Influential Factors in Black and White Breast Cancer Survivors’ Beliefs about Breast Cancer

Abstract

Purpose

Breast cancer beliefs are widely studied to improve preventative screening behaviors in women without cancer; however, limited research has examined breast cancer beliefs among breast cancer survivors. To fill this gap in research we investigated racial differences and the predicting role of influential factors (e.g., stage) in survivors’ beliefs about their breast cancer.

Methods

This study is a secondary analysis of data from the Narrowing Gap in Adjuvant Therapy Study (2006-2011), where Black (N=210) and White women (N= 149) were interviewed within 20 weeks following their breast cancer diagnosis and primary surgery in Washington D.C and Detroit, MI. Outcomes of this analysis were perceived susceptibility to a breast cancer recurrence and perceived severity of breast cancer. Bivariate analyses were conducted to assess racial differences in sample characteristics, and on the study outcomes. Adjusted multiple regression models examined correlates between independent variables (e.g., sociodemographic/clinical) and women’s breast cancer beliefs about susceptibility of a recurrence and disease severity.

Results

Most of the sample were Black women (58%), had breast-conserving surgery (64%), and were privately insured (67%). Black women reported higher perceived disease severity beliefs than White women (p= 0.004). Other associated factors with greater perceived severity beliefs included lower education (p=0.008), public health insurance (p=0.021) and greater levels of medical mistrust (p=0.016). In our adjusted multiple regression models’ women with lower satisfaction regarding financial aspects of their healthcare were more likely to have higher perceived severity beliefs (p=0.007); women with stage II cancer compared to stage I had greater susceptibility beliefs to a cancer recurrence (p=0.001).

Conclusion

We found racial differences in women’s perceived severity beliefs, and identified theory-based clinical and psychosocial correlates in survivor’s breast cancer beliefs by race. Specifically, women diagnosed at stage (II) compared to stage (I) reported greater perceived susceptibility to a recurrence. Survivors diagnosed at stage (I) and (III) cancers may serve as important target groups to monitor their surveillance and follow-up behaviors. This study contributes salient predictors in survivors’ beliefs about their BC and informs navigation strategies to improve cancer survivorship recommendations in the context of psycho-oncology and follow-up cancer care.

Introduction

While breast cancer (BC) incidence rates are higher among White women (130.8 per 100,000) when compared to Black women (126.7 per 100,000),¹the distribution of BC mortality is not equally shared across women in the U.S^{1,2 3} Black women bear the greatest burden of BC morbidity/mortality compared to all racial/ethnic groups of women. ^4,5 Reasons for survival disparities are multifaceted involving the underuse of adjuvant treatment, screening, late-stage diagnosis, as well as structural factors (e.g., medical mistrust), and inequality of social factors such as, health care access and neighborhood inequality. ^6-11 To better understand and improve disparities in breast cancer outcomes, such as mammography screening health beliefs are widely studied.^12-15 In fact, extensive research in BC beliefs from the general population of women has aided in successful mammography screening interventions;^16-19 however, limited research has observed breast cancer-related beliefs among BC survivors. ^20-22-23 To help fill this gap in research, the purpose of this study provides a robust description of BC survivors’ perceived severity and susceptibility of a cancer recurrence to determine racial differences and other important factors in survivors BC beliefs.

A deeper analysis of BC survivors’ beliefs about their cancer is critically important to better understand survivors screening behaviors and inform effective planning of navigation strategies during survivorship care, such as breast surveillance guidelines. ^24,25 While, there is a widespread of BC-related research on women’s perceived severity and susceptibility from the general population,^26-31 very few studies have observed susceptibility to a BC recurrence and disease severity among BC survivors.^{15,23,32 33} More recently we investigated Black BC survivor’s adjuvant treatment attitudes, and found women reporting higher susceptibility to a BC recurrence had more positive adjuvant endocrine therapy attitudes, and women with higher disease severity and susceptibility to a BC recurrence had more positive chemotherapy attitudes.¹⁵ Another study found a positive association with readiness for genetic counseling among high-risk BC survivors with greater perceived severity of their cancer. ²³ While these studies assessed important factors among BC survivors’ beliefs, the associated role of demographics (e.g., race, age) cultural factors, (e.g., medical mistrust) and health care related factors (e.g., health insurance) in survivors BC beliefs, is less understood.

Race-related beliefs may in part contribute to disparities in cancer care delivery³⁴, thus there is a need to examine whether racial differences exist in survivors BC beliefs, given much of what is known regarding racial differences in BC beliefs is drawn from women without cancer.^35-39 One study reported that low-income Black women did not perceive themselves to be more susceptible or to suffer more severely from BC, nor did they believe this for other racial groups across economic levels.³⁸ Conversely, another study found Black women compared to White women had greater susceptibility of being diagnosed.³⁹ Given, these studies have contributed to cancer screening advancements among minority women without a BC history, more work is needed to capture racial differences in survivors’ beliefs about BC to address BC survival dispairties.^40-42 Examining racial differences in survivors BC beliefs will extend current survivorship research and provide clinical professionals a well-rounded understanding of survivor’s health beliefs to inform behavioral interventions.

The goal of this study was to determine influential factors in survivors’ BC beliefs. Given that BC survivors are susceptible to late effects of treatment and have an increased risk of disease relapse in the breast or distant sites compared to women without a history of cancer, ^43-45 we utilized the Behavioral Model for Vulnerable Populations to guide this study.⁴⁶ An extension of Andersen’s original model,⁴⁷ the Behavioral Model for Vulnerable Populations posits that health care utilization is directly influenced by three domains: predisposing factors such as, demographic characteristics; (2) enabling factors such as, social, health care and community resources; and (3) need factors, which includes perceived need and actual need factors (e.g., treatment services and perceived health) based on health condition/illness. ⁴⁶ In this study we conceptualize BC survivors’ beliefs as a need factor domain examined through two-subscales (perceived susceptibility to a BC recurrence and perceived disease severity).

Methods

Setting and Population

This study is a secondary analysis of data obtained from the Narrowing Gap in Breast Cancer Adjuvant Therapy Study (2006-2011), an observational trial that investigated factors associated with receipt of adjuvant therapy in Black and White female breast cancer patients. Detailed methods and recruitment strategies has been previously described.⁴⁸ Women were recruited from 3 organizational health facilities including two NCI-designated Cancer Centers in Washington, DC and Detroit MI. Women included in the study: self-identified as Black/African American or White/European American, 21 years old or older, diagnosed with non-metastatic breast cancer, and <20 weeks past their definitive surgery. Institutional Review Boards from each participating site approved all study procedures (IRB Approval # 2016-0036).

Data collection

Trained clinical research assistants (CRA) screened 678 women for study eligibility from electronic pathology reports and appointment logs. CRA’s interviewed the women 3-months post-surgery utilizing a computerized telephone interview system (CATI). Clinical data were abstracted from medical records. Of the 477 women identified and meeting study eligibility requirements, 82% (N=395) were consented into the study. Due to missing clinical data and the exclusion of women who did not identify as Black/African American or White, 36 women were excluded from the analyses leaving a final analytic sample of 359.

Measures

The Behavioral Model for Vulnerable populations⁴⁶ guided selection of study measures from the three theoretical domains (predisposing, enabling and need), with consideration of vulnerable characteristics among BC survivors, such as adjuvant treatment use which characterizes their actual need of their cancer diagnosis (need domain). The primary outcomes of this study were perceived severity and perceived susceptibility of cancer recurrence. These outcomes utilized two subscales from the Adherence Determinants Questionnaire.⁴⁹ Four items captured women’s agreement or disagreement about their perceived severity (e.g., “There are many diseases more severe than my breast cancer”), and four items assessed agreement or disagreement on perceived susceptibility to a recurrence (“The chances I might develop cancer again are pretty high”) on a 5-point Likert scale. Items were reverse coded for each subscale when needed. Responses ranged from 4-20 for each subscale. (Perceived Severity: Cronbach’s = 0.41). (Perceived Susceptibility: Cronbach’s = 0.42).

Predisposing Factors

Predisposing factors included demographic information including age at the time of diagnosis and race (Black and White). Marital status was categorized (married/living as married or currently single. Employment was dichotomized as full time employed or other. Education was categorized (no college, some college, bachelors and above). Religiosity was assessed using Lukwago et al. 9-item scale. Higher scores from the scale were indicative of high religiosity (e.g., “I am often aware of the presence of God in my life”) (Cronbach’s alpha overall = 0.95) Collectivism assessed women’s connection with their family using Lukwago et al. 6-point Likert scale, where higher scores reflected greater collectivism.

Enabling Factors

Perceived racial discrimination in healthcare settings was ascertained using 7-items from the Race-Based and SES-Based experience scale. ⁵⁰ Women were asked questions to reflect on their experiences within the medical system (e.g., “felt like a doctor or nurse was not listening to what you were saying”). Similar to other studies responses were dichotomized to any versus none.^51,52A subscale from the Group-Based Medical Mistrust scale measured perceived level of group-based distrust in healthcare settings (Cronbach alpha= 0.84). ⁵³ Questions asked women to think about relationships between various racial/ethnic groups and the American medical system and to rate how strongly they agreed or disagreed. Higher scores reflected higher levels of medical mistrust. We used two subscales from The Patient Satisfaction Questionnaire Short Form (PSQ-18) to measure women’s satisfaction about financial aspects of their care (e.g., “I feel confident that I can get the medical care I need without being set back financially”) and their satisfaction with provider communication (e.g., Doctors sometimes ignore what I tell them). Higher scores were indicative of greater satisfaction with financial aspects and provider communication. ⁵⁴

Need Factors

Estrogen receptor status was dichotomized as ER-positive and ER-negative, breast cancer surgery was ascertained as mastectomy or lumpectomy, tumor size was described as <2cm or ≥ 2cm. Comorbidities were evaluated using the Charlson comorbidity index score.⁵⁵ Adjuvant treatment initiation to chemotherapy and radiation were medically abstracted from women’s medical records and categorized (yes vs. no).

Statistical Analysis

Descriptive statistics (means and frequencies) were computed to describe the characteristics of the sample. In bivariate analyses, p-values from F-test were used to assess differences on both outcomes and covariates (e.g. marital status, age) by race. Multiple regression models were employed to determine the association of covariates (e.g. perceived racial discrimination) with perceived severity and susceptibility scores. Multivariate analysis adjusted for predisposing (e.g., race, age, marital status) enabling (e.g., health insurance type) and need (e.g., comorbidities, BC stage) factors, consistent with prior research assessing BC screening utilization among BC survivors.^56-58 Normality assumptions were validated with Q-Q plots. All statistical analyses were conducted using SAS Version 9.4, using two-tailed alpha level of 0.05.

Results

Study Sample

Of the 359 BC survivors, most respondents were Black women (58.7%), diagnosed at stage I (46%), and privately insured (67%). Ages ranged from 25-89 (m=54 sd= 12) years. Table 1 shows that Black women are significantly different from White women in almost all domains and variables. For predisposing study variables Black women, compared to White women were less likely to have a college degree, more likely to be single, had higher ratings for religiosity, and reported higher collectivism. With regard to enabling factors, Black women were more likely to have public health insurance, reported higher levels of medical mistrust, were more likely to report health care discrimination and had less satisfaction toward financial aspects regarding the medical care they received. For need variables Black women had more comorbidities, higher prevalence of larger tumors (≥2cm), and higher initiation of chemotherapy and radiation when compared to White women.

Table: 1.

Descriptive statistics for breast cancer survivors by race N=359

	All Women	Black Women	White Women	P-value
	N (%) 359	N (%) 210 (58.0)	N (%) 149 (41.5)
Predisposing Factors
Education
≤HS diploma/GED	78 (21.7)	65 (18.1)	13 (3.6)
Some college	106 (29.5)	74 (20.6)	32 (8.9)	<0.001
Bachelors's or more	175 (48.7)	71 (19.7)	104 (28.9)
Marital status
married	182 (50.7)	74 (20.6)	108 (30.0)	<0.001
single	177 (49.3)	136 (37.8)	41(11.4)
HR Status
Negative	274(76.3)	154 (42.9)	120 (33.4)	0.113
Positive	85(23.6)	56 (15.6)	29 (8.0)
Tumor Size
≥ 2cm	152 (46.0)	104 (31.5)	48(14.5)	<0.001
<2cm	178 (53.9)	89 (26.9)	89 (26.9)
Age (M+SD)	54.8 (11.7)	54.1 (12)	55.7 (11.2)	0.197
Religiosity (M+SD)	16.8 +6.7	31.08+4.7	23.7 +7.0	<0.001
Collectivism (M+SD)	1.4 +0.5	1.54+0.59	1.3+0.5	0.007
Perceived Severity(M+SD)	9.8 +2.1	10.1+2.1	9.5+2.2	0.004
Perceived Susceptibility(M+SD)	9.7 +2.1	9.7+2.0	9.7+2.2	0.997
Enabling Factors
Insurance
Private	218 (67.7)	108 (33.5)	110 (34.1)	<0.001
Public	104 (32.2)	78 (24.2)	26 (8.0)
Employment
full time	210 (62.3)	64 (18.9)	63 (18.6)	0.084
not full time	127 (37.6)	126 (37.3)	84 (24.9)
Healthcare Discrimination
Any	116 (32.3)	92(25.6)	24 (6.6)	<.0001
None	243 (67.6)	118 (32.8)	125 (34.8)
Medical Mistrust (M+SD)	26.1 +6.8	29.1+6.0	22.0+5.5	<.0001
Communication(M+SD)	4.1+0.6	4.06+0.7	4.1+0.6	0.144
Financial Aspects(M+SD)	3.8 +0.7	3.8+0.7	4.0+0.8	0.021
Need Factors
Surgery type
Lumpectomy	230 (64.4)	141 (39.5)	89 (24.9)	0.154
Mastectomy	127 (35.5)	68 (19.0)	59 (16.5)
Stage
I	156 (46.4)	82 (24.4)	74 (22.0)
II	135 (40.1)	84 (25)	51(15.18)	0.161
III	45 (3.3)	29 (8.6)	16 (4.7)
Chemotherapy
Yes	141 (39.2)	97 (27.0)	44 (12.2)	0.001
No	218 (60.7)	113 (31.4)	105(29.2)
Radiation
Yes	214 (59.6)	141 (39.2)	73(20.3)	<0.001
No	145 (40.3)	69 (19.2)	76 (21.1)
Comorbidities(M±SD)	(1.6+1.7)	(1.8±1.8)	(1.4+1.5)	0.012

M=mean SD= standard deviation

Survivors perceived severity scores ranged from 4-18 (m=9.8; sd=2.19). Black women had higher scores (m=10.1; sd=2.1) compared to White women (m=9.5; sd=2.2). Scores for perceived susceptibility of a recurrence were similar across races with an overall range from 4-18 (m = 9.7; sd=2.15).

Bivariate

In bivariate analyses (Table 1), we found significant associations with perceived severity and susceptibility beliefs with the predisposing factors: race, religiosity and educational level. Black women were found to have higher perceived severity beliefs about their breast cancer than White women (p = 0.004). Women with higher education had lower perceived severity than women with lower education levels (p=0.008). Women who reported higher levels of religiosity were more likely to have greater perceived susceptibility of a cancer recurrence (p=0.029). Insurance type and medical mistrust were then most significant enabling predictors for perceived severity beliefs. Women with private insurance compared to those with public insurance had lower levels of perceived severity (p=0.021). For need factors, lower breast cancer stage (II) (p=0.023), and radiation (p<.0001) were linked with having higher perceived susceptibility to a recurrence; chemotherapy predicted greater perceived severity beliefs (p= 0.003). Perceived susceptibility to a cancer recurrence were similar across both racial groups.

Multivariate Analyses

Table 3. presents the results of the multiple regression models of women's perceived severity and susceptibility beliefs. It shows that race did not remain a significant factor for greater perceived severity beliefs among Black women (p= 0.4113), after controlling for potential confounder variables (education, stage tumor size, and health insurance). In our adjusted regression model for perceived severity, financial satisfaction was the only significant factor. Women with lower levels of financial satisfaction had higher perceived severity beliefs toward their breast cancer (p=0.006). When modeling perceived susceptibility breast cancer stage remained significant. Women with stage II cancer (p=0.001) had greater perceived susceptibility to a cancer recurrence compared to women with Stage I or III cancers.

Table 3:

Multivariable Analysis of women's perceived severity and susceptibility beliefs

	Perceived Susceptibility		Perceived Severity
	Estimate	p value	Estimate	p value
Predisposing Factors
Race
Black	0.18	0.638	0.38	0.344
White	Ref.		Ref.
Education
<HS diploma/GED	Ref		Ref.
Any college	−0.08	0.824	−0.2	0.615
Bachelors and above	0.27	0.506	−0.62	0.145
Marital status
Married	−0.01	0.949	0.43	0.171
Single	Ref.		Ref.
HR Status
HR positive	0.24	0.444	0.44	0.180
HR negative	Ref.		Ref.
Tumor Size
≥ 2cm	−0.59	0.088	−0.04	0.903
<2cm	Ref.		Ref.
Age	0	0.969	0	0.743
Religiosity			0.04	0.111
Collectivism	0.16	0.500	0	0.974
Enabling Factors
Employment
full time	−0.01	0.95	0.18	0.568
not full time	Ref.		Ref.
Insurance type
private	0.15	0.74	−0.38	0.422
public	Ref.		Ref.
Health care discrimination
Any	0.4	0.229	−0.03	0.911
None	Ref.		Ref.
Medical Mistrust	0.02	0.406	0.04	0.133
Communication	0.24	0.267	0.31	0.236
Financial Aspects	0.02	0.899	−0.52	0.007**
Need Factors
Breast Cancer Stage
Stage I	Ref.		Ref.
Stage II	1.18	0.001*	−0.28	0.443
Stage III	0.44	0.354	−0.01	0.976
Breast Cancer Surgery
Mastectomy	0.24	0.445	0.45	0.159
Lumpectomy	Ref.		Ref.
Chemotherapy
Yes	−0.28	0.382	0.57	0.091
No	Ref.		Ref.
Radiation
Yes	−0.44	0.169	−0.12	0.704
No	Ref.		Ref.
Comorbidities	0.08	0.398	−0.02	0.837

^*p<0.05

^**p<0.01

Discussion

Breast cancer (BC) survivors health beliefs are important drivers of their health behaviors^59,60 including adjuvant treatment decisions and uptake of preventative health care services.^15,23 Unfortunately, BC beliefs are understudied in BC survivors. To fill this gap, in BC survivorship research, we examined predictors of Black and White BC survivors’ perceived susceptibility to a cancer recurrence and perceived severity of their breast cancer. Black race, breast cancer surgery, education, health insurance type and medical mistrust were top predictors with perceived severity attitudes. In adjusted analysis, women with lower financial satisfaction in their health care had higher perceived severity; lower cancer stage was associated with greater perceived susceptibility to a recurrence.

Black women were found to have greater perceived severity compared to White women. This finding builds upon our earlier study where we investigated correlates of adjuvant treatment attitudes in Black BC patients, to build a deeper understanding of Black BC patients treatment decisions.¹⁵ In our study Black women with higher perceived severity levels was positively associated with positive chemotherapy attitudes.¹⁵ These findings suggest higher levels of perceived severity beliefs may heighten survivors fear appraisals toward BC and, result in optimal adherence to adjuvant treatment; however Black BC survivors have the highest non-adherence rates for adjuvant endocrine therapy and surveillance mammography, thus Black women’s adherence behaviors are complex.^58,61-63 One explanation behind Black women’s adherence behaviors may be supported by Black women’s higher ratings of medical mistrust and health care discrimination, which was observed in our sample. Higher medical mistrust contributes to the underuse of clinically recommended guidelines, in the context of cancer survivorship care. ^17,53,64 One study found greater mistrust in Black women was associated with their underuse of adjuvant therapies.⁸ Other studies commonly report the relationship between medical mistrust and impaired BC cancer screening rates, genetic counseling uptake and poorer satisfaction ratings in medical care.^53,64-66 Medical mistrust is a historical issue in the medical delivery system.^66,67 Further, the negative role medical mistrust plays in the uptake of cancer screening behaviors among Black women,^66,68 brings an imperative argument to further investigate pathways of mistrust from a survivorship delivery perspective. Future research should develop educational strategies to mitigate the negative effects from medical mistrust attitudes among Black women in support of their continuum of care.

Women’s educational level (predisposing factor), insurance type and satisfaction about financial aspects of their healthcare (enabling factor) were top predictors in survivors’ beliefs about their BC. Women with private insurance (vs. public insurance) reported greater susceptibility to a cancer recurrence. Black women with higher education (vs. lower education) had greater levels of perceived severity, which may illuminate why better cancer screening behaviors are associated among women with higher education (vs. lower educational levels).⁶⁹ In multivariable analysis higher levels of perceived severity were among women with lower satisfaction regarding their financial aspects of healthcare. Black women compared to White women were more likely to report lower levels of satisfaction for their healthcare finances in the sample. Similar findings reported that having financial concerns was a commonly unmet healthcare barrier among BC survivors following diagnosis.⁷⁰ Our findings bring special attention to the financial concerns Black women face in their cancer journey. Survivors with more financial concerns regarding aspects of their healthcare may be a targeted group to intervene and to support during survivorship.

Survivors clinical characteristics (e.g., stage) were influential factors in their BC beliefs. Regarding survivors’ beliefs about their susceptibility to a cancer recurrence, receipt of adjuvant treatment and breast cancer stage were top need predictors. When comparing women who had chemotherapy and radiation versus women who did not, greater perceived susceptibility to a recurrence was found among women with receipt of treatment. These findings suggest higher susceptibility beliefs toward a cancer recurrence are important in treatment utilization behaviors among women diagnosed with BC. In our final model, women with stage II cancer (vs. I) was the only predictor for having greater perceived susceptibility of a recurrence. One study obtained similar results, but measures were different, survivors with lower health literacy perceived a lower risk to a recurrence toward BC survivors diagnosed at earlier stages.⁷¹ While we did not observe racial differences in survivors perceived susceptibility, a prior study found that lower ratings of perceived susceptibility to cancer recurrence were more common among non-white BC survivors.⁷² Secondly, findings suggest a connection between surgery choice and beliefs, while insignificant there was a higher trend of greater perceived severity beliefs among survivors with a mastectomy versus a lumpectomy. Future studies should include survivor’s health beliefs as intervention targets and investigate whether there are behavioral differences in survivorship care among BC survivors diagnosed at earlier stages vs. later stage cancers.

Study Limitations

Limitations in this study include our cross-sectional study design, lack of surveillance and follow-up care variables (e.g., surveillance mammogram) and potential sampling biases. The majority of our sample were highly educated, had private health insurance, diagnosed at early stages (vs. later stage) and received breast surgeries with radiation for their BC; women diagnosed at later stages without a history of treatment may provide different results. Further, we must acknowledge that the majority of women in this sample had non-metastatic BC, thus our sample may not be generalizable to every women perspective with a history of BC.

Clinical Implications

This study provided new evidence regarding BC survivors’ beliefs about their cancer that should be considered in clinical practice and intervention development. While Black survivors reported greater perceived severity beliefs toward their cancer, their lower financial satisfaction regarding their health care may serve as a potential barrier for their continuity of care (e.g., physician visits), and/or completion of treatment. Clinicians should support and target survivors with financial challenges in their cancer journey. Additionally, BC survivors diagnosed with stage I and III reported lower perceived susceptibility to a cancer recurrence, women with these clinical characteristics may serve as intervention groups to monitor their follow-up care behaviors. Moreover, this study improves our understanding of survivor’s psychological responses about their cancer and provide context on potential determinants that may influence adherence to surveillance regimens, such as genetic counseling and surveillance mammograms among survivors.

Figure 1.

Behavioral Model for Vulnerable Populations

Table 2:

Bivariate Analysis of women's perceived severity and susceptibility beliefs

	Perceived Severity Attitudes		Perceived Susceptibility Attitudes
	N= 359		N=359
	Estimate	p value	Estimate	p value
Predisposing Factors
Race
Black	10.17+2.1	0.004	9.72+2.0	0.997
White	9.50+2.2		9.71+2.2
Education
<HS diploma/GED	10.44 ± 2.2		9.69 ± 2.2
Any college	10.04 ± 2.0	0.008	9.39 ± 2.1	0.143
Bachelors and above	9.55 ± 2.2		9.92 ± 2.1
Marital status
Married	9.84 ± 2.0	0.657	9.73 ± 2.2	0.924
Single	9.94 ± 2.3		9.70± 2.0
HR Status
HR positive	10.24 ± 2.0	0.098	9.80 ± 2.2	0.670
HR negative	9.78 ± 2.2		9.69 ± 2.1
Tumor Size
> 2cm	9.99+2.0	0.583	9.66+2.2	0.889
<2cm	9.74+2.2		9.74+2.1
Age		0.701		0.368
Religiosity		0.365		0.053
Collectivism		0.089		0.902
Enabling Factors
Employment
full time	9.78+2.3	0.405	9.61+2.3	0.831
not full time	9.99+2.0		9.66+1.9
Insurance type
private	9.78+2.1	0.021	9.73+2.1	0.853
public	10.54+2.1		9.67+2.2
Health care discrimination
Any	10.13+2.0	0.157	9.61+2.1	0.196
None	9.77+2.2		9.93+2.0
Medical Mistrust		0.016*		0.524
Communication		0.905		0.694
Financial Aspects		0.003		0.447
Need Factors
Breast Cancer Stage
Stage I	9.84 ± 2.7		9.42 ± 1.8
Stage II	9.88 ± 2.2	0.733	10.10 ± 2.3	0.023*
Stage III	10.14 ± 1.8		9.47 ± 2.4
Breast Cancer Surgery
Mastectomy	10.12+2.1	0.132	9.91+2.0	0.211
Lumpectomy	9.75+2.2		9.61+2.1
Chemotherapy
Yes	10.19+2.1	0.037	9.55+2.2	0.242
No	9.69+2.1		9.82+2.0
Radiation
Yes	9.78+2.2	0.273	9.50+2.1	0.021
No	10.04+2.1		10.0+2.1
Comorbidities		0.446		0.790

^*p<0.05

^**p<0.01