Psychosocial Influences on Suboptimal Adjuvant Breast Cancer Treatment Adherence Among African American Women: Implications for Education and Intervention

Article (PDF Available)inHealth Education & Behavior 35(6):835-54 · November 2007with83 Reads
DOI: 10.1177/1090198107303281 · Source: PubMed
Abstract
Despite lower incidence, African American women are at increased risk of dying from breast cancer relative to their European American counterparts. Although there are key differences in both screening behavior and tumor characteristics, an additional part of this mortality difference may lie in the fact that African American women receive suboptimal adjuvant chemotherapy and may receive suboptimal hormonal therapy, therapies that are known to increase survival. The authors consider ethnic differences in the psychosocial factors that have been shown to relate to poor screening adherence and consider how they may influence adherence to breast cancer adjuvant treatment, thus the receipt of suboptimal adjuvant chemo or hormonal therapy. To this end, they review ethnic differences in cognitive, emotional, and social network variables. Psychosocial variables should be included in research designed to understand cancer disparities as well interventions that can be tailored to culturally diverse populations to improve treatment adherence.
Psychosocial Influences on Suboptimal Adjuvant
Breast Cancer Treatment Adherence Among
African American Women: Implications
for Education and Intervention
Carol Magai, PhD
Nathan S. Consedine, PhD
Brenda A. Adjei, EdD
Dawn Hershman, MD, MPh
Alfred Neugut, MD, PhD
Despite lower incidence, African American women are at increased risk of dying from breast cancer rel-
ative to their European American counterparts. Although there are key differences in both screening behav-
ior and tumor characteristics, an additional part of this mortality difference may lie in the fact that African
American women receive suboptimal adjuvant chemotherapy and may receive suboptimal hormonal therapy,
therapies that are known to increase survival. The authors consider ethnic differences in the psychosocial fac-
tors that have been shown to relate to poor screening adherence and consider how they may influence adher-
ence to breast cancer adjuvant treatment, thus the receipt of suboptimal adjuvant chemo or hormonal therapy.
To this end, they review ethnic differences in cognitive, emotional, and social network variables. Psychosocial
variables should be included in research designed to understand cancer disparities as well interventions that
can be tailored to culturally diverse populations to improve treatment adherence.
Keywords: breast cancer; African Americans; treatment adherence
Although the incidence of breast cancer is lower in African American than European
American women,
1
its mortality is higher (Jemal et al., 2004). Despite the fact that mor-
tality rates are declining in all groups, the mortality gap has been increasing across the
past 15 years (Ghafoor et al., 2003). This disparity is likely related to ethnic differences
835
Carol Magai, Nathan S. Consedine, and Brenda A. Adjei, Long Island University, Brooklyn, New York.
Dawn Hershman and Alfred I. Neugut, Columbia University, New York, New York.
Address correspondence to Carol Magai, PhD, Long Island University, Department of Psychology,
1 University Plaza, Brooklyn, NY 11201; e-mail: cmagai@liu.edu.
This research was supported by grants from the National Institute on Aging (K07 AG00921; R01
AG021017), the National Institutes of Health (2S06 GM54650), and the National Cancer Institute (1P20 CA
91372; 1U54 CA101388) to the first author, and U54 CA101598 and K07 CA95597 Career Development
Award from the National Cancer Institute and BC043120 from the Department of Defense to the third author.
Health Education & Behavior, Vol. 35 (6): 835-854 (December 2008)
DOI: 10.1177/1090198107303281
© 2008 by SOPHE
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in genetic factors (Jones et al., 2004), tumor characteristics (Royak-Schaler & Rose,
2002), screening rate differences, and, consequently, more advanced diagnoses (Hunter,
2000; Roetzheim et al., 1999). However, several studies indicate that differences in sur-
vival remain even after controlling for demographic and biological factors (Campbell,
2002; Simon & Severson, 1997), meaning that other avenues of exploration regarding
ethnic outcome disparities require attention.
One area of promise involves consideration of ethnic differences in treatment. Recent
evidence indicates that African American women receive quantitatively less treatment and
have reported lower adherence to prescribed breast cancer treatment regimens (Gwyn
et al., 2004; Tropman et al., 1999) and greater delay prior to initiation (Hershman, Wang,
et al., 2006a). An appreciation of the factors likely to contribute to these treatment
(vs. screening) differences (Mandelblatt et al., 2004) may directly affect our understand-
ing of ethnic differences in breast cancer mortality.
AFRICAN AMERICAN WOMEN AND BREAST
CANCER TREATMENT DIFFERENCES
The use of adjuvant chemotherapy and adjuvant hormonal therapy in the treatment of
breast cancer is undoubtedly an important factor underlying increased survivorship over
the past 15 years (Benson & Pitsinis, 2003; Jatoi & Miller, 2003). However, a surprising
number of women do not receive complete adjuvant therapy (Bickell & McEvoy, 2003;
Bloom, de Pouvourville, Chhatre, Jayadevappa, & Weinberg, 2004). Although part of the
problem with suboptimal treatment in both chemotherapy and adjuvant hormonal treat-
ments may be related to age differences (Nagel, Rohrig, Hoyer, Wedding, & Katenkamp,
2003), a growing body of research has begun to document racial and ethnic differences
in treatment initiation (Hershman, McBride, et al., 2006; Hershman, Wang, et al., 2006b)
and adherence (Bickell et al., 2006). One study reported that 22.4% of African American
women and 14.3% of White women had delays of greater than 3 months between initial
consultation and treatment; access to care and socioeconomic status only partially
accounted for racial differences in delay (Gwyn et al., 2004). Prior research indicates
Black women are less likely to initiate adjuvant chemotherapy when appropriate (Harlan
et al., 2002) and receive less aggressive intravenous chemotherapy (Tropman et al.,
1999). At least two studies have found that being non-White was associated with a
decreased likelihood of being treated with radiation after breast-conserving therapy
(Giordano, Hortobagyi, Kau, Theriault, & Bondy, 2005; Mandelblatt et al., 2000). Other
data indicates that Black women are less likely to complete chemotherapy and that pre-
mature discontinuation of treatment adversely affects survival (Partridge, Wang, Winer,
& Avorn, 2003).
Perhaps consequently, researchers have argued that the underlying causes of ethnic
differences in treatment use, adherence, and outcome demand further evaluation
(Giordano et al., 2005; Mancino et al., 2001). Although the impact of recommendation
practices (Roila et al., 2003) and ethnic differences in biological treatment-response
characteristics (Flaws & Bush, 1998; Hershman et al., 2003) are active areas of research,
the literature describing the psychological reasons behind poor treatment adherence
remains critically underdeveloped (Andersen, 2002), and poor adherence to treatment is,
at root, a behavioral problem (Ottevanger, De Mulder, Grol, van Lier, & Beex, 2004;
Partridge et al., 2003). Thus, there is a strong rationale for examining the impact of
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ethnically varying psychological and psychosocial characteristics on breast cancer
treatment adherence behaviors and success. Presenting an outline for this agenda is the
primary aim of this article.
THEORETICAL FRAMEWORK
In developing our thesis, we draw on self-regulatory theories of health behavior, notably
those that provide consideration of both cognitive (i.e., beliefs, knowledge, and attitudes)
and affective elements of the person (i.e., feelings, emotional dispositions, social related-
ness), while paying attention to the role of culture and ethnicity (Cameron & Leventhal,
1995; Consedine, Magai, Krivoshekova, Ryzewicz, & Neugut, 2004). In the dual-process
regulatory model of Leventhal and colleagues, cultural factors provide the global backdrop
for the affective, cognitive, and social elements that come into play in health behaviors and
in determining how people interpret and adapt to specific health threats and consequences
(Cameron & Leventhal, 1995; Leventhal, Diefenbach, & Leventhal, 1992); for us, it
is through psychosocial variables that ethnicity, as an index variable, can be conceptual-
ized as influencing adherence behavior (Consedine, Magai, Cohen, & Gillespie, 2002;
Consedine, Magai, & Neugut, 2004). A major advantage of this approach is that it does not
conceptualize race or ethnicity as either a global factor that influences outcomes in a non-
specific manner (Alvidrez, Azocar, & Miranda, 1996; Beutler, Brown, Crothers, Booker,
& Seabrook, 1996) or, as is common, treat race or ethnicity as a proxy for sociodemo-
graphic disparities. Instead, ethnicity is viewed as a descriptive-level variable that circum-
scribes a constellation of psychosocial and psychological variables that ultimately mediate
the relations between race and adherence outcomes.
Racial or ethnic differences in cognition, including cancer-related knowledge (Donovan
& Tucker, 2000), beliefs (Consedine, Magai, Spiller, Conway, & Neugut, 2004), and risk
(Glanz, Resch, Lerman, & Rimer, 1996; Valdini & Cargill, 1997), are well established,
related to screening-rate differences (Magai, Consedine, Conway, Neugut, & Culver,
2004), and likely to affect treatment adherence. However, the impact of emotional factors has
received less empirical scrutiny (Consedine, Magai, & Neugut, 2004); thus, the treatment
adherence model we propose urges researchers to consider adding affective processes, such
as emotion and emotion regulatory styles and aspects of social networks, to the more cogni-
tive factors of perceived risk and the perceived costs and benefits of self-protective actions
(Becker, 1974; Rosenstock, 1974).
As we expand upon below, our suspicion is that for some African American women, the
initiation of breast cancer treatment, subsequent adherence to prescribed treatment regi-
mens, and/or early termination of treatment may be the function of a complex interplay of
socioeconomic, psychosocial, and situational factors (Partridge et al., 2003). This review
concentrates on the likely role of ethnic differences in particular psychosocial variables—
health beliefs, emotion, coping and emotion regulatory styles, and social network charac-
teristics—that have been found to account for substantial proportions of the ethnic variance
in screening behavior (Consedine, Magai, Horton, Neugut, & Gillespie, 2005; Magai et al.,
2004), follow-up to abnormal screening results (Engelstad et al., 2001; Juarbe et al., 2005),
and decision making at the initiation of treatment (Bober, Hoke, Duda, Regan, & Tung,
2004; Lam, Fielding, Chan, Chow, & Or, 2005). As stated, although the primary goal of
this article focuses on the psychosocial factors that may influence breast cancer treatment
adherence, it is important not to minimize the contribution that the more common sociode-
mographic covariates, such as older age, socioeconomic and insurance status (Bickell et al.,
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2006; Gwyn et al., 2004) have on access to and timely use of health services (Mays,
Cochran, & Barnes, 2007).
It is our thesis that these factors may come into play with respect to breast cancer
treatment adherence and the ethnic disparities therein. We begin the review by briefly
outlining some of the issues confronting women as they respond to a diagnosis of breast
cancer, interact with the medical establishment, and evaluate their treatment options,
before considering how ethnic differences in psychosocial characteristics may affect
treatment decisions and adherence disparities.
CANCER TREATMENT CONSIDERATIONS,
EFFECTS, AND SIDE EFFECTS
A woman who receives a diagnosis of breast cancer is confronted with a bewilder-
ing array of information, advice, conflicting demands, and treatment options (Fortner
et al., 2004; Lam et al., 2005). The distinction between pretreatment decision making
and adherence behavior, however, is important, for although many of the same psy-
chosocial factors relating to initial treatment choices may remain relevant to adherence,
a woman on a course of adjuvant treatment is also influenced by the ongoing demands
and toxicities of her treatment regimen.
Foremost among the relevant demands of the treatment process are economic and
logistic considerations (Fortner et al., 2004), as well as short- and long-term side
effects. Women undergoing breast cancer treatment have to withstand numerous phys-
ical and psychological demands, many of which are unpleasant (Griffin & Fentiman,
2002), affect decision making (Bober et al., 2004), and almost certainly contribute to
noncompliance. Physical side effects include hair loss, nausea, fatigue, mucositis, diar-
rhea, weight gain (Demark-Wahnefried et al., 2001), changes in taste (Dikken & Sitzia,
1998), changes in sexuality and sense of self (Stead, 2003; Wilmoth, Coleman, Smith,
& Davis, 2004), and menopausal symptoms in response to hormone treatments (Fisher
et al., 1998).
There are also a host of cognitive and emotional effects that occur in response to can-
cer diagnosis and treatment. Cognitively, patients have impairments regarding verbal
memory, executive functioning, and motor function (Morse, Rodgers, Verrill, & Kendell,
2003; Phillips & Bernhard, 2003). Estimates suggest that nearly one third of patients
receiving adjuvant chemohormonal therapy experience some form of cognitive impair-
ment (Olin, 2001), often lasting more than 2 years beyond treatment (Ahles et al., 2002).
Emotionally, cancer patients experience considerable uncertainty, vulnerability, isolation
(Halldorsdottir & Hamrin, 1996), and depression (Stommel, Kurtz, Kurtz, Given, &
Given, 2004), although it is unclear how these responses vary across different treatment
schedules and dosages or how they relate to adherence behavior.
As with most chronic diseases, there is an inevitable tension between treatment-
related constraints and side effects and the patient’s desire to maintain a normal life
(Kutner, 2001). In the context of breast cancer treatment, this balancing act often
involves trading off toxicity concerns against survival and quality-of-life benefits (Chung
& Carlson, 2003; Detmar, Muller, Schnornagel, Wever, & Aaronson, 2002). Our sug-
gestion in this regard is that because (a) the effects of biological cancer treatments are
clearly manifest in elements of the patient’s social and psychological functioning (Del
Mastro et al., 2002; Jacobsen et al., 2002) and (b) these variables are embedded in the
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patient’s ethnic context, adherence decisions must be understood within the context of a
woman’s broader life, situational determinants, and sociocultural context (C. M. Hughes,
2004; Lam et al., 2005).
ETHNIC DIFFERENCES IN PSYCHOSOCIAL VARIABLES AND THEIR
RELEVANCE TO ADHERENCE BEHAVIOR
African American women are characterized by their cultural diversity, and although
often grouped within a major racial category, this aggregation masks the broad range
of cultural experiences, beliefs, values, and behaviors that epitomize this population
(Kreuter, Lukwago, Buckholtz, Clark, & Sanders-Thompson, 2003; McBarnette, 1996).
An understanding of the unique experiences, beliefs, and behaviors of African American
women provides a better appreciation for the culture itself (Collins, 2000) and, more
specifically, offers a framework within which to base interventions designed to address
ethnic health disparities facing this population of women (Watts, 2003).
Although the cultural heterogeneity within major ethnic divisions may complicate our
understanding of both biological (Li, Malone, & Daling, 2002) and psychosocial factors
(Magai et al., 2004), a growing psychosocial literature nonetheless enables us to offer
some preliminary observations regarding key ethnic and racial differences in psychoso-
cial characteristics and their possible impact on adherence behavior.
Cognitive Variables
Because of the dominance of health beliefs models in the health psychology literature,
research relevant to understanding how psychosocial characteristics might affect cancer
screening, treatment adherence, and outcome has concentrated on examining cognitive
variables. The links between cognitive variables and screening outcomes is well estab-
lished (Consedine, Magai, & Neugut, 2004), with less knowledgeable women, as well as
those who do not believe in the efficacy of breast cancer treatments, having lower esti-
mates of personal risk and greater fatalism, being less likely to screen. There have been,
however, almost no studies of cognitive variables, much less a consideration of ethnic dif-
ferences, in the area of cancer treatment adherence. Most work has focused on the initia-
tion of treatment or on treatment choices (Bober et al., 2004; Fink, Gurwitz, Rakowski,
Guadagnoli, & Silliman, 2004) and has shown that perceived risk, physician recommen-
dation, and assessing the costs and benefits of treatment implications influence treatment
adherence. Although this literature is small, research examining compliance with hyper-
tensive medication regimens suggests that health beliefs regarding the effectiveness of
treatment, locus of control (Wang et al., 2002), and knowledge (Balazovjech & Hnilica,
1993), may be important in understanding cancer treatment adherence.
Almost all knowledge, attitude, and belief variables vary across racial and ethnic
groups, meaning they are likely to be of particular relevance to the understanding of
adherence disparities. African Americans have consistently reported poorer cancer knowl-
edge than European Americans (Consedine et al., 2005; C. Hughes et al., 1997) and are
less likely to believe in the efficacy of treatments (Buelow, Zimmer, Mellor, & Sax, 1998;
Mandelblatt et al., 1999). Moreover, within ethnic subpopulations (i.e., English and
French-speaking Caribbean) of women of African descent, variability in these cognitive
constructs has also been observed (knowledge, health beliefs, fatalism, etc.; Consedine
et al., 2005; Consedine, Magai, Spiller, et al., 2004). Attitudes concerning fatalism (Powe &
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Finnie, 2003; Powe & Weinrich, 1996), medical mistrust (Boulware, Cooper, Ratner,
LaVeist, & Powe, 2003; LaVeist, Nickerson, & Bowie, 2000), and lowered estimates of
personal risk are generally more prevalent among African Americans (Glanz et al., 1996;
Mandelblatt et al., 1999).
These findings suggest that African American women may be at particular risk for
nonadherence to treatment and may be unlikely to maintain a treatment regimen that has
so many costs in terms of convenience and side effects when they do not believe the
treatment will work and where they believe the course of cancer is determined by God.
Furthermore, issues of medical mistrust are important for African American women,
especially when interacting with a medical establishment they do not believe is cultur-
ally prepared to address their health issues (Thompson, Valdimarsdottir, Winkel, Jandorf,
& Redd, 2004) or culturally sensitive enough to understand the situational factors that
may influence their treatment decisions (Collins, 2000). Historically, the medical system
has not adequately tailored its programs to meet the needs of ethnically diverse popula-
tions (Pasick, Hiatt, & Paskett, 2004), and education specifically tailored toward African
American women receiving treatment is clearly needed. Education programs tailored to
African American women will help them understand the importance of treatment and,
perhaps moreover, provide them with the knowledge they need to anticipate and accom-
modate the side effects and disruptions to life that a comprehensive treatment program
may require. More broadly, although there are not any studies that have systematically
examined whether ethnic disparities in adherence can be accounted for by ethnic differ-
ences in cognitive variables, it seems likely that interventions targeting cancer treatment
adherence in diverse populations will need to consider the health belief profile, situa-
tional determinants, and sociocultural context of the patient population in question if
they are to succeed.
It is, however, worth recalling that cognitive decision-making models, including the
health belief model, the theory of reasoned action, and the theory of planned behavior,
assume a high degree of rationality in decision-making processes (Broadstock & Michie,
2000). In addition to the commonsense clinical observation that patients frequently make
treatment decisions on the basis of “nonrational” (i.e., non-cancer-related outcome) con-
siderations, several studies indicate that cognitive variables offer an incomplete under-
standing of many health behaviors. In fact, they have been cited for failing to recognize
the emotional elements that are present in the decision-making process (Ogden, 2003).
Although many of these value-expectancy theories have assessed the attributions of atti-
tudes and feelings in the decision-making process, the contribution of distinct emotional
characteristics has not been adequately addressed.
One recent breast screening study, for example, found that emotional characteristics—
stress, cancer worry, and embarrassment—predicted screening even after demographic
variables, physician recommendation, access, and cognitive variables (knowledge,
beliefs, risk perceptions) were statistically controlled (Magai et al., 2004). Compliance
literatures also offer a mixed picture, with knowledge-based interventions being intermit-
tently successful; writers have noted that even when information is effectively communi-
cated, knowledge may be variably important (Kutner, 2001; Wolcott, Maida, Diamond, &
Nissenson, 1986), and it has been suggested that the consideration of other factors is
needed (Wang et al., 2002).
Emotion and Emotion Regulatory Variables
Emotions (feelings, moods, behavioral propensities) are an intrinsic aspect of human
nature and have a powerful motivating effect of behavior of the individual as well as of
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the social surround. Despite their obvious relevance to human motivation and informa-
tion processing, comparatively little research attention has considered how ethnic differ-
ences in the realm of emotions and emotion regulation relate to health behaviors. The
notion that emotions are strongly implicated in health behavior processes is, however,
consistent with emotion theory (Consedine & Magai, 2006; Izard, 1991; Magai, 2001)
as well as models of emotion and self-regulation (Cameron & Leventhal, 1995). Because
emotions have well-documented motivational functions (Consedine, Strongman, &
Magai, 2003; Mayne, 2001), the experience of negative affects, particularly worry or
anxiety, depression, and embarrassment (Consedine, Krivoshekova, & Harris, 2007;
Harewood, Wiersema, & Melton, 2002), as well as the manner in which the individual
regulates or fails to regulate these feelings (Consedine, Magai, & Bonanno, 2002), is
likely to exert a powerful influence on health behavior.
For example, in one study assessing interest in genetic testing for breast cancer
(Thompson et al., 2002), researchers found that the anticipation of negative emotional
reactions, family-related worry, and family-related guilt was prevalent among African
American women. Again, however, there have been few studies of how ethnically vary-
ing emotional characteristics affect breast cancer treatment adherence and decision
making. In one study of palliative care patients, changes in treatment were found to vary
significantly as a function of health-related quality of life (HRQL) ratings, at least
among patients without tumor progression and without serious toxicity (Del Mastro
et al., 2002); when HRQL was good, treatment was only modified 6% of the time
(vs. 17% when HRQL was poor) and discontinued in none (vs. 14%).
Another major emotional construct, anxiety or breast cancer worry, has been associ-
ated with an increased likelihood of choosing to take tamoxifen (Bober et al., 2004).
However, depression, which may often co-occur with clinically elevated levels of anxiety,
has been related to poorer treatment adherence, at least in the more developed literatures
examining adherence to antihypertensives and diabetes treatments (Kaplan, Bhalodkar,
Brown, Wflite, & Brown, 2004; Wang et al., 2002). In studies of cancer treatment, depres-
sion has been associated with greater sensitivity to the unpleasant side effects of medica-
tions (Demissie, Silliman, & Lash, 2001), which, in turn, has been associated with poorer
adherence. In one study of women being treated with tamoxifen, for example, those in
better emotional health reported fewer side effects; women reporting more side effects
were more likely to have discontinued tamoxifen 3 years after diagnosis (Demissie et al.,
2001). Finally, one recent study found that adherence to clinic sessions among HIV-
positive women at risk for cervical dysplasia was significantly lower among women with
inhibited coping styles at 1- and 2-year follow-up, even after controlling for depressed
mood (Pereira et al., 2004).
As with the cognitive variables discussed above, both cancer-specific and more charac-
terological emotion and emotion regulatory variables vary systematically across ethnic
groups, creating the possibility that they are differentially relevant to the adherence behav-
ior of women from different groups. Prior research has suggested that African American
women tend to report less negative emotion, in response to specific threats such as breast
cancer (Consedine, Magai, & Neugut, 2004), as well as less fear and anxiety, anger, and
sadness in general (Consedine & Magai, 2002) or in response to stressful situations
(Lawton, Rajagopal, Brody, & Kleban, 1992). Conversely, however, embarrassment
regarding cancer screening appears somewhat greater among African Americans, although
breast cancer screening results are mixed (Breitkopf, Catero, Jaccard, & Berenson, 2004;
Consedine, Magai, & Neugut, 2004). Studies of depression are consistent with a pattern of
generally lowered trait negative emotion among African Americans (Connell & Gibson,
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1997; S. Hughes, Giobbie-Hurder, Weaver, Kubal, & Henderson, 1999), although there are
exceptions (Williams, 2000). It is important to note, however, there also appear to be
marked ethnic differences in how depressed emotion is manifest (Baker, 2001; C. Brown,
Abe-Kim, & Barrio, 2003), with some African Americans tending to present with somatic
(rather than psychological) symptoms (C. Brown, Schulberg, & Madonia, 1996). Some
studies have suggested that African Americans exhibit more depressive symptomatology in
response to cancer (Kurtz, Kurtz, Stommel, Given, & Given, 2001) and abnormal screen-
ing results (Alderete, Juarbe, Kaplan, Pasick, & Perez-Stable, 2006), although others have
found no relation (Stommel et al., 2004). Once again, we note the heterogeneity of the
African American culture in the interpretation of these findings.
It is not surprising that the lowered reporting of negative emotions is also evidenced in
systematic ethnic differences in patterns of emotion regulation. Research has suggested
that some African Americans may be somewhat less emotionally expressive (Brantley,
O’Hea, Jones, & Mehan, 2002; Consedine & Magai, 2002), report less stress when car-
ing for others (Adams, Aranda, Kemp, & Takagi, 2002; McCabe, Yeh, Lau, Garland, &
Hough, 2003), and may manifest global differences in patterns of coping with stress
(Kudadjie-Gyamfi, Consedine, & Magai, 2006). In particular, African Americans tend to
engage in more problem-focused coping as well as distancing and escape avoidance
(Plummer & Slane, 1996) and make greater use of positive reappraisal, benefit finding,
and prayer when coping (Levkoff, Levy, & Weitzman, 1999; Tomich & Helgeson, 2004).
Although the absence of any research linking breast cancer treatment adherence to
emotion variables means observations must be considered preliminary, findings from
other adherence literatures coupled with the implications of emotions theory provide
grounds for some remarks. First, it is worth recalling that self-regulatory theories of emo-
tion and health behavior suggest that the effect of anxiety on behavior is determined by
the object of the fear (i.e., whether the woman is afraid of cancer, the treatment, or both)
and the extent to which the recommended behavior is expected to alleviate or exacerbate
felt anxiety (Consedine, Magai, Krivoshekova, et al., 2004). Research has shown that
women who were worried about breast cancer were 3 times more likely to be interested
in taking a preventive drug (Bober et al., 2004), and it seems likely that women who are
more worried about outcomes will be more likely to adhere to treatment regimens.
This might suggest that intervening to ensure African American women are aware of
the consequences of not adhering would raise anxiety and thus be an effective way to
maximize adherence (Bober et al., 2004). However, the screening literature suggests that
anxiety may be differentially relevant to outcomes for different groups of women.
Anxiety about breast cancer may not necessarily predict screening among African
American women (L. Y. Miller & Hailey, 1994), and, in fact, fear of cancer and the med-
ical establishment has been shown to predict poorer screening for this group of women
(Duke, Gordon-Sosby, Reynolds, & Gram, 1994; Vernon, Laville, & Jackson, 1990). The
combination of these data suggest that greater anxiety among some African American
women may facilitate adherence when combined with psychoeducational interventions
designed to increase the belief that breast cancer treatments work.
Recalling that depression is more likely to be manifest somatically among African
Americans (Baker, 2001; C. Brown et al., 2003), this may also place them at greater risk
for noncompliance with breast cancer treatment (Alderete et al., 2006). As noted above,
although greater anxiety about mortality outcomes would seem likely to facilitate adher-
ence, depressed affect has been shown to interfere with adherence to treatment regimens
(Kim, Han, Hill, Rose, & Roary, 2003), in part because it creates greater sensitivity to
somatic symptoms (Demissie et al., 2001; Leventhal & Patrick-Miller, 2000) and drug
intolerances, at least for hypertensives (Davies, Jackson, Ramsay, & Ghahramani, 2003).
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Difficulty in tolerating side effects is, in turn, one of the more robust predictors of cancer
treatment nonadherence (Demissie et al., 2001), which might suggest that African
American women may be more compliant because of lower depression. Conversely, how-
ever, it may be that greater somatic sensitivity means that some African American women
will (a) experience a greater level of unpleasant side effects in response to breast cancer
treatments and, consequently, (b) have greater difficulty adhering to prescribed regimens.
Being sensitive to ethnic variations in the manifestations of cancer-related depression and
ensuring that either psychological or pharmacological treatments are appropriately pre-
scribed may be one way in which to increase adherence.
Finally, the emotion regulatory and coping profile of African American women is also
a consideration, as it may have implications for breast cancer treatment adherence. For
some African Americans, socialization practices may generate emotional restriction
(Brody & Flor, 1998; Pinderhughes, Dodge, Bates, Pettit, & Zelli, 2000) and result in
more avoidant, defended, and repressive personality traits (Consedine, Magai, & Neugut,
2004). Thus, these individuals may be more likely to manage threatening and unpleasant
situations (such as breast cancer treatment and the associated side effects) by avoiding the
situation and the treatment. Research has shown that stress, depression, and smoking are
more closely related among African American women (Ludman et al., 2002). Second,
because negative emotional experiences may be less accessible to some African American
women, the salutary motivational impact of cancer worry or anxiety on self-protective
behaviors (Jorgensen, 1998; Witte, 1998) may be lost, compromising the ability to main-
tain adherence to therapies that have the capacity to prolong life. Inhibited regulatory
styles may also influence adherence by altering the individual’s ability to absorb, retain,
or recall information (Consedine, Magai, & Bonanno, 2002; Richards, Butler, & Gross,
2003), perhaps meaning that cancer knowledge is less readily absorbed and appointments
and medication scheduling are more easily forgotten. Finally, although religious coping is
complex (Pargament, Koenig, Tarakeshwar, & Hahn, 2004), the importance of religion
and spirituality among African Americans may suggest that interventions incorporating
aspects of religiosity or spirituality may also positively influence adherence behavior in
these women (Holt, Lukwago, & Kreuter, 2003).
Social Network Variables
Social network variables have shown themselves to be robustly predictive of both mor-
bidity and mortality (Michael, Berkman, Colditz, Holmes, & Kawachi, 2002), although
the causal mechanisms are unclear (W. M. Brown, Consedine, & Magai, 2005) and the
exact aspects of social networks that contribute to health remains an area of active debate
(DiMatteo, 2004). One recent study of 708 women who developed breast cancer across a
4-year period found that role functioning, vitality, and physical functioning was lower
among socially isolated women (Michael et al., 2002). Another study found that feeling
unable to talk about cancer at the time of the diagnosis was associated with a higher all-
cause risk of death 10 years later, even after adjusting for tumor characteristics (Soler-
Vila, Kasl, & Jones, 2003). Although we are aware of no studies that have directly
examined adherence in the context of breast cancer treatment, social network variables
have been shown to predict compliance in the taking of lipid-lowering medications
(Kaplan et al., 2004) and dialysis (Bernardini, Nagy, & Piraino, 2000) and have shown
very large effect sizes in a recent meta-analysis of the more than 100 studies from the
compliance literature (DiMatteo, 2004). Social network partners, particularly spouses,
exert considerable influence on the behavior of individuals undertaking a treatment regi-
men. Ideally, they can offer both practical (e.g., transport or child care) and emotional
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support, encourage healthy lifestyles, provide physical care, promote optimism, reduce
the stresses of being ill, and reduce depression (DiMatteo, 2004).
As with both cognitive and emotional characteristics, an accumulating literature on
ethnic differences in socioemotional functioning points to distinct differences in patterns
of social relations between African Americans versus Caucasians that may affect treat-
ment decisions and adherence. First, despite an early emphasis on the extended family
as an economic adaptation and a strength of African American communities (Coll, 1990;
Howes, 1999), recent large-scale, population-based research has indicated that the social
networks of older African Americans are smaller than those of Caucasians (Ajrouch,
Antonucci, & Janevic, 2001; Barnes, de Leon, Bienias, & Evans, 2004). At the same
time, however, there is an increasing trend for middle-aged and older African Americans
to be charged with the care for their grandchildren (Conway & Stricker, 2002) and/or the
home-based care of other relatives with dementia and other chronic debilitating illnesses
(Cagney & Agree, 1999; B. Miller, McFall, & Campbell, 1994). Thus, the social, phys-
ical, and emotional resources of African American women may be strained in ways not
typically faced by Caucasian women.
In addition to ethnic differences in the characteristics of social networks per se, there
are additional ethnic differences in normative styles of relating to others—patterns of
attachment. The concept of an attachment style refers to an individual’s typical pattern
of relating to others (Cassidy & Shaver, 1999), in particular encompassing whether and
how readily a person will approach others for support when distressed. Research has
suggested that African Americans of all ages, but especially older adults, are more likely
than Caucasians to be characterized by the dismissing/avoidant attachment pattern
(Magai et al., 2001; Mickelson, Kessler, & Shaver, 1997), a pattern that is associated
with stoicism, a preference for self-reliance rather than emotional closeness, and dis-
comfort with dependency.
Both the structural and relational differences noted above have implications for treat-
ment adherence. First, in terms of size, smaller social networks, particularly where they
are financially strained and/or beset with other caregiving and illness demands, may
struggle to provide the levels of practical and emotional support that will maximize
adherence for African American women undergoing breast cancer treatment. Although
research suggests that the mere presence of other people does not matter as much as the
quality of relationships with them (DiMatteo, 2004), research in areas other than breast
cancer has suggested that African American women frequently feel that their networks
do not provide enough help or understanding (Carter-Edwards, Skelly, Cagle, & Appel,
2004) and that African Americans may require slightly different forms of support
(Hamilton & Sandelowski, 2004). Nonsupportive social networks can interfere with
adherence by limiting the time and energy the patient has available for the treatment or
compromise the attitudes necessary for adherence (DiMatteo, 2004). Ethnically speak-
ing, there is some suggestion that social support–based interventions aimed at maxi-
mizing adherence may be of particular benefit to African American women. At least one
study has indicated that support group interventions for breast cancer are more effec-
tive among individuals with fewer financial and social resources (Taylor et al., 2003)
Second, differences in the manner in which individuals from different racial and eth-
nic groups deal with the social dependencies that cancer treatments may engender have
clear implications for their adherence behavior. One possible consequence is that for
some African American women, pride in self-reliance and stoicism may allow them to
tolerate adverse medical conditions and demanding pharmacological regimens with
more equanimity and ultimately greater success, all other things being equal. On the
other hand, discomfort with dependency, and the very real demands on resources due to
844 Health Education & Behavior (December 2008)
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greater caregiving burdens, may make it harder for African American women to attend
to their own needs, especially, among older adults, given their more limited social
networks. Social support received under conditions of dependency is known to create
negative emotions (S. L. Brown, Nesse, Vinokur, & Smith, 2003), and although social
network members may generally provide emotional and physical resources in times of
need, there are large ethnic differences in the level of support provided and in the qual-
ity of support. The relation between social network variables and adherence is complex
(DiMatteo, 2004), and it appears that for some African American women, once again sit-
uational determinants as they relate to social networks may influence adherence behav-
ior as well. Consideration of how social network variables relate to adherence behavior
in diverse groups will be an important area of future research.
IMPLICATIONS FOR EDUCATION AND INTERVENTION
Prior research has suggested some important psychosocial differences between African
Americans and Caucasians—concerning health beliefs, the experience and reporting of
emotional distress, emotion regulation styles, coping, and social networks—and we have
suggested some pathways through which these variables may be germane to ethnic dif-
ferences in adherence and breast cancer treatment outcomes. In contrast to active research
in the consideration of hypertension, diabetes, and renal treatment, the cancer treatment
adherence literature is critically underdeveloped, and there are few studies that have con-
sidered the particular psychosocial characteristics that may relate to adherence.
In the interests of space, we have limited our comments regarding the important role
of both (a) sociodemographic and other patient characteristics (e.g., comorbidities) and
(b) possible racial or ethnic variations in breast tumor characteristics to treatment adher-
ence. This is not because these are not important considerations but instead reflect the
advantages of considering racial and ethnic differences in psychosocial, rather than exclu-
sively sociodemographic, terms (Consedine, Magai, & Conway, 2004) and the particular
class of interventions that is informed and capacitated by them. Compared to sociodemo-
graphics, racial and ethnic variations in psychosocial characteristics are comparatively
tractable, and thus eminently suited to intervention (Dusseldorp, van Elderen, Maes,
Meulman, & Kraaij, 1999). As noted, these characteristics vary across racial and ethnic
groups, suggesting that they may be partially responsible for the treatment disparities
noted by other researchers (Mandelblatt et al., 2004). Our review provides clear indica-
tions that aspects of cognition, emotion, emotion regulation, and social networks likely
contribute to treatment adherence for breast cancer. Specific implications for education
and intervention to be considered include
Providing women with educational interventions that enhance their understanding of how
effective treatments are, together with the changes in outcome they may expect as a func-
tion of adhering or not adhering to treatment-optimal schedules and dosages as one way in
which adherence could be increased.
Increasing provider awareness of the facilitative and impeding aspects of various psy-
chosocial characteristics of African American women, such as the socioemotional (emo-
tional dispositions, regulatory styles, and coping styles) and sociocognitive (beliefs about
treatment efficacy, medical mistrust, and perceived risk) representations that may influence
adherence to breast cancer treatment in African American women (Theunissen, Ridder,
Bensing, & Rutten, 2003).
Broadening our view of culture to include a worldview of individuals as we design inter-
ventions aimed at increasing adherence to breast cancer treatment. For African American
Magai et al. / Psychosocial Influences on Cancer Treatment 845
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women, this may be translated into the development of culturally sensitive materials,
sensitivity to communication about particular sociocultural issues (i.e., incorporating
issues related to secondary access, attention to specific obstacles to treatment adherence,
etc.), and more important, increasing the dialogue about issues that specifically affect
adherence to breast cancer treatment for African American women.
Ethnic differences in psychosocial variables are not only a barrier to effective
treatment—something to be worked around, ameliorated, or circumvented—but also
an opportunity to intervene. The identification of interracial or intergenerational dif-
ferences in emotion regulation, preference for self-reliance, and so forth, will enable
researchers to orient to interventions they might not otherwise have considered. For
example, in recent research we have explored how “empowerment-framed” breast
cancer screening messages (Consedine, Horton, Magai, Makoni, & Kukafka, 2007),
which capitalize on the preference for self-reliance among African Americans and
older adults at large (Magai et al., 2001), may be activated to facilitate breast screening
practices.
CONCLUDING REMARKS
In summary, in order to effectively capture culture-specific psychosocial aspects of
functioning that may differ between groups and contribute to poorer treatment adherence
and outcomes in African American women, we will need to tap the culture-permeable
aspects of cognition as well as emotion and social relations. We note also that although
we examine differences in adherence behavior among groups, the focus of this article is
not to highlight individual explanations for adherence disparities, rather to draw atten-
tion to those psychosocial factors that may usefully supplement our understanding of
adherence research and enhance our awareness of the complexity of treatment adher-
ence. We thus conclude this review with a call to action, urging researchers who study
cancer disparities to begin to study the influence of the full range of psychosocial vari-
ables on breast cancer treatment and to design interventions that will capitalize on cul-
tural competence in the service of closing the health disparities gap between minority
and majority populations.
Note
1. Consistent with our prior studies differentiating among ethnic subpopulations, we have used the term
African American” when describing disparities in adherence. However, in referring to prior studies, we have
elected to use the terms they have used because the absence of clean operationalizations makes it difficult to
determine exactly who is being referred to.
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    • "However, associations between social support and participation in health care have received less attention in the literature. Perceived social support may affect receipt of cancer follow-up care through the availability of practical assistance obtaining and attending appointments, or, as observed for other chronic health conditions, through creation of an emotionally supportive environment, which facilitates healthy behavior and treatment adherence16171819 . However , attendance at follow-up care appointments does not guarantee active participation in patient-centered care. "
    [Show abstract] [Hide abstract] ABSTRACT: Cancer survivors play an important role in coordinating their follow-up care and making treatment-related decisions. Little is known about how modifiable factors such as social support are associated with active participation in follow-up care. This study tests associations between social support, cancer-related follow-up care use, and self-efficacy for participation in decision-making related to follow-up care (SEDM). We also identified sociodemographic and clinical factors associated with social support among long-term survivors. The FOllow-up Care Use among Survivors study is a cross-sectional, population-based survey of breast, prostate, colon, and gynecologic cancer survivors (n = 1522) 4-14 years post-diagnosis. Multivariable regression models were used to test associations between perceived social support (tangible and emotional/informational support modeled separately), follow-up care use (past 2 years), and SEDM, as well as to identify factors associated with perceived support. Neither support type was associated with follow-up care use (all p > 0.05), although marital status was uniquely, positively associated with follow-up care use (p < 0.05). Both tangible support (B for a standard deviation increase (SE) = 9.75(3.15), p < 0.05) and emotional/informational support (B(SE) = 12.61(3.05), p < 0.001) were modestly associated with SEDM. Being married, having adequate financial resources, history of recurrence, and better perceived health status were associated with higher perceived tangible and emotional support (all p < 0.05). While perceived social support may facilitate survivor efficacy for participation in decision-making during cancer follow-up care, other factors, including marital satisfaction, appear to influence follow-up care use. Marital status and social support may be important factors to consider in survivorship care planning. Copyright © 2014 John Wiley & Sons, Ltd.
    Full-text · Article · Jul 2014
    • "The distinction is among secure attachment, and two or three insecure styles, that is dismissive, preoccupied, and fearful avoidant attachment. Whereas security is characterized by a positive view of the self and others, a desire for intimacy and closeness (Kachadourian, Fincham, & Davila, 2004), and the ability to balance autonomy and interdependence (Merz & Consedine, 2009; Merz, Consedine, Schulze, & Schuengel, 2009), dismissiveness is linked to a positive self/negative other view, emotional stoicism, difficulties with trust and reliance on others ( Magai, Consedine, Adjei, Hershman, & Neugut, 2008), and lower social support (Collins & B. C. Feeney, 2000; Kobak & Sceery, 1988). Preoccupation is associated with a negative view of the self, pessimistic views of relationships (Mikulincer, Shaver, & Pereg, 2003), and hyper vigilance to rejection (Kobak, Cole, Ferenz-Gillies, Fleming, & Gamble, 1993; Mikulincer, 1998) whereas fearful or fearful avoidant styles are associated with a negative sense of self, and view of others as untrustworthy, unreliable and rejecting. "
    [Show abstract] [Hide abstract] ABSTRACT: Attachment styles are associated with well-being across the life span. Particularly in later life, when individuals face declining health and increasing dependency, patterns of attachment may relate to affective outcomes. However, few studies have empirically examined the attachment-well-being link at the end of the life span or considered whether ethnic group membership may moderate attachment-well-being links. Data from a sample of older adults (N = 1,116) were used to investigate how secure, dismissive, and fearful/avoidant styles predicted well-being in 4 ethnic groups; African Americans, European Americans, Eastern European immigrants, and English-speaking Caribbean immigrants. As expected, both secure and dismissive attachment dimensions were related to greater well-being, whereas fearful/avoidant attachment was associated with less. This positive impact of a secure attachment style of relating to others on well-being was stronger among African Americans and English-speaking Caribbeans compared with the European American and Eastern European immigrant groups. The negative impact of a fearful/avoidant attachment style of relating on well-being was buffered by being an English-speaking Caribbean but not for the other 3 groups. Results are interpreted in light of general and culture-specific premises of attachment. The article concludes with some implications and suggestions for future work. (PsycINFO Database Record (c) 2012 APA, all rights reserved).
    Full-text · Article · Aug 2012
  • [Show abstract] [Hide abstract] ABSTRACT: The current study examines the association between family support and wellbeing in the elderly, paying particular attention to the possible moderating role of attachment style. Data from a community-dwelling, ethnically diverse, elderly sample (N = 1118) were analyzed to determine the best linear combination of emotional support, instrumental support, and attachment styles predicting wellbeing. Emotional support generally was associated with higher wellbeing whereas instrumental support was related to decreased wellbeing. As expected, however, these associations were qualified by attachment style. Receiving emotional support had stronger positive and instrumental support less negative effects on the wellbeing of elderly individuals with higher attachment security. Given increased longevity, family networks may become important sources of support for the elderly. Work detailing when, how, and for whom particular types of family support are beneficial is a key agenda within developmental psychology and social gerontology.
    Full-text · Article · Apr 2009
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