher rate of PTSD among African Americans has been attributed to both race-related stressors (e.g., racial discrimination, prejudice, stigmatization) and higher exposure to environments in which traumatization is common (e.g., neighborhoods with high rates of crime and/or violence) [24
]. Greater distress in response to the diagnosis of cancer has also been associated with traumatic stress [9
]. The literature on cancer-related PTSD has been mixed in terms of the extent to which clinical characteristics are predictive of the disorder [9
], but it is possible that greater difficulty adjusting to changes in physical functioning for African American men [5
] may also contribute to their higher degree of traumatic stress. The significant main effect for mood disturbance and the impact of illness in this study is consistent with the role of distress and illness-related adjustment in the development of traumatic stress symptoms reported in the literature.
The prevalence of clinically significant traumatic stress among African Americans in this sample is also noteworthy. While overall estimates of the prevalence of PTSD following cancer range from 0 to 32% [9
], the prevalence of clinically significant traumatic stress symptoms (as determined by a score of ≥ 27 on the Impact of Events total score) among African Americans in this sample was from 26 to 41% depending on the assessment point. This prevalence is much higher than the estimated lifetime prevalence of PTSD for African Americans (9.10%), Caribbean blacks (8.42%), and non-Hispanic whites (6.84%) [23
]. While the IES is not a diagnostic tool for PTSD, it has been shown to predict cases of PTSD [22
], and it has been used extensively in the literature on traumatic stress in cancer patients and survivors [9
]. Whether they could be diagnosed with clinical cases of PTSD or show only subsyndromal manifestations of the disorder, it appears evident that African American men with prostate cancer are experiencing significant traumatic stress in response to diagnosis, treatment, and survivorship.
Clearly, the higher levels of traumatic stress symptoms among African American prostate cancer survivors indicate that culturally appropriate, targeted interventions are needed in order to address the needs of African American cancer patients and cancer survivors [27
]. The same principle holds for interventions involving men in general. It is already known that men with cancer are less likely to seek help from support groups than women and that those men who do participate are primarily interested in the information and education they receive regarding the disease [28
]. To the extent that group interventions are desirable for their efficiency, their effectiveness with men may be enhanced by an emphasis on the provision of information and education rather than the expression of emotion, which can come later. When African American men are the targets of such intervention, the information should be specific to their experience and may potentially address the psychosocial stressors associated with race that likely compound the immediate stressor of cancer diagnosis and treatment. Culturally appropriate suggestions for coping (e.g., use of familiar community resources like churches, social and fraternal organizations for support) might also be incorporated along with the opportunity for individual psychotherapeutic intervention should individuals express interest. Such culturally appropriate, targeted interventions need to be tested for effectiveness in African American and other racial and ethnic minority male cancer populations. To date women have been the primary focus of interventions addressing psychological adjustment to cancer and quality of life. More interventions targeted at diverse populations of men with cancer are needed.
Several limitations should be noted. First, this was a secondary analysis of data collected for a psychological intervention trial. The original study was not designed to test the specific questions under investigation in this secondary analysis. Second, while African American recruitment was roughly in line proportionally with the representation of African Americans in the United States population, the relatively small sample size makes it difficult to generalize to all African American men with prostate cancer. While this study is not unique in having a small number of African American subjects, future studies including larger numbers of African American men are needed to confirm our findings. In addition, it is possible that African American men who were willing to participate in a group therapy intervention may differ in significant ways from other African American men with prostate cancer. For example, the former may have been in greater distress and therefore sought out this option to alleviate distress. This study was also limited by its inability to account for time since diagnosis as a relevant variable in analyses. Eligibility requirements of the parent study only stipulated that group therapy sessions had to begin within 24 months of the date of diagnosis of all group members. Data on the exact dates of diagnosis and subsequent treatment were not collected, and therefore, were not available for analyses. Despite these limitations, this study provides important information in an area of health disparities given relatively little attention in the literature, namely the psychological functioning of African American prostate cancer patients.
Our findings suggest that African American men may be experiencing significant traumatic stress symptoms in response to cancer diagnosis and treatment, and that these symptoms remain elevated for some time afterwards. In light of the disproportionate burden of prostate cancer carried by African American men and the increased survival of all men with prostate cancer, it is imperative that their psychological needs be assessed and that proper treatment be provided. Referrals for mental health intervention should be combined with the use of appropriate community resources in order to ensure culturally appropriate care for this vulnerable population.