Date of Award

5-2025

Document Type

Dissertation

Degree Name

Doctor of Philosophy (PhD)

Program

Nursing Science

Research Advisor

Carolyn Graff

Committee

Athena Davenport; Betsy Tolley; Gregory Vidal; Ilana Graetz; Mona Wicks

Keywords

Breast Cancer, Distress Symptoms, Health Disparities, Hormone Receptor-Positive, Mental Health, Racial Differences

Abstract

Introduction. Depression is a pervasive mental health condition, often likened to the "common cold" of psychiatry due to its high prevalence, particularly among women. It significantly contributes to disability, personal suffering, and increased mortality, especially in the context of chronic illnesses like breast cancer. As one of the most common cancers affecting women globally, breast cancer not only poses physical health challenges but also engenders profound psychological distress, with rates of depression varying widely among patients. This emotional burden is exacerbated by the complexities of cancer treatment and the societal factors that influence health outcomes, particularly among racial minorities. Research indicates that women diagnosed with breast cancer experience significant rates of distress and depression throughout their treatment and survivorship phases. The co-occurrence of these psychological symptoms can complicate treatment adherence, leading to poorer health outcomes and quality of life. Notably, Black women face unique challenges, including systemic barriers to healthcare access, cultural attitudes toward treatment, and experiences of discrimination, which contribute to their lower adherence rates to adjuvant endocrine therapy (AET) compared to their White counterparts. Understanding the trajectories of distress and depression among breast cancer survivors, particularly through the lens of racial differences, is crucial for developing effective interventions that enhance psychological resilience and improve patient outcomes. This dissertation aims to explore the intersection of depression, treatment adherence, and racial disparities among women with early-stage hormone receptor-positive (HR+) breast cancer. By examining the psychological and psychosocial impacts of breast cancer across different stages of the disease trajectory, this research seeks to identify key predictors of distress and develop tailored interventions that address the unique needs of diverse populations. Ultimately, this work underscores the importance of a multidisciplinary approach to cancer care that prioritizes the mental health and well-being of all survivors.

Methods. This dissertation encompasses three distinct studies examining psychological distress and depression among women diagnosed with early-stage hormone receptor-positive breast cancer. The first study is a narrative review of literature that involved a systematic search of the PubMed and CINAHL databases, supplemented by Google Scholar to capture relevant articles published in English. Utilizing search terms such as "breast cancer," "distress," "depression," "trajectories," "racial differences," and "survivorship," a total of 24 studies were included based on criteria that focused on adult breast cancer survivors and examined psychological distress or depression as a primary outcome. The second study employed qualitative methods through four focus groups with 28 women, divided into two groups of Black women and two groups of White women, all diagnosed with early-stage hormone receptor-positive breast cancer. Participants were recruited from the West Cancer Center and engaged in discussions about their experiences with breast cancer diagnosis, treatment, and survivorship. These discussions were audio-recorded, transcribed, and analyzed using Saldana’s value-based coding method, which facilitated the identification of themes related to emotions, values, attitudes, and beliefs. The third study utilized a historical cohort design to assess the prevalence of distress and depression among women undergoing AET at the West Cancer Center from January 1, 2015, to December 31, 2019. A total of 1,501 patient charts were reviewed, yielding 122 eligible participants. Data were collected at five time points using the Patient Care Monitor (PCM), which captures patient-reported outcomes regarding treatment side effects and emotional symptoms. Distress and depression were measured using single-item scales ranging from 0 (not a problem) to 10 (as bad as possible), alongside sociodemographic and clinical characteristics to analyze their relationship with reported levels of distress and depression.

Results. The results of this dissertation reveal significant insights into the psychological distress and depression trajectories among women diagnosed with early-stage HR+ breast cancer. In the narrative review, diverse trajectories of psychological distress were identified, including stable low distress, acute distress with recovery, and persistent high distress, with studies indicating that Black survivors experienced consistently higher levels of distress compared to non-Hispanic White survivors. Notably, pre-existing mental health conditions were found to significantly influence these trajectories, underscoring the need for tailored interventions. The qualitative study highlighted six salient themes from focus group discussions with women undergoing AET, including Emotional Resilience and Support, Information Needs and Communication, Treatment Adherence Strategies, the Impact of Side Effects on Quality of Life, Spiritual Beliefs and Coping Mechanisms, and Healthcare System Navigation Challenges. Participants emphasized the critical role of emotional support and clear communication with healthcare providers while navigating treatment side effects and adhering to medication regimens. In the quantitative cohort study, baseline characteristics of 122 women showed significant differences in age and body mass index between Black and White participants, with Black women being younger and having a higher BMI. The prevalence of distress and depression at AET initiation was reported at 72.1\% and 75.4\%, respectively, with trends indicating an increase over time, particularly at the 12-month follow-up. Significant predictors of distress included a history of mental health diagnoses and baseline anxiety, while depression was associated with menopausal status and previous mental health conditions. Correlation analyses revealed that the total number of medications at diagnosis and AET initiation was significantly associated with distress and depression, suggesting that medication burden may serve as a proxy for other clinical predictors. Overall, these findings highlight the complex interplay of demographic, clinical, and psychosocial factors affecting the emotional well-being of breast cancer survivors, emphasizing the necessity for ongoing support and targeted interventions throughout their treatment journeys.

Discussion and Conclusion. This dissertation provides a multifaceted exploration of psychological distress and depression trajectories among women with hormone receptor-positive breast cancer, emphasizing the nuanced influences of race, mental health history, and social determinants on these experiences. The narrative review revealed a complex interplay of demographic and clinical factors affecting psychological outcomes, highlighting that while many survivors experience improvements in well-being over time, a significant number continue to face persistent challenges, particularly among Black women who may encounter systemic barriers and cultural stigmas that complicate their mental health journeys. The qualitative findings underscored the importance of personalized patient-provider communication and the role of emotional support systems in navigating treatment, with distinct differences in coping strategies observed between Black and White women. Specifically, Black women often drew strength from their faith and community, while White women expressed feelings of fear and isolation. In the quantitative analysis, pre-existing mental health diagnoses emerged as critical predictors of distress and depression, overshadowing race as a direct determinant, indicating that addressing mental health concerns is essential for improving psychological outcomes during adjuvant endocrine therapy. The moderate predictive ability of the models suggests the need for further research into additional unmeasured factors, such as social support and treatment adherence, which may also influence psychological well-being. Overall, these findings highlight the urgent need for culturally competent, holistic approaches to breast cancer care that integrate mental health support, tailored interventions, and ongoing follow-up to enhance the overall quality of life for all survivors. Future research should prioritize diverse populations and longitudinal studies to better understand the long-term impacts of treatment on mental health, ultimately contributing to more equitable healthcare practices and improved outcomes for women facing breast cancer.

ORCID

https://orcid.org/0009-0004-8556-1938

DOI

10.21007/etd.cghs.2025.0688

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