Breast cancer impacts many individuals despite continued research and development within the scientific field.

Received: 21 September 2018 Revised: 12 February 2019 Accepted: 16 February 2019

DOI: 10.1002/pon.5035

PA P E R

Comparing provider and patient views of issues for low‐ resourced breast cancer patients

Cassandra J. Enzler1 | Shioban Torres2 | Jennifer Jabson3 | Arin Ahlum Hanson4 |

Deborah J. Bowen5

1Public Health Department, UT Health Science

Center at Houston, Houston, Texas

2Community Health Sciences, Boston

University, Boston, Massachusetts

3Department of Public Health, University of

Tennessee, Knoxville, Tennessee

4Living Beyond Breast Cancer, Program

Administration, Bala Cynwyd, Pennsylvania

5Department of Bioethics and Humanities,

University of Washington, Seattle, Washington

Correspondence

Deborah J. Bowen, Department of Bioethics

and Humanities, University of Washington,

1959 NE Pacific Street A204, Seattle, WA

98195.

Email: [email protected]

Funding information

Centers for Disease Control and Prevention,

Grant/Award Number: 1 U58 DP005403

1018 © 2019 John Wiley & Sons, Ltd.

Abstract

Objective: The purpose of this study was to compare provider and patient views

from the same clinical settings on issues raised by low‐socioeconomic status (SES)

breast cancer survivors.

Methods: We conducted qualitative interviews among two groups: low‐SES breast

cancer survivors (n = 37) and medical personnel (ie, physicians, nurses, and navigators;

n = 8) who interact and serve with these patients from two geographically distinct

low‐resourced clinical settings. These semistructured qualitative interviews used

grounded theory to identify several potential themes, such as finances, resources,

and medical care. Transcripts were coded and summarized into themes.

Results: We analyzed each type of interview data separately then compared

patient and provider perspectives. From these qualitative interviews, we discovered

that low‐SES breast cancer survivors reported many unmet needs, including transpor-

tation, housing, health literacy, and language, among others. Providers reported that

many of these needs are served by the extensive network of supports surrounding

these patients.

Conclusions: These results illustrate that low‐SES breast cancer survivors have

unique needs that differ from other breast cancer survivors. Many providers feel that

these needs are being met, but patients have more diverse experiences. By better

addressing the links between resource needs and low‐SES breast cancer survivors,

quality of life can be improved.

KEYWORDS

comparative interviews, low‐resourced settings, patients, poverty, providers

1 | INTRODUCTION

Breast cancer impacts many individuals despite continued research

and development within the scientific field.1,2 In addition to increased

mortality, breast cancer negatively impacts an individual’s quality of

life.3-5 Breast cancer also has a financial impact with some individuals

accruing years of medical debt even after completing treatment.6,7 It is

critical to understand the needs of breast cancer patients, so the most

wileyonlinelibrary.

pressing needs can be addressed efficiently and effectively to support

their quality of life.

There is very little evidence about the unmet needs of low‐

socioeconomic status (SES) breast cancer survivors.8-10 These needs

may differ considerably from the needs of other higher SES women

affected by this disease; correlates of low‐SES include lower educa-

tion, poverty, and poor health, which can impact how low‐SES breast

cancer patients respond to their diagnosis and/or treatment.11-13

Psycho‐Oncology. 2019;28:1018–1024.com/journal/ponhttps://orcid.org/0000-0003-2420-4422mailto:[email protected]https://doi.org/10.1002/pon.5035http://wileyonlinelibrary.com/journal/pon

ENZLER ET AL. 1019

The aim of this study is to assess the needs of low‐SES breast cancer

patients from the perspective of the patient and the provider. Qualita-

tive interview methods were used to assess resource needs among

low‐SES breast cancer patients in two different low‐resourced sites.

We then interviewed providers from the same two sites who work

with low‐SES breast cancer patients.

2 | METHODS

Patients and providers were recruited from Boston Medical Center

and the University of Tennessee Cancer Institute. These locations

are safety‐net organizations that provide medical care and resources

for the population of interest and areas where living beyond breast

cancer (LBBC) has limited reach with the population. This study

received the Fred Hutchinson Cancer Research Center Institutional

Review Board (IRB) approval (reference number 9511). We focused

on both patient and provider samples for these interviews because

clinical impression provided support for the idea that these perspec-

tives would be different in some key ways that could inform future

intervention efforts. We include a consolidated criteria for reporting

qualitative (COREQ) checklist in the Table S1.

2.1 | Patient recruitment

We recruited 37 cancer patients overall (26 cancer patients, from Bos-

ton, MA and 11 from Knoxville, TN). In Boston, community health

workers from the Boston Public Housing Developments and Survivor-

ship Staff from Boston Medical Center recruited patients via fliers, in

person, or through medical records. Eligibility requirements included a

diagnosis of breast cancer, received or receiving treatment from one

of the medical centers, self‐identified as low income, and having

completed nomore than a high school education or living in public hous-

ing. Interviews were scheduled with patients if they were both eligible

and gave verbal consent to participate in the study. In Knoxville, we

recruited patients by contacting the University of Tennessee Cancer

Institute and local not‐for‐profit organizations, including support groups

that provide resources to low‐income women with breast cancer.

Interviews were scheduled with patients if they were both eligible and

gave verbal consent to participate. Each interview took between 30

and 69 minutes. Authors JJ and ST conducted the reviews.

2.2 | Provider recruitment

We also recruited providers and professionals that worked with low‐

SES breast cancer patients in Boston, MA and Knoxville, TN, including

oncologists, nursing staff, health educators, and patient navigators.

We invited these individuals to share their experiences via a

semistructured telephone interview if they were eligible and gave

verbal consent to participate. We also asked providers to refer us to

other providers or professionals, using snowball sampling, who might

be interested in participating in our study. Providers were eligible to

participate if they had at least 5 hours of interaction with low‐SES

breast cancer patients per week and were employed at either Boston

Medical Center or University of Tennessee Cancer Institute. We

recruited four providers from each institution, resulting in a total of

eight providers included in the study.

2.3 | Theoretical underpinnings

We identified no overarching theory of how low SES potentially

affects patient experiences. Therefore, we used a grounded theory

approach to these interviews, which allowed us to identify elements

of future theoretical models for subsequent research. The patient

interview was semistructured and included topics such as finances,

worries, and support programs and groups, among others. We also

encouraged patients to discuss topics that were not prompted by

the interviewer. We invited patients to share the met and unmet

resource needs that existed during their experiences with or because

of breast cancer. For providers, the interview guide included similar

topics, such as finance, support programs and groups, and medical

treatment, among others, affecting their low‐SES breast cancer

patients; we also encouraged providers to discuss topics that were

unprompted by the interviewer. Interview guides (please see Data

S1 and S2) were reviewed for validity by providers and patients at

each site to improve the quality of the interview guides.

2.4 | Analyses

For both types of interviews, we stopped interviewing when we

approached saturation within the interviews. We developed a draft

coding manual to initiate the process of coding. We then piloted this

manual with pilot interviews conducted for this purpose. We refined

both the guide and the manual and applied it to three of the real inter-

views to finalize it. Interviews were all audio‐recorded and transcribed,

and two coders analyzed each type of transcript separately by hand

using the initial draft of a coding guide, supplemented by codes iden-

tified by coders and investigators during the coding process. The two

coders discussed coding differences and resolved the conflicts until

80% agreement was reached. This was calculated with a simple

miss/hit calculation. We compared rural versus urban and provider

versus patient themes with visual inspection.

3 | RESULTS

Table 1 presents demographic and background data on all patients.

As seen in this table, most patients were women, with a mixture of

ethnic backgrounds. All patients were low income because of eligibility

criteria. Over half were not White, and less than half were married or

partnered. Most (70%) were previously diagnosed with breast cancer.

Table 2 presents a summary of the key themes that were discov-

ered after analyzing the patient and provider transcripts, which are

elaborated below. The key themes focus on finances, emotions,

support groups meeting needs, support groups not meeting needs,

the health care team, and social determinants of health. The key

themes are separated into patient and provider perspectives.

TABLE 1 Demographic characteristics of cancer survivors who par- ticipated in interviews

Characteristics Variables n, %

Gender Male 3 (12)

Female 23 (88)

Race/Ethnicity Black/African American 13 (50)

Hispanic/Latino 3 (12)

10 (28)

White

Age <40 2 (1)

40‐49 6 (15) 50‐59 9 (24) 60‐69 9 (24) >70 2 (1)

Type of cancer Breast 26 (70)

Cervical 2 (1)

Colorectal 5 (13)

Other 11 (16)

Number of times

diagnosed with cancer

1 31 (84)

2 5 (13)

3 1 (1)

Marital status Married/Domestic Partners 17 (46)

Never Married 7 (19)

Divorced 10 (27)

Widow 3 (8)

Education Less than high school 6 (23)

High school or GED 7 (27)

1‐4 years at university/college 9 (34) Bachelor’s degree 4 (16)

Master’s degree 0

Employment status Full Time 2 (1)

Part Time 17 (46)

Unemployed 18 (49)

Abbreviation: GED, General Education Development.

1020 ENZLER ET AL.

3.1 | Common themes among patients

Many cancer patients expressed difficulties or concerns that medical

costs were a burden. Several patients described having to choose

between medications and living expenses.

“If it gets too bad, where I can’t pay for the medicine,

then I weigh my option as [to] what I can get away

with and what I can’t. Then, I pay for what helps me

more…My finances have drastically changed a lot. That

kinda weighs on me a lot.” ‐Boston BC Patient

Several times, patients stated that a cancer diagnosis negatively

impacted their job or created difficulties in securing employment.

Many patients had difficulty paying daily living expenses.

“Financially, it was just hard, no real money coming in, so

it was just a struggle for everything, food, utilities,

everything that normal people would worry about.” ‐

Knoxville BC Patient

Many patients also expressed how treatment costs affected their

ability to afford adequate housing or provide for their family. Living

expenses that were commonly affected included rent, utilities, gas,

and food.

Several patients feared having to choose between living expenses

and meeting treatment recommendations. Some patients mentioned

having anxiety about future appointments because of limited money

for transportation. One patient from Knoxville expressed anxiety

about, “…how we were going to do everything, between the gas and

the medicines and the doctors.”

Some patients mentioned that breast cancer had multiple emo-

tional impacts. One person stated, “I’m a very healthy person other

than of course the cancer. I’ve been healthy my whole life, never

smoked or anything. And you’re just—just sad.” Others mentioned that

they were happy once treatment was over but felt depressed when

thinking of how breast cancer impacted their life. One patient from

Boston stated, “I was happy [after treatment]. I was happy, but I was

also depressed because of what I went through.”

Patients expressed several fears when told their diagnosis. Some of

the patients felt that they did not know, at first, who or where to turn

to for help, or what to expect after diagnosis. Several of the patients

expressed fear of the unknown or experienced anxiety during appoint-

ments. Many patients feared breast cancer recurrence. One patient

stated that their fear of recurrence was, “something black that you

have there. It’s fear that just shows up.” Several other patients worried

about the cancer metastasizing.

Several patients also mentioned that they eventually gathered

strength to accept their diagnosis and move forward with treatment.

One patient expressed, “I just took it as I need to just move forward

with my life.” Other patients mentioned gathering strength by focus-

ing on other health problems or the needs of their family. Some

patients highlighted multiple ways that support groups and programs,

both within the clinic and in the community, met their needs. Many

patients mentioned how support groups provide a social aspect during

their treatment, and several patients mentioned how strongly this

need was met.

“They have a website or a Facebook page where you can

go and talk about your latest problem and they give you

support from other cancer survivors and from nurses and

things like that. It’s very supportive.” ‐ Knoxville BC

Patient

Many patients mentioned that the support groups and programs

assisted with financial need. One patient stated, “…we got some finan-

cial help through some of the organizations to help with the gas and

the food.” Many patients also mentioned that the support groups

and programs provide healthy opportunities, such as camping or

white‐water rafting and personal development activities, such as

painting or pottery. Some patients expressed that social support

groups and programs provide opportunities for relaxation, such as

yoga and opportunities to learn more information about breast cancer

and treatment opportunities. A few patients mentioned how support

groups and programs provide emotional support. Overall, many

TABLE 2 Comparison of key themes for patients and providers

Key Themes Patient Perspective Provider Perspective

Patient finances serve as

barrier to high quality

care

Many patients expressed how cancer affected their ability to

work, which negatively impacted their financial wellbeing.

Many patients also expressed concerns with affording

treatment, housing, and transportation. However, many

patients expressed how resources within and outside of the

hospital provided financial assistance, even if it did not fully

meet their financial needs.

Many Providers mentioned that cancer negatively affected

patients’ finances, impacting rent, living expenses, and

transportation. However, many providers also mentioned

that most patients had insurance and that resources both

within and outside the hospital provided funds to assist

with medication and living expenses.

Negative emotions

hamper recovery

Several cancer patients expressed happiness when treatment

was over but felt sad when thinking about how much cancer

had impacted their life. Many patients expressed fear or

anxiety about the unknown, recurrence, or knowing what to

do or who to turn to. Several patients expressed gathering

strength and moving on.

Many providers mentioned that patients expressed anxiety

when thinking about paying for treatments and medication

in addition to living expenses.

Support groups available

to help

Many cancer patients expressed how support groups and

resources met several of their needs by offering financial

assistance, emotional support, relaxation opportunities, and

healthy activities.

Many providers expressed that support groups and resources

offered patients assistance with living expenses,

transportation, medical expenses and prosthetics, and

social support, as well as providing opportunities for

relaxation and healthy activities.

Support groups are

inadequate to meet all

needs

Several cancer patients expressed how support groups and

resources did not provide emotional support, adequate

transportation options, guidance on what to do or expect

past treatment, or support for family members.

Several providers expressed that some of their patients did

not or could not utilize support groups and resources

offered to them.

Health care team is

important source of

support and resources

Many patients expressed receiving support from their

oncologist and primary care doctor. Several expressed that

the hospitals provided a supportive environment and that

the medical team became like family to them. Several

patients also expressed relying on their doctors for

trustworthy information. However, several patients

expressed feeling uninformed about their health or how to

navigate medical resources. Several others expressed that

they felt the medical team was disconnected and

uncollaborative and that their PCP did not provide adequate

support or information. Many patients felt uninformed

about posttreatment expectations and expressed that their

PCP assumed the patients wants and needs. Additionally,

many patients felt that follow‐up appointments were burdensome either financially or as a time commitment.

Several providers expressed that patients receive information

about medical resources from social workers in the

hospital. Several providers also expressed how the medical

center was the main clinic for surrounding communities

and provided the same quality of care as those received by

higher SES populations.

Social determinants of

health impact care

… Many providers expressed how limited funding constrained resources and that patient financial insecurity also

contributes to inaccessibility of resources. Many providers

expressed how education and wealth causes differences in

health status or resource utilization between low‐SES and high‐SES cancer patients. Additionally, many providers expressed how low‐SES patients have fewer resources and support systems and that stress causes inaccessibility of

resources. Some providers also expressed how the location

of a patient’s residence can cause difficulty in accessing

resources.

Abbreviations: SES, low‐socioeconomic status; PCP, primary care provider.

ENZLER ET AL. 1021

patients expressed that nationally recognized cancer organizations

support their needs, although some women felt that these organiza-

tions were not helpful during their treatment.

Patients expressed how participation in support groups and pro-

grams did not meet several of their needs. Several patients mentioned

that resources did not provide emotional support. One patient stated

that support groups needed to provide, “… emotional support like a

psychiatrist that’s available just for cancer patients.” Some patients

also expressed inadequate preparation for what to do beyond

treatment, such as obtaining prosthetics or developing a healthy

lifestyle upon remission. Some patients mentioned that transportation

was inadequate, which resulted in difficulty meeting treatment recom-

mendations without private transportation. Several other patients

mentioned that services did not provide support for families. One

1022 ENZLER ET AL.

patient mentioned that poorly managed family stress made their

quality of life worse rather than better.

“And as much as I feel like we’ve got a lot of family folks

around. I don’t mean to disrespect the family people, but

sometimes I think they make you more sick than what

you are. They make you feel bad about this and that

and you know. Sometimes, I don’t think people heal

properly because of all the heavy stuff that they got on

them.” ‐Boson BC Patient

Patients expressed both negative and positive perspectives of the

medical team during treatment. Many patients expressed that the

oncologist ensured their needs were met, and some patients also felt

that their primary care doctor was supportive during their care.

Several patients felt that the hospital provided a supportive environ-

ment, and some patients viewed the medical team as family. Several

patients mentioned relying on their doctors for trustworthy

information.

Several patients had negative experiences with their primary care

providers (PCPs) or surrounding medical team. Several patients felt

uninformed about their health and how to navigate medical resources;

for example, one patient stated, “And sometimes I felt like I was not

really informed enough about my health and insurance…” In addition,

some patients felt that the medical team was disconnected or that

medical teams in various specialties did not collaborate for the

integrated health of the individual. Several patients felt very strongly

that their PCP did not adequately explain treatments and were

emotionally unavailable and unsupportive.

“But that’s one of the, I guess, worst things. I think also

the breast surgeons can probably be a little more—I

remember that when my breast surgeon called me at

work to tell me that I needed a mastectomy he was so

blunt about it. There was no like not feeling or

anything.” ‐Knoxville BC Patient

Many patients also felt strongly that PCPs did not inform them

about posttreatment expectations. Some patients stated that their

PCP assumed what they needed or wanted, such as prosthetics.

One patient questioned her PCP’s assumptions by saying, “I was like

did I say anything about wanting bigger breasts?” Several patients also

noted that follow‐up appointments were burdensome for them, either

financially or as a time commitment.

3.2 | Common themes among providers

Table 2 presents a comparison between patient and provider themes.

A prominent theme that providers discussed was patient financial

burden. All providers expressed that patients had access to or were

utilizing state sponsored insurance but whether this health coverage

was sufficient for the needs of the patients varied by provider. Several

providers mentioned that patients had adequate insurance while

others felt that patients lacked adequate health coverage. Some

providers stated that insurance did not cover prosthetics needed by

patients, such as lymphedema sleeves or cold caps.

Most providers mentioned that breast cancer negatively affected

patient’s living expenses. Several providers felt that breast cancer

affected transportation. One provider highlighted how difficult it was

for low‐SES breast cancer patients to afford transportation by stating,

“… they can’t afford to either—can’t afford the gas or they can’t pay

someone to bring them.” Many providers also mentioned how difficult

it was for patients to pay rent or mortgage.

“If you’re talking about comparing them to people who

have higher…if you’re really putting your lens on SES

level, those are some of the main challenges I’m seeing.

Like really tangibly difficulties in both finances and in

housing.” ‐Boston BC Provider

Providers expressed several similar perspectives of patient fear

and methods of coping. Almost all providers strongly expressed that

low‐SES patients typically experience more anxiety and fear when

thinking about financing treatment in addition to current living

expenses.

“I will tell you that patients who come from disparate

backgrounds tend to, in my estimate, in my experience,

tend to worry much more about “How am I gonna pay

for this.” ‐Knoxville BC Provider

Many providers expressed that current support groups and

resources met many of the needs of the low‐SES populations.

All providers mentioned that support programs helped breast cancer

patients with living expenses, such as vouchers or money for food,

utilities, and rent.

“And when those needs were identified, then we provide

things like…essentially cover folks utilities or rent or

support for groceries or gas cards for transportation

needs.” ‐Knoxville BC Provider

All providers also expressed, several of them strongly, that current

resources connected patients with transportation services or offered

financial assistance for transportation. One provider stated that a

transportation method heavily utilized among patients allowed individ-

uals to, “…arrange to have this bus come and pick them up from their

house and bring them in to have their appointment.” Many providers

also mentioned that offered resources addressed needs, including

social support, relaxation, and opportunities for exercise and healthy

living. Several providers stated that patients could access support for

medical expenses and prosthetics through current resources. A few

providers also expressed that church and religious groups were useful

resources for low‐SES patients during treatment.

Providers felt that local and national organizations outside of the

medical center helped address low‐SES breast cancer patient needs.

Many providers said that collaborating with organizations provided

funds and resources that address patient needs. For example, Boston

providers mentioned that the American Cancer Society previously

sponsored a highly utilized event called “Look Good, Feel Better” that

ENZLER ET AL. 1023

helps low‐SES breast cancer patients obtain wigs and improve their

self‐esteem. While many providers felt that patients could utilize

resources and programs outside of the medical center, some providers

felt that low‐SES breast cancer patients did not or were unable to

utilize outside resources.

Providers expressed that most commonly low‐SES breast cancer

patients received information about medical resources and programs

through a social worker within the clinic. Several providers mentioned

that the medical center they worked at was the main clinic for the

surrounding community and region. While these medical centers

typically serve low‐SES populations, a few providers noted that the

medical treatment is the same quality as the care given to higher‐SES

populations. Several providers felt that the health status of low‐SES

populations differed from those classified as higher‐SES; one provider

mentioned that low‐SES individuals may not have access to a primary

doctor, “…so they tend to come in with more advanced cancers.”

Providers gave many reasons as to why low‐SES populations may

have different needs than those with higher SES. Many providers felt

that limited funding constrained current resources. Almost all

providers strongly felt that patient financial insecurity contributes to

inaccessibility of resources.

“Well, I mean I think when you have a higher income, you

don’t have any of the financial challenges that I just sort

of outlined for you with regard to paying for your bills and

having a home. Pay for your medicines, getting private

health insurance, having access to care and usually

having a financial buffer in your ability to take off work

and go get your cancer treated.” ‐Boston BC Provider

Many providers also felt that social determinants of health, such as

education or wealth, cause differences in health status or resource

utilization between low‐SES and high‐SES breast cancer patients. Some

providers mentioned that low‐SES populations have fewer resources

available in the home, such as computers or private transportation

options. Providers also stated that stress causes an inaccessibility of

resources among low‐SES populations. Several providers felt strongly

that low‐SES breast cancer patients have less support systems within

their social network, which creates difficulty in obtaining needed

resources. A few providers also mentioned that an individual’s

location of residence may result in difficult accessing resources.

4 | CONCLUSIONS

We wanted to discover unique needs of low‐SES breast cancer

patients from both an urban and a rural setting by conducting

interviews of these patients at the UT Cancer Institute and Boston

Medical Center. The patient and provider perspectives we captured

elucidated how low‐SES breast cancer patients have unique needs

that differ from those of other breast cancer patients and how views

of those needs differ between providers and patients.

Resources offered at both Boston Medical Center and UT Cancer

Institute were available to meet several low‐SES breast cancer patient

needs, such as living expenses and social support programs. These

resources are critical in providing needed support. However, patients

from both regions also expressed many unmet needs, while many pro-

viders expressed the adequacy of meeting these needs for many

patients. The gaps between providers and patients in perceptions of

these unmet needs highlight a gap in current resource offerings from

both locations. From these, data indicate that the linkages between

patient and resources to meet all the needs are not adequate.

Both low‐SES breast cancer patients and providers from both

regions expressed met and unmet needs that were specific to each

region, which demonstrates that resources are not spread universally

nor are the wants and needs of low‐SES breast cancer patients equal

across the country. As an example, low‐SES breast cancer patients

and providers from Knoxville agreed that transportation was a large

unmet need; however, low‐SES breast cancer patients and providers

from Boston discussed that this was less of an issue for their region.

Low‐SES breast cancer patients and providers from Boston, MA

expressed that housing costs were a large barrier for individuals. While

low‐SES breast cancer patients and providers from Knoxville, TN

mentioned that individuals had financial difficulties, homelessness or

eviction were more commonly expressed by patients from Boston,

MA. These differences could reflect differences in the effects of rural

versus urban poverty or differences in support offered by the institu-

tions or something else entirely. A different assessment of these

issues at multiple institutions might provide insight into the differ-

ences reported here.

There have been very few studies in the literature that focus solely

on the needs of low‐SES breast cancer patients. Studies assessing the

needs of breast cancer patients in the general population of breast

cancer survivors present different themes than those collected by this

study. In the general population of breast cancer patients, survivors

face many needs as well that include psychological care, information

about their disease, and coping mechanisms.14-16 Low‐SES breast

cancer patients in this study expressed some similar needs as those

represented in other studies, but they also had greater pressing needs

that were fundamental, including transportation options, financial

assistance, and posttreatment support. This could suggest that low‐

SES breast cancer patients face more difficulty with basic needs than

higher SES breast cancer patients. This also demonstrates that

national and regional breast cancer nonprofit organizations could fill

this gap in unmet needs and so support patients and providers better.

Future direction should include advocating for increased funding

to reduce resource gaps for low‐SES breast cancer patients and con-

tinuing to research the unmet needs for this population. Providers

need to maintain awareness of the diversity and complexities of needs

for low‐SES patients, as current resource provision does not seem to

cover all needs. As evidenced by this study, different regions may

result in unique needs for low‐SES breast cancer patients. Future stud-

ies should also assess why low‐SES breast cancer patients cannot

access or use existing support programs and services, as these reasons

may elucidate how to better serve this population without increasing

costs. Low‐SES breast cancer patients also have unique and unmet

needs beyond medical treatment. Improving resources outside of

1024 ENZLER ET AL.

medical treatment may allow low‐SES breast cancer patients to better

adhere to treatment or improve their health that has positive implica-

tions for health care expenditures.

4.1 | Clinical implications

These data indicate that there is more to be done to meet the needs of

low‐SES breast cancer patients. But more resources and dollars will

not completely fill the gaps observed. One implication is to better

connect the patients with the resources available, through multiple

communication channels, depending on the population. More long‐

distance resources might be made available for rural women or women

with transportation difficulties. Women at both sites expressed feeling

left out or disconnected from a more human touch. Perhaps peer or

navigator driven resources can be employed to fill that void. Providers

should not assume that because a resource was offered, it will be

perceived by the patients as available, free, and accessible.

4.2 | Limitations

The study had limitations that constrain the generalizability of the

findings. First, it was conducted in two specific geographic locations

that do not represent a population of low‐SES breast cancer patients.

The qualitative nature of the study prohibits us from assessing rates of

distress or concurrence between patients and providers. Finally, we

did not measure these issues over time, and a longitudinal study might

have identified changes that changed with distance from treatment.

Given the target of low‐SES women, we did not think measuring SES

in participants was necessary, but even among these women, it is pos-

sible to imagine variation in SES that could alter responding. All of

these could be addressed through future research.

Numbers do not total 100% because of missing data.

CONFLICTING INTERESTS

The author(s) declare(s) that there is no conflict of interest.

FUNDING INFORMATION

This journal article was supported by the grant or cooperative agree-

ment number, 1 U58 DP005403, funded by the Centers for Disease

Control and Prevention. Its contents are solely the responsibility of

the authors and do not necessarily represent the official views of

the Centers for Disease Control and Prevention or the Department

of Health and Human Services.

ORCID

Deborah J. Bowen https://orcid.org/0000-0003-2420-4422

REFERENCES

1. Bray F, McCarron P, Parkin DM. The changing global patterns of

female breast cancer incidence and mortality. Breast Cancer Res.

2004;6(6):229‐239.

2. McPherson K, Steel CM, Dixon JM. ABC of breast diseases. Breast

cancer‐epidemiology, risk factors, and genetics. BMJ (Clin Res Ed). 2000;321(7261):624‐628.

3. Baqutayan SMS. The effect of anxiety on breast cancer patients.

Indian J Psychol Med. 2012;34(2):119‐123.

4. Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A.

Depression and anxiety in women with early breast cancer: five year

observational cohort study. BMJ. 2005;330(7493):702.

5. Zimmermann T. Intimate relationships affected by breast cancer:

interventions for couples. Breast Care. 2015;10(2):102‐108.

6. Fenn KM, Evans SB, McCorkle R, et al. Impact of financial burden of

cancer on survivors’ quality of life. J Oncol Pract. 2014;10(5):332‐338. https://doi.org/10.1200/JOP.2013.001322

7. Jagsi R, Pottow JAE, Griffith KA, et al. Long‐term financial burden of breast cancer: experiences of a diverse cohort of survivors identified

through population‐based registries. J Clin Oncol Off J Am Soc Clin Oncol. 2014;32(12):1269‐1276.

8. Girgis A, Boyes A, Sanson‐Fisher RW, Burrows S. Perceived needs of women diagnosed with breast cancer: rural versus urban location. Aust

N Z J Public Health. 2000;24(2):166‐173.

9. Park BW, Hwang SY. Unmet needs of breast cancer patients relative to

survival duration. Yonsei Med J. 2012;53(1):118‐125.

10. Todd BL, Feuerstein M, Gehrke A, Hydeman J, Beaupin L. Identifying

the unmet needs of breast cancer patients post‐primary treatment: the Cancer Survivor Profile (CSPro). J Cancer Surviv. 2015;9(2):

137‐160.

11. Bradley CJ, Given CW, Roberts C. Race, socioeconomic status, and

breast cancer treatment and survival. Cancer Spectr Knowledge Environ.

2002;94(7):490‐496.

12. Farley TA, Flannery JT. Late‐stage diagnosis of breast cancer in women of lower socioeconomic status: public health implications. Am J Public

Health. 1989;79(11):1508‐1512.

13. Thomson CS, Hole DJ, Twelves CJ, Brewster DH, Black RJ, Scottish

Cancer Therapy Network. Prognostic factors in women with breast

cancer: distribution by socioeconomic status and effect on differences

in survival. J Epidemiol Comm Health. 2001;55(5):308‐315.

14. Akechi T, Uchida M, Nakaguchi T, et al. Difference of patient’s

perceived need in breast cancer patients after diagnosis. Jpn J Clin

Oncol. 2015;45(1):75‐80.

15. Degner LF, Kristjanson LJ, Bowman D, et al. Information Needs and

Decisional Preferences in Women With Breast Cancer. JAMA.

1997;277(18):1485‐1492.

16. Thewes B, Butow P, Girgis A, Pendlebury S. Assessment of Unmet

Needs Among Survivors of Breast Cancer. J Psychosoc Oncol. 2004;

22(1):51‐73.

SUPPORTING INFORMATION

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Supporting Information section at the end of the article.

How to cite this article: Enzler CJ, Torres S, Jabson J, Ahlum

Hanson A, Bowen DJ. Comparing provider and patient views

of issues for low‐resourced breast cancer patients. Psycho‐

Oncology. 2019;28:1018–1024. https://doi.org/10.1002/

pon.5035https://orcid.org/0000-0003-2420-4422https://doi.org/10.1200/JOP.2013.001322https://doi.org/10.1002/pon.5035https://doi.org/10.1002/pon.5035