Disparities in Psychological Distress and Coping Behaviors Amongst Patients with Indolent Hematologic Malignancies

Introduction: Patients with indolent blood cancers often do not have an indication for treatment at diagnosis and are recommended to undergo observation as the initial management strategy. This strategy may lead to psychological distress which is associated with decreased cancer-specific survival. In the US, there are significant racial disparities in survival for patients diagnosed with blood cancers, yet less is known about the basis for these differences. One potential contributor to disparities in survival is the differential impact of mental health comorbidities given that racial minorities living in the US disproportionately experience more psychosocial stress. The aims of this study are to evaluate for racial disparities in the level of cancer-related stress experienced by patients undergoing active observation for indolent blood cancers and to contrast coping strategy use by race.

Methods: This study employs use of existing data from a prospective observational research study where participants with indolent blood cancers managed by observation were asked to complete measures regarding sociodemographic background, health behaviors, cancer-specific stress, and psychological adjustment to cancer. Participants were enrolled from April 2016 to November 2020 and measures were obtained at study entry. Patients with chronic lymphocytic leukemia, follicular lymphoma, smoldering myeloma, and a B-cell lymphoma not otherwise specified were included. Race/ethnicity was defined into several categories: African American/Black, Asian, White, more than one race/other or Hispanic. For study comparison, patients were grouped into racially minoritized (Asian, Black or Hispanic/Latinx) and non-minoritized (White non-Hispanic) arms. Cancer-specific stress was assessed using the Revised Impact of Events Scale (RIES). Psychological adjustment to cancer was assessed using the Mental Adjustment to Cancer (MAC) scale which measures several types of coping responses. Patient health behaviors were also measured by self-report, including smoking status and physical activity. We used linear regression models to compare scores on the RIES to examine for differences in levels of cancer-related stress, in psychological adjustment to cancer on the MAC and in smoking status. A proportional odds model was used to compare levels of physical activity.

Results: 233 participants were enrolled into the study of which 11% self-identified as Black/African American, 5% were of Hispanic/Latinx ethnicity, 0.85% identified with both races and 1.3% identified as Asian. In multivariable analyses, minoritized patients had comparable levels of stress compared to White patients (mean difference of 0.06, 95%CI -0.39-0.50, p = 0.8). Notably, the racial minority group did report significantly higher responses of fatalism on the MAC scale compared to the White patient group (mean difference of 1.8, 95% CI 0.47-3.17, p = 0.01). A significantly higher percentage of patients in the racial minority group were active smokers (OR 12.2, 95% CI 2.0-72.7, p=0.01. There was no difference in levels of physical activity between the two groups (OR 1.01 95% CI 0.46-2.22, p = 0.99).

Conclusions: To our knowledge, this is the first study to evaluate for racial disparities in the level of cancer-related stress experienced by patients undergoing active observation for indolent blood cancers. Notable findings include significantly higher levels of fatalism demonstrated in the racial minority group in addition to higher levels of smoking. These findings align with prior studies demonstrating that cancer fear and fatalism tend to be higher in ethnic minorities, leading to a perception that developing cancer is out of one’s control and death is inevitable. As fatalistic beliefs can hinder engagement in preventative health behavior, this may negatively impact the health outcomes of racially minoritized groups with indolent blood cancers who may be less inclined to follow-up for surveillance and participate in active treatment when necessary. Moreover, fatalistic beliefs may promote detrimental coping behaviors such as smoking. These findings suggest that further steps must be taken, through both educational and psychological support, to address fatalistic beliefs about cancer in racial minority patients with indolent blood cancer.