Depression emerged as a significant barrier to secondary cancer screening in Latina survivors of breast cancer in a thought-provoking study released Sept. 19 at the American Association of Cancer Research Conference on the Science of Cancer Health Disparities in Washington.
The cross-sectional study explored adherence to recommended screening guidelines for ovarian and colorectal cancer among 117 Latina breast cancer survivors. Not surprisingly, but disturbingly, adherence was low among this very-high-risk group. Nearly 60% (69 of 117) failed to receive standard screening for either disease.
By Betsy Bates Freed, Psy.D.
One would hope that these high-risk women knew, based on their prior treatment, how to negotiate financial and logistical barriers to care. It would seem likely that they formed relationships with health care professionals. Certainly, it would be expected that they learned that early detection saves lives; perhaps, it had already saved theirs.
So what happened? How did the prevention message fail to reach women who had already directly faced the reality of a cancer diagnosis, and survived?
One sobering possibility lies in the fact that nearly a third of Latinas in the study met the criteria for depression, according to scores for the simple but comprehensive CES-D (Center for Epidemiologic Studies) screening tool.
The self-administered questionnaire assesses mood "("I felt that I could not shake off the blues, even with help from family or friends"; "I [did not] feel hopeful about the future"), somatic symptoms ("I did not feel like eating; my appetite was poor"), behavior ("I talked less than usual"), and self-concept ("I thought my life had been a failure").
Depression was associated with poor rates of ovarian screening, along with language barriers, unemployment, worries about the cost of screening, and the lack of a family history of cancer.
Poor rates of colorectal cancer screening were associated with being unmarried.
In online video interview from a 2010 AACR breast cancer meeting, the current study’s primary investigator, Amelie G. Ramirez, Dr. P.H., spoke of challenging issues surrounding Latina access to cancer prevention and care, driven by cultural as well as socioeconomic issues.
Sheer terror of cancer, she explained, wields a powerful influence over portions of the Latina community.
"When they hear the word cancer, it’s very fearful for them. It almost shuts down all ... communication," said Dr. Ramirez, director of the Institute for Health Promotion Research and professor of epidemiology and biostatistics at the University of Texas, San Antonio.
Depression, too, casts a dark, silent cloud over the Latino community.
In a 2009 study, University of California, Los Angeles, researchers identified a strong link between self-perceived stigma and secrecy surrounding depressive symptoms, less likelihood of taking antidepressants, and – importantly with regard to the current screening study – more missed medical appointments among Latinos.
Taken together, these studies and observations begin to paint a picture of the type of woman whose life might be reflected in the numbers in Dr. Ramirez’s study. She is poor and unemployed; she struggles with English. She survived a disease that is unspeakably terrifying in her community and perhaps in her family as well. She may be unmarried.
And now, with bills and scars still reminding her of the trauma, a new, equally unmentionable burden shadows her days. She sleeps restlessly and cannot eat; she is quiet and withdrawn; she cannot shake off the blues. She feels that her life has been a failure.
Assuming the best possible scenario, a card arrives in the mail, reminding her that she is due for cancer screening: an annual pelvic exam, perhaps, or a colonoscopy.
Is it any wonder she fails to comply?
Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist. She has no relevant financial disclosures.