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1.  The Importance of Contextual Factors and Age in Association with Anxiety and Depression in Black Breast Cancer Patients 
Psycho-oncology  2013;23(2):143-150.
Objectives
Limited research exists on correlates of psychosocial distress in Black breast cancer patients. The goals of the study were to describe the prevalence of distress (anxiety and depression) in Black women with breast cancer and to examine the influence of demographic, clinical, contextual (e.g. self-efficacy, medical mistrust), and process of care factors (e.g., patient satisfaction) on women’s level of anxiety and depression.
Methods
Eighty-two Black women diagnosed with invasive non- metastatic breast cancer were interviewed by phone. Collected data included demographics, clinical, contextual, and process of care factors. Bivariate correlations were used to examine relationships between those variables. Multiple linear regressions were used to examine predictors of anxiety and depression.
Results
About one-third of the women (32%) met cut-off thresholds for distress. Medical mistrust and positive attitude had significant influences on anxiety levels while age and positive attitude were determinants of levels of depression. Participants with higher medical mistrust reported more anxiety (r=.379; p<.001) and depression (r=.337 p=.002) while women with higher self-efficacy reported less anxiety (r=−.401; p<.001) and depression (r=−.427; p < .001). Age was inversely related to both anxiety and depression (r=−.224, r=−.296, respectively; p<.05).
Conclusions
Findings support national recommendations for routine distress screening in the delivery of cancer care particularly in younger Black patients. Interventions targeted to boost self-efficacy or reduce medical mistrust through enhanced patient-provider interactions may decrease psychological distress. Psychosocial needs of younger patients warrant particular attention.
doi:10.1002/pon.3382
PMCID: PMC4144019  PMID: 24150907
2.  Correlates of Depressive Symptomatology in African American Breast Cancer Patients 
Purpose
This study assessed the levels of depressive symptomatology in African Americans women with breast cancer compared to those of women without breast cancer and examined demographic, psychosocial, and clinical factors were correlated with depression.
Methods
A total of 152 African American women were recruited from Washington DC and surrounding suburbs. Breast cancer patients (n=76 cases) were recruited from a healthcare center and women without cancer were recruited from health fairs (n=76 comparison). We assessed depression, psychosocial variables (ego strength and social support) and socio-demographic factors from in-person interviews. Stage and clinical factors were abstracted from medical records. Independent sample t-test, chi square test, ANOVA, and multiple regression models were used to identify differences in depression and correlates of depression among the cases and comparison groups.
Results
Women with breast cancer reported significantly greater levels of depression (m=11.5 SD=5.0) than women without breast cancer (m=3.9; SD=3.8) (p<.001). Higher cancer stage (beta=.91) and higher age (beta =.11) were associated with depression in the breast patients, explaining 84% of the variance. In the comparison group, ego strength and tangible support were inversely associated with depressive symptoms, accounting for 32% of the variance.
Conclusions
Women with more advanced disease may require interdisciplinary approaches to cancer care (i.e., caring for the whole person).
Implications for cancer survivors
Depression is often under-recognized and under-treated in African American breast cancer patients. Understanding the factors related to depression is necessary to integrate psychosocial needs to routine cancer care to improve survivors’ quality of life.
doi:10.1007/s11764-013-0273-y
PMCID: PMC3737401  PMID: 23471730
Breast cancer; oncology; depression; African American; ego strength; social support
3.  Narrowing Racial Gaps in Breast Cancer Chemotherapy Initiation: The Role of the Patient-Provider Relationship 
Purpose
Chemotherapy improves breast cancer survival but is underused more often in black than in white women. We examined associations between patient-physician relationships and chemotherapy initiation and timeliness of initiation among black and white patients.
Methods
Women with primary invasive, non-metastatic breast cancer were recruited via hospitals (in Washington, DC and Detroit) and community outreach between July 2006 and April 2011. Data were collected via telephone interviews and medical records. Logistic regression models evaluated associations between chemotherapy initiation and independent variables. Since there were race interactions, analyses were race-stratified. Factors associated with time from surgery to chemotherapy initiation and delay of ≥ 90 days were evaluated with linear and logistic regressions, respectively.
Results
Among eligible women, 82.8% were interviewed and 359 (90.9%)of those had complete data. The odds of initiating chemotherapy were 3.26 times (95% CI: 1.51, 7.06) higher among black women reporting greater communication with physicians (vs. lesser), after considering covariates. In contrast, the odds of starting chemotherapy were lower for white women reporting greater communication (vs. lesser) (adjusted OR .22, 95% CI: .07, .73). The opposing direction of associations was also seen among the sub-set of black and white women with definitive clinical indications for chemotherapy. Among those initiating treatment, black women had longer mean time to the start of chemotherapy than whites (71.8 days vs. 55.0 days, p= .005), but race was not significant after considering trust in oncologists, where initiation time decreased as trust increased, controlling for covariates. Black women were also more likely to delay ≥ 90 days than whites (27% vs. 8.3%; p=.024), but this was not significant after considering religiosity.
Conclusion
The patient-physician dyad and sociocultural factors may represent leverage points to improve chemotherapy patterns in black women.
doi:10.1007/s10549-013-2520-3
PMCID: PMC3662254  PMID: 23588954
chemotherapy initiation; disparities; patient-provider communication
4.  PHYSICAL ACTIVITY REDUCES BREAST CANCER RISK IN AFRICAN AMERICAN WOMEN 
Ethnicity & disease  2011;21(4):406-411.
Objective
To examine the relationship between physical activity and breast cancer in African American women.
Design
A population-based case-control study was conducted with 199 women (97 cases and 102 controls) from the Washington, DC metro area. A self-report physical activity questionnaire elicited responses on walking for exercise and vigorous physical activity (e.g., running, aerobics, etc.) in the past year. Responses were used to calculate a metabolic equivalent (MET) score [MET-hours/week = hours/week vigorous activity×7+ hours/week walking ×3]. The MET score was categorized into low, medium and high tertiles. Multivariate logistic regression examined the association between physical activity and breast cancer.
Results
African American women who engaged in vigorous physical activity (> 2 hours/week in the past year) had a 64% reduced risk of breast cancer compared to those who did not participate in any vigorous activity (odds ratio, OR = 0.36; 95% confidence interval, CI = 0.17–0.75). We also found a 64% reduced breast cancer risk in women with a high versus low tertile of total activity (OR = 0.36; 95% CI = 0.16–0.79). For postmenopausal women, vigorous physical activity and total activity (high versus low tertile) also had an inverse relationship with breast cancer (p<.05).
Conclusion
Data regarding the association of physical activity and breast cancer has been equivocal and lacking for African American women. This study found that modest levels of physical activity reduced breast cancer risk in this group. Targeted efforts are needed to encourage more African American women to engage in physical activity.
PMCID: PMC3760197  PMID: 22428342
Total activity; blacks; postmenopausal; women
5.  Medical Mistrust and Self-efficacy Influence Black Women’s Level of Engagement in BRCA1/2 Genetic Counseling and Testing 
Clinical evidence supports the value of BRCA1/2 genetic counseling and testing (GC/T) for managing hereditary breast and ovarian cancer risk; however, BRCA1/2 GC/T is underutilized among Black women and reasons for low use remain elusive. We examined the potential influence of socio-cultural factors (medical mistrust, concerns about genetic discrimination) on GC/T engagement in a sample of 100 Black women at increased risk for carrying a BRCA1/2 mutation. Eligible participants fell into one of three groups: 1) healthy women with ≥ 1 first-degree relative (FDR) affected by breast and/or ovarian cancer, 2) women diagnosed with breast cancer at age ≤ 50, and 3) women diagnosed with breast and/or ovarian cancer at age ≥ 50 with either one FDR or two second degree relatives with breast and/or ovarian cancer. Participants were recruited from clinical and community settings and completed a semi-structured interview. Study variable relationships were examined using bivariate tests and multivariate regression analysis. Forty-three percent of participants were aware of GC/T services. Yet referral and receipt of GC/T services in this sample was low (28%). After accounting for sociodemographic factors, women with higher self-efficacy had greater GC/T engagement (B = 0.37, p < .001), while those with higher medical mistrust had lower GC/T engagement (B = −0.26, p <. 01). Interventions targeted towards increasing provider referrals may facilitate higher levels of engagement in GC/T services. Individual interventions that enhance women’s personal confidence in obtaining GC/T may also be useful in promoting GC/T engagement.
PMCID: PMC3721431  PMID: 23862292
Medical Mistrust; Self-efficacy; BRCA 1/2; African American
6.  Patient and Physician Decision Styles and Breast Cancer Chemotherapy Use in Older Women: Cancer and Leukemia Group B Protocol 369901 
Journal of Clinical Oncology  2012;30(21):2609-2614.
Purpose
Physician and patient decision styles may influence breast cancer care for patients ≥ 65 years (“older”) because there is uncertainty about chemotherapy benefits in this group. We evaluate associations between decision-making styles and actual treatment.
Methods
Data were collected from women treated outside of clinical trials for newly diagnosed stage I to III breast cancer (83% response) from January 2004 through April 2011 in 75 cooperative group sites. Physicians completed a one-time mailed survey (91% response), and clinical data were abstracted from charts. Patient decision style was measured on a five-point scale. Oncologists' preference for prescribing chemotherapy was based on standardized vignettes. Regression and multiple imputation were used to assess associations between chemotherapy and other variables.
Results
There were 1,174 women seen by 212 oncologists; 43% of women received chemotherapy. One-third of women preferred to make their own treatment decision. Patient and physician decision styles were independently associated with chemotherapy. Women who preferred less physician input had lower odds of chemotherapy than women who preferred more input (odds ratio [OR] = 0.79 per 1-point change; 95% CI, 0.65 to 0.97; P = .02) after considering covariates. Patients whose oncologists had a high chemotherapy preference had higher odds of receiving chemotherapy (OR = 2.65; 95% CI, 1.80 to 3.89; P < .001) than those who saw oncologists with a low preference.
Conclusion
Physicians' and older patients' decision styles are each associated with breast cancer chemotherapy use. It will be important to re-evaluate the impact of decision styles when there is greater empirical evidence about the benefits and risks of chemotherapy in older patients.
doi:10.1200/JCO.2011.40.2909
PMCID: PMC3413274  PMID: 22614985
7.  Promoting mammography adherence in underserved women: The telephone coaching adherence study 
Contemporary clinical trials  2013;35(1):35-42.
Background
Despite interventions to promote regular mammography, underserved women face barriers to mammography. This is evident in high no-show appointment rates in community-based clinics. Understanding why women fail to follow-through with appointments may help improve adherence.
Objectives
We conducted a focus group with women who were non-adherent to mammograms to evaluate psychosocial and structural barriers and design intervention messages. In phase two we conducted a small randomized controlled trial (RCT) to pilot test a brief telephone coaching adherence intervention (vs. control) to address barriers.
Method
Eligible women were non-adherent to their mammography screening appointment at a community-based setting. Psychosocial factors and perceptions of barriers were measured via a baseline survey and used to tailor the telephone coaching session. In the RCT, the primary outcome was whether women rescheduled and kept their appointment (yes vs. no). Descriptive statistics were used to summarize the results.
Results
Fifty-four women participated in the study (17 in phase 1 and 31 in phase 2); 89% were Black and 11% were Latina. Overall, prior to the intervention, women had low perceptions of risk (m=4.2; SD=2.4) and cancer worry (m=4.2; SD=2.6) and these characteristics informed the telephone coaching. After the intervention, most women (94.5%) rescheduled their missed appointment. More women in the intervention group kept their appointment (54%) than those in the usual care group (46%).
Conclusion
It appears feasible to implement a RCT in non-adherent underserved women. Addressing psychosocial and structural barriers in a brief telephone intervention may reduce non-adherence. Future studies that will test the efficacy of this approach are warranted.
doi:10.1016/j.cct.2013.02.005
PMCID: PMC4255458  PMID: 23415629
Mammography; Low-income; Minority; Breast cancer; Disparities; RCT
9.  Providers’ Perceptions and Practices Regarding BRCA1/2 Genetic Counseling and Testing in African American Women 
Journal of Genetic Counseling  2011;20(6):674-689.
We examined healthcare providers’ perceptions of genetic counseling and testing in African American women (AAW) at moderate to high-risk of carrying a BRCA1/2 mutation. We conducted 20 in-depth interviews with genetic counselors (n=5), medical oncologists (n=8), obstetrician/gynecologists (n=2) and surgeons (n=5). Interviews were audiotaped, transcribed and independently coded by two coders using a content analysis approach. Seven themes emerged relevant to providers’ perceptions of AAW’s use of BRCA1/2 genetic services: access factors, cultural beliefs and preferences, effects of testing, patient motivators for genetic counseling and testing, patient-provider communication, reasons for provider referral, and reasons for patient refusal. Providers identified individual- and system-level barriers to AAW’s use of genetic services, including lack of follow-up after referrals to genetic specialists and challenges to obtaining financial coverage for under- and uninsured high-risk women. Results have implications for physician and patient education regarding appropriate referrals to and uptake of genetic services in at-risk AAW.
doi:10.1007/s10897-011-9396-3
PMCID: PMC3286616  PMID: 21822773
African American women; BRCA1/2; breast cancer genetics; genetic counseling; genetic testing; cancer providers
10.  A Peer-Led Decision Support Intervention Improves Decision Outcomes in Black Women with Breast Cancer 
Previous reports suggest that Black breast cancer patients receive less patient-centered cancer care than their White counterparts. Interventions to improve patient-centered care (PCC) in Black breast cancer patients are lacking. Seventy-six women with histologically confirmed breast cancer were recruited from the Washington, DC area. After a baseline telephone interview, women received an in-person decision support educational session led by a trained survivor coach. The coach used a culturally appropriate guidebook and decision-making model—TALK Back!© A follow-up assessment assessed participants’ acceptability of the intervention and intermediate outcomes. After the intervention, participants reported increased: self-efficacy in communicating with providers (70 %) and self-efficacy in making treatment decisions (70 %). Compared to baseline scores, post-intervention communication with providers significantly increased (p=.000). This is the first outcome report of an intervention to facilitate PCC in Black breast cancer patients. Testing this intervention using RCTs or similar designs will be important next steps.
doi:10.1007/s13187-013-0459-z
PMCID: PMC4180493  PMID: 23576067
African-American; Black; Adjuvant therapy; Decision support
11.  Outcomes of a Systems-Level Intervention Offering Breast Cancer Risk Assessments to Low-Income Underserved Women 
Familial cancer  2012;11(3):493-502.
Background
Hereditary breast and ovarian cancer risk assessments (CRAs) are underutilized by low-income and racial/ethnic minority women, potentially exacerbating cancer-related disparities observed within these populations. We deployed and evaluated a systems-level intervention designed to identify patients potentially at-risk for hereditary breast/ovarian cancer, refer them for CRAs, and facilitate CRA utilization at an urban community-based breast health care center.
Methods
Cancer family history forms were completed by patients seen at the center during an 18-month period and reviewed by staff for CRA eligibility against published referral criteria. A patient navigator educated eligible patients about the benefits of CRA, navigating interested patients to this service. CRA-specific patient interest and utilization outcomes are reported.
Results
In total, 94.7% of all patients (n = 2,436) completed forms and 65 patients (2.7%) met CRA eligibility criteria. Most eligible patients (72.3%) were interested in CRA. Interested patients had a greater risk for hereditary breast/ovarian cancer (i.e., more affected relatives, greater objective risk scores) than uninterested patients: 57.4% scheduled a CRA appointment and 51.9% of scheduled patients utilized CRAs. Patients scheduling a CRA were contacted in less time and required fewer follow-up contacts by the patient navigator, and were more likely to be African American, than those who declined a CRA or were lost to follow-up (all p’s ≤ .05).
Conclusions
The systems-level intervention successfully identified patients eligible for CRA and linked interested and at-risk patients with CRA resources. More intensive patient navigation addressing the unique barriers encountered within this population may be required to enhance utilization.
doi:10.1007/s10689-012-9541-7
PMCID: PMC3521596  PMID: 22711611
Cancer risk assessment; Systems intervention; Disparities; Underserved populations
12.  Development of Decision Support Intervention for Black Women with Breast Cancer 
Psycho-oncology  2010;19(1):62-70.
Adjuvant therapy improves breast cancer survival but is underutilized by Black women. Few interventions have addressed this problem. This preliminary report describes the process we used to develop a decision support intervention for Black women eligible for adjuvant therapy. Aims were to use qualitative methods to describe factors that influence Black women’s adjuvant therapy decisions, use these formative data to develop messages for a treatment decision-support intervention, and pilot test the acceptability and utility of the intervention with community members and newly diagnosed women. Thirty-four in-depth interviews were conducted with breast cancer patients in active treatment, survivors and cancer providers to gather qualitative data. Participant ages ranged from 38 to 69 years. A cultural framework was used to analyze the data and to inform intervention messages. Most women relied on their providers for treatment recommendations. Several women reported problems communicating with providers and felt unprepared to ask questions and discuss adjuvant treatment options. Other factors related to treatment experiences were: spiritual coping, collectivism, and sharing breast cancer experiences with other Black survivors. Using these formative data, we developed an intervention that is survivor-based and includes an in-person session which incorporates sharing personal stories, communication skills training and decision support. Intervention materials were reviewed by community members, researchers/clinicians and patients newly diagnosed with breast cancer. Patients reported satisfaction with the intervention and felt better prepared to talk with providers. The intervention will be tested in a randomized trial to enhance decision support and increase use of indicated adjuvant treatment.
doi:10.1002/pon.1530
PMCID: PMC3136087  PMID: 19267384
African-American; breast cancer; treatment decisions; communication; oncology
13.  Breast Cancer Adjuvant Chemotherapy Decisions in Older Women: The Role of Patient Preference and Interactions With Physicians 
Journal of Clinical Oncology  2010;28(19):3146-3153.
Purpose
Breast cancer chemotherapy decisions in patients ≥ 65 years old (older) are complex because of comorbidity, toxicity, and limited data on patient preference. We examined relationships between preferences and chemotherapy use.
Methods
Older women (n = 934) diagnosed with invasive (≥ 1 cm), nonmetastatic breast cancer from 2004 to 2008 were recruited from 53 cooperative group sites. Data were collected from patient interviews (87% complete), physician survey (93% complete), and charts. Logistic regression and multiple imputation methods were used to assess associations between chemotherapy and independent variables. Chemotherapy use was also evaluated according to the following two groups: indicated (estrogen receptor [ER] negative and/or node positive) and possibly indicated (ER positive and node negative).
Results
Mean patient age was 73 years (range, 65 to 100 years). Unadjusted chemotherapy rates were 69% in the indicated group and 16% in the possibly indicated group. Women who would choose chemotherapy for an increase in survival of ≤ 12 months had 3.9 times (95% CI, 2.4 to 6.3 times; P < .001) higher odds of receiving chemotherapy than women with lower preferences, controlling for covariates. Stronger preferences were seen when chemotherapy could be indicated (odds ratio [OR] = 7.7; 95% CI, 3.8 to 16; P < .001) than when treatment might be possibly indicated (OR = 1.9; 95% CI, 1.0 to 3.8; P = .06). Higher patient rating of provider communication was also related to chemotherapy use in the possibly indicated group (OR = 1.9 per 5-point increase in communication score; 95% CI, 1.4 to 2.8; P < .001) but not in the indicated group (P = .15).
Conclusion
Older women's preferences and communication with providers are important correlates of chemotherapy use, especially when benefits are more equivocal.
doi:10.1200/JCO.2009.24.3295
PMCID: PMC2903313  PMID: 20516438
14.  Are Health-care Relationships Important for Mammography Adherence in Latinas? 
Journal of General Internal Medicine  2008;23(12):2024-2030.
Background
Latinas are the fastest growing racial ethnic group in the United States and have an incidence of breast cancer that is rising three times faster than that of non-Latino white women, yet their mammography use is lower than that of non-Latino women.
Objectives
We explored factors that predict satisfaction with health-care relationships and examined the effect of satisfaction with health-care relationships on mammography adherence in Latinas.
Design and Setting
We conducted a cross-sectional survey of 166 Latinas who were ≥40 years old. Women were recruited from Latino-serving clinics and a Latino health radio program.
Measurements
Mammography adherence was based on self-reported receipt of a mammogram within the past 2 years. The main independent variable was overall satisfaction with one’s health-care relationship. Other variables included: self report of patient-provider communication, level of trust in providers, primary language, country of origin, discrimination experiences, and perceptions of racism.
Results
Forty-three percent of women reported very high satisfaction in their health-care relationships. Women with high trust in providers and those who did not experience discrimination were more satisfied with their health-care relationships compared to women with lower trust and who experienced discrimination (p < .01). Satisfaction with the health-care relationship was, in turn, significantly associated with mammography adherence (OR: 3.34, 95% CI: 1.47–7.58), controlling for other factors.
Conclusions
Understanding the factors that impact Latinas’ mammography adherence may inform intervention strategies. Efforts to improve Latina’s satisfaction with physicians by building trust may lead to increased use of necessary mammography.
doi:10.1007/s11606-008-0815-6
PMCID: PMC2596511  PMID: 18839258
Latinas; immigrants; mammograms; satisfaction; adherence
15.  BRIEF REPORT: If You Build It, They Will Come 
BACKGROUND
Latinos have low representation in cancer prevention trials and intervention studies. Culturally appropriate recruitment strategies are needed to address this issue.
OBJECTIVE
To describe and summarize the effectiveness of recruitment strategies used by the Latin American Cancer Research Coalition (LACRC).
DESIGN
Descriptive report of recruitment methods.
PARTICIPANTS
Uninsured Latino immigrants (N=1,170; 77% female, 23% male) from Central and South America recruited to 7 cancer control studies.
APPROACH
The LACRC recruitment model involved inclusion of Latino researchers and providers, and use of culturally acceptable materials released through culturally appropriate outlets such as Latino radio stations.
RESULTS
The overall participation rate was high—96% of patients identified as eligible agreed to participate. Women were excellent referrals for recruiting men to research studies. Additionally, a local Latino radio program was used to efficiently recruit eligible study participants.
CONCLUSIONS
Latinos are interested and willing to participate in cancer control studies when culturally relevant approaches are used. Research teams that partner with Latino researchers and with Latino service providers are important in educating Latinos about cancer control and encouraging participation in research.
doi:10.1111/j.1525-1497.2005.0083.x
PMCID: PMC1490123  PMID: 15963169
minorities; clinical trials; recruitment; Latinos

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