Distress Trajectories in Black and White Breast Cancer Survivors: From Diagnosis to Survivorship

Abstract

Background: Black breast cancer survivors have greater morbidity and mortality than White survivors. However, evidence comparing Black survivors' psychological symptoms with their White counterparts has been mixed. Prior studies have not compared Black and White survivor's distress-related symptom trajectories from pre- to post-treatment - the goal of the current study.

Methods: At three annual visits from shortly after diagnosis to 6 and 18 months post-treatment, 195 women (n = 163 White; n = 32 Black) reported their cancer-related distress (intrusive thoughts and avoidance), perceived stress, anxiety and depressive symptoms, fatigue, and pain.

Results: Adjusting for age, educational attainment, income, treatment type, stage at diagnosis, and physical comorbidities, Black and White breast cancer survivors had different trajectories of cancer-related distress (p = .004), intrusive thoughts about cancer diagnosis and treatment (p = .002), perceived stress (p = .04), emotional fatigue (p = .01), and vigor (p = .02). Specifically, among White women, these distress-related symptoms improved from diagnosis to 6 months post-treatment (ps < 0.0001) and then remained stable between 6 and 18 months post-treatment, whereas Black women had persistently elevated distress - even 18 months after finishing treatment. Additionally, Black women reported more avoidance of cancer-related thoughts and emotions across visits (p = .047). Race was unrelated to the trajectories of anxiety and depressive symptoms, other fatigue subscales, or pain levels (ps > 0.08).

Conclusion: Longitudinal assessment of the same breast cancer survivors from diagnosis to early survivorship revealed that Black and White survivors had divergent trajectories of psychological distress symptoms that were not reliably evident at a single timepoint. Overall, White women reported less psychological distress from pre- to post-treatment, but Black women's distress remained high from diagnosis to 18 months post-treatment. If left untreated, Black women's high distress levels may contribute to their poorer health throughout survivorship.

Keywords: Breast cancer; Distress; Health disparities; Race.

Figure 1.

Cancer-Related Distress Trajectories by Race. From shortly after diagnosis to approximately 20 months post-treatment, Black and White breast cancer survivors differed in their trajectories of cancer-related distress (p=.004) and intrusive thoughts (p=.002), and Black women had higher levels of avoidance when averaged across all visits (p=.047). IES=Impact of Events Scale; *p<.05 for between-race comparison at each visit. Models adjusted for age, income, education, cancer stage and treatment type, and comorbidities.

Figure 2.

Perceived Stress Trajectory by Race. Black and White women had divergent trajectories of perceived stress across visits (p=.04). Although there were no between-race differences at any visit (ps>.14), White survivors had numerically higher perceived stress levels than Black survivors shortly after diagnosis, which then significantly declined from pre-treatment to 6 months post-treatment (p<.0001). Black survivors did not experience this decline in perceived stress, and therefore had numerically higher perceived stress levels than their White peers 6 and 18 months after treatment. PSS-Short=Perceived Stress Scale. Models adjusted for age, income, education, cancer stage and treatment type, and comorbidities.

Figure 3.

Fatigue and Vigor Trajectories by Race. Black and White breast cancer survivors had different emotional fatigue (p=.01) and vigor (p=.02) trajectories across visits. Although White women reported more emotional fatigue (p=.04) and less vigor (p=.001) than Black women before treatment (Visit 1), their symptoms signfiicantly improved by 6 monts post-treatment (Visit 2) (ps<.0001), whereas Black women’s fatigue and vigor did not change across time (ps>.40). Models adjusted for age, income, education, cancer stage and treatment type, and comorbidities.