ORI GI NAL PAPER

Cancer Patient Ethnicity and Associations with Emotional

Distressthe 6th Vital Sign: A New Look at Dening Patient
Ethnicity in a Multicultural Context
Bejoy C. Thomas Linda E. Carlson
Barry D. Bultz
Published online: 5 September 2008
Springer Science+Business Media, LLC 2008
Abstract Variations in access to care, utilization of
available resources and treatment outcomes in the context
of ethnicity have been recognized, but very little research
of this nature exists in the oncology context. The present
paper is an in-depth analysis of data on a large represen-
tative sample of Canadian cancer patients with a focus on
the role of ethnicity, its association to psychological
distress, and its impact on the cancer experience. Because
of a heterogeneous representation of ethnic self-identi-
cations which were not easily grouped or classied,
English as a second language was considered as a surrogate
marker to ethnicity. People who self-reported to be from an
English-speaking country were grouped together and
compared to those hailing from countries which do not
have English as a primary language. In a hierarchical
logistic regression model (n = 2,402) the demographic and
cancer-related variables associated with signicant clinical
distress in the rst block were gender (male, except those
with prostate cancer), age less that 68 years, less than a
year since diagnosis, diagnosis of lung cancer, and recur-
rent disease. In the second block, after controlling for the
inuence of these factors, patient-reported ethnicity (being
originally from a non-English speaking country) added
signicantly to the prediction of patient distress. Though
compelling, there is a need to understand the relationship
between the ethnic features and language (English versus
non-English language). A hypothesis is presented as an
attempt to understand an individuals ethnicity within the
framework of a multicultural society.
Keywords Ethnicity Distress Screening
Acculturation Malignant neoplasm
Background
Incidence of high levels of emotional distress amongst
cancer patients in North America ranges from 35% to 45%
[1, 2]. Similar incidence rates are reported from Asia [35],
the Middle East [68], Europe [911] and South America
[12]. Awareness of this problem is reected in the Cana-
dian Strategy for Cancer Controls endorsement of
Emotional Distress as the 6th vital sign in Cancer Care in
June 2004 [13, 14] with the implication that psychosocial
distress be monitored and treated in all patients on a regular
basis. It has also been recommended as a standard of care
by the Institute of Medicines 2008 report [15], and become
part of the Canadian Council of Health Services Accredi-
tations 2009 guidelines [16]. Clinical studies have
repeatedly demonstrated patient benets from psychosocial
care in terms of improved quality of life, decreased distress
and better treatment adherence [1, 2, 1719]. However,
these intervention studies have rarely been ethnicity-spe-
cic, with the focus of this literature almost entirely on
non-Hispanic Whites [20].
This is a problem, because ethnic minorities have higher
rates of some cancers, as well as other documented out-
come disparities compared to Caucasians. For example, in
the United States (U.S.), the cancer death rate is on a
steadily declining trend, though not uniformly across ethnic
B. C. Thomas (&) L. E. Carlson B. D. Bultz
Department of Psychosocial Resources, Tom Baker Cancer
Centre - Holy Cross Site, Alberta Cancer Board, 2202 2nd St.
S.W., Calgary, AB, Canada T2S 3C1
e-mail: tombejoy@cancerboard.ab.ca; bejoyct@gmail.com
B. C. Thomas L. E. Carlson B. D. Bultz
Department of Oncology, University of Calgary, Calgary, AB,
Canada
1 3
J Immigrant Minority Health (2009) 11:237248
DOI 10.1007/s10903-008-9180-0
and racial groups [21]. This is especially the case among
Black men, who have 25% higher incidence rates and 43%
higher mortality rates than White men for all cancers
combined. Canadian cancer statistics disaggregated by race
and/or ethnicity are not currently available [22]a large
gap in our understanding of the magnitude of any Canadian
disparities. Ethnic disparities are also present in terms of
screening behavior and follow-up of abnormal ndings [20,
2326], length of survival [21, 27, 28], quality of life [20,
29, 30], adherence to treatment [31], and access to ade-
quate care and interactions with physicians [20, 32], all to
the disadvantage of ethnic minority populations.
These disparities are not necessarily because people are
from a different country or racial background. In fact, the
psychosocial impact of cancer seems to be globally con-
sistent and comparable across nations when people are
assessed in their home country. For example, psychosocial
oncology research from Indiain general cancer popula-
tions [33] and breast cancer survivors [34], Chinain
breast cancer survivors [35] and Japanin breast recon-
struction patients [36], show comparable psychosocial
distress to ndings seen in non-Hispanic White cancer
patient populations in the U.S. [20, 33, 34]. Hence, it
appears these ethnic disparities are related to the status of
individuals as immigrants to a new country, rather than
their heritage or racial background.
A recent review has highlighted the signicant lack of
attention to the inclusion of minorities (or other under-
served populations) in current cancer survivorship
initiatives, pointing out a need for culturally sensitive
programs [37]. It is recognized that the road of cancer
diagnosis, treatment and survivorship is traveled differently
by individual cancer patients depending on an individuals
ethnicity, socio-economic status, culture, gender and age
[37]. However, despite such recognition this aspect has
received little serious empirical investigation. The goal of
the present study is to explore the relationships between
patient ethnicity and emotional distress.
Current Study
In 2004 a study from the Tom Baker Cancer Centre mea-
sured levels of distress and fatigue in cancer patients [1].
Patient ethnicity was one of the questions that were posited
to the respondents. The published study did not explore in
detail the role of ethnicity in distress or psychosocial
treatment preferences. We now present the results of the
relationship of patient ethnicity to emotional distress. The
study was approved by the Conjoint Health Research
Ethics Board of the Faculty of Medicine and Tom Baker
Cancer Centre (TBCC). More than 3,000 patients of het-
erogeneous diagnoses were assessed using the Brief
Symptom Inventory-18 (BSI-18) [38] to identify distress.
Further details on the process of data collection are docu-
mented elsewhere [1].
Methods
Measures
Brief Symptom Inventory 18
Published in 2001 [38], the BSI 18-item instrument is
shortened from the original Symptom Checklist (SCL-90-
R) [39] and the 53-item Brief Symptom Inventory (BSI)
[40] and has been normed for use with cancer patients. The
BSI yields three subscale scores: Somatization, Depression
and Anxiety, with internal consistencies ranging from 0.74
to 0.89, and correlations with the longer BSI ranging from
0.91 to 0.96. A composite score, the General Severity
Index (GSI), also shows similar high levels of reliability.
Average completion time is 13 min. In screening for
distress in the cancer population cut-off values as dened
by Zabora et al. [41] were used.
Classifying Ethnicity as a Psychological Construct
Patients were given the opportunity to self-report their ethnic
status by lling in a blank labeled ethnicity. This self-
reported ethnic identity yielded 82 different categories of
single ethnicity (e.g. Iranian, Brazilian, Hungarian, Brit-
ish, or Korean) and 45 multiple ethnicity groups (e.g.
Ukrainian/German, Dutch/British, etc.). These were cate-
gorized into 20 peoples groups (Fig. 1) based on geographic
distribution. However, reasonable reclassication to fewer
homogeneous subgroups could not be made. Even in terms of
a continental comparison (African versus Asian versus
European) the within-group heterogeneity seemed rather
high, and population sizes highly varied (e.g. only 9 patients
from the African continent which included South Africa,
Egypt, Ethiopia, etc. compared to 121 people from Asia).
In the previously published manuscript four groups were
createdCanadian, British, European, and others. However,
the other group had a large a variance culturally, geo-
graphically, and socially. It also lacked a common factor
besides being non-Canadian, which arguably British and
European were as well. Grouping by language of origin
seemed more likely to encompass similar challenges to
people immigrating to an English-speaking part of Canada.
Therefore, patients (73% of the patients) from countries
where English was the ofcial rst language (English rst
language countryEFLc) were compared to patients (27%
of the patients) from a non-English rst language country
(non-EFLc). Neither of these methods of classication were
238 J Immigrant Minority Health (2009) 11:237248
1 3
optimal, due to problems with heterogeneous groups and
samples sizes. It is useful to note however, that whether
participants were divided on this basis, or on the basis of
country of origin as described above, the results were
essentially the same.
Participants
Questionnaires were distributed to 3,095 patients, over
90% of all patients visiting the centre over the data col-
lection period. Approximately 10% (319 patients) did not
complete the questionnaires, due to reasons such asnot
interested (43.5% of decliners), cannot read English
(13.2%), feeling too sick (11%), too rushed (10.7%), too
tired (6.6%), and other (15.4%). Of the 2,776 patients that
did provide data, 13% (374 patients) did not provide details
on their ethnicity. Therefore for the present study, the valid
sample size was 2,402 cancer patients (77.6% of those
approached and 87% of those who provided data).
Statistical Analysis
In order to study the role of patient ethnicity in psycho-
social and disease outcomes, hierarchical logistic
regression analysis was used to assess predictive relation-
ships of relatively permanent demographic variables on the
outcomes of distress. Patients gender, age, income, edu-
cation, time since diagnosis, recurrence and cancer
category were entered into the regression model as block 1
(Table 1). The language surrogate of ethnicity (EFLc/non-
EFLc) however was entered into the regression model as
block two.
Results
Psychosocial Distress
The mean BSI GSI scores of the all the ethnic peoples
groups were plotted (Fig. 1). The mean score of those who
identied themselves as Canadian (host nation) were used
as the point of comparison for the other groups. Visual
observation suggests that patients who identied with a non
English rst language country had consistently higher
distress scores, patients originating from Japan being the
only exception, compared to the Canadian mean, but due to
wide variation in sample sizes no formal statistical com-
parisons across these groupings were conducted.
Results of the hierarchical logistic regression are pre-
sented in Table 2. In the rst block of the regression,
positive predictors of the Somatization subscale were being
male (OR = 1.57, CI = 1.192.08), below the age of
70 years (age was divided by the 33.3rd and 66.6th per-
centilespatients \54 years: OR = 1.43, CI = 1.081.9;
patients aged 5469 years: OR = 1.38, CI = 1.071.79),
having an annual income less that $40,000 (OR = 1.71,
CI = 1.382.12), less than a year since the diagnosis
(OR = 1.37, CI = 1.051.79), with recurrent/metastatic
disease (OR = 2.06, CI = 1.672.54), having Haemato/
Lymphoproliferative cancers (OR = 1.67, CI = 1.72.37)
and lung cancer (OR = 2.49, CI = 1.544.03). Patients
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Fig. 1 Overall BSI scores
across categories
J Immigrant Minority Health (2009) 11:237248 239
1 3
with prostate cancer however, had signicantly lower odds
of reporting distress on the Somatization subscale
(OR = 0.62, CI = 0.40.96). Introducing the ethnicity
variable in the second block added to the explanatory
power of the model (change in the log likelihood = 4.97,
degrees of freedom = 1, signicance = 0.026); the non-
EFLc patient predicted a higher Somatization score
(OR = 1.3, CI = 1.031.62).
Positive predictors of the Depression subscale (block
one) were being below the age of 54 years and between 54
and 69 years (OR = 2.48, CI = 1.853.34; OR = 1.59,
CI = 1.222.08, respectively), an annual income less than
$40,000 (OR = 1.86, CI = 1.52.31), with recurrent/met-
astatic disease (OR = 2.19, CI = 1.732.78), having lung
cancer (OR = 2.55, CI = 1.584.11), and having a cancer
of the head and neck (OR = 1.69, CI = 1.042.76).
Introducing the ethnicity variable in the second block
added to the explanatory power of the model (change in the
log likelihood = 5.08, degrees of freedom = 1, signi-
cance = 0.024); the non-EFLc patient predicted a higher
Depression score (OR = 1.3, CI = 1.041.64).
Positive predictors of the Anxiety subscale in the rst
block were being male (OR = 1.46, CI = 1.11.94),
below the age of 70 years (patients\54 years: OR = 2.29,
CI = 1.683.1; patients aged 5469 years: OR = 1.59,
CI = 1.212.1), less than a year since the diagnosis
(OR = 1.34, CI = 1.011.76), with recurrent/ metastatic
disease (OR = 1.7, CI = 1.342.17) and having lung
cancer (OR = 1.99, CI = 1.243.19). Adding the ethnicity
variable in the second block (being in the non-EFLc cate-
gory) did not predict an increase or decrease in Anxiety
score, and therefore did not signicantly add to the
explanatory model (change in the log likelihood = 3.31,
degrees of freedom = 1, signicance = 0.069).
Positive predictors of Global Severity (block one) were
being male (OR = 1.41, CI = 1.071.86), below the age of
70 years (patients\54 years: OR = 1.93, CI = 1.452.58;
patients aged 5469 years: OR = 1.46, CI = 1.121.89),
an annual income less than $40,000 (OR = 1.62, CI =
1.312.01), within a year of diagnosis (OR = 1.5, CI =
1.151.96), with recurrent/metastatic disease (OR = 2.41,
CI = 1.93.05) and having lung cancer (OR = 1.93, CI =
1.233.1). Patients with prostate cancer however, had sig-
nicantly lower odds of reporting distress on the Global
Severity (OR = 0.54, CI = 0.350.84). Introducing the
ethnicity variable in the second block added to the explan-
atory power of the model (change in the log likelihood =
5.02, degrees of freedom = 1, signicance = 0.025); the
Table 1 Variables used in the
hierarchical logistic regression
with respective referent
categories
Variable Subgroup n % Category
Gender Male 1,141 47.5
Female 1,257 52.3 Referent
Age \54 770 32.1
5469 807 33.6
[69 806 33.6 Referent
Income \$40,000 990 41.2
[40,000 1,173 48.8 Referent
Education No college education 1,097 45.7
With college education 1,157 48.2 Referent
Time since diagnosis \1 year 902 37.6
13 years 639 26.6
[3 years 801 33.3 Referent
Recurrence Yes 801 33.3
No 1,601 66.7 Referent
Cancer category Haemato/lymphoproliferative 331 13.8
Gynecological 167 7.0
Digestive/gastrointestinal 273 11.4
Other 289 12.0
Lung 144 6.0
Head and neck 130 5.4
Prostate 420 17.5
Breast 569 23.7 Referent
Patient from English First
Language country (EFLc)?
No (non-EFLc) 653 27.2
Yes (EFLc) 1,749 72.8 Referent
240 J Immigrant Minority Health (2009) 11:237248
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Table 2 Hierarchical logistic regression analysis of factors predicting BSI-18 scale and subscale score identied distress
Variable Subgroup b SE Wald (df = 1) P Exp (b) 95% CI for Exp (b)
Somatisation
Block 1
Gender Male 0.454 0.142 10.252 0.001** 1.574 (1.192.08)
Age \54 years 0.36 0.146 6.085 0.014* 1.433 (1.0771.907)
5469 years 0.322 0.132 6.019 0.014* 1.381 (1.0671.786)
Income \$40,000 0.536 0.109 24.209 0.000** 1.709 (1.382.115)
Education Without college education -0.023 0.17 0.144 0.833 0.978 (0.7931.205)
Time from
diagnosis
Less than 1 year 0.315 0.136 5.397 0.02* 1.371 (1.051.789)
13 years 0.16 0.134 1.427 0.232 1.174 (0.9021.527)
Recurrence Yes 0.831 0.12 48.355 0.000** 2.296 (1.8172.903)
Cancer site Haemato/lymphoproliferative 0.51 0.18 7.987 0.005** 1.665 (1.1692.371)
Gynecological 0.026 0.21 0.016 0.9 1.027 (0.681.548)
Digestive/gastrointestinal 0.055 0.197 0.077 0.781 1.056 (0.7181.554)
Other -0.12 0.2 0.359 0.549 0.887 (0.61.312)
Lung 0.914 0.245 13.944 0.000** 2.493 (1.5444.028)
Head and neck 0.139 0.249 0.313 0.576 1.149 (0.7061.872)
Prostate -0.474 0.222 4.548 0.033* 0.623 (0.4030.962)
Block 2
Gender Male 0.449 0.142 10.001 0.002** 1.567 (1.182.07)
Age \54 years 0.353 0.146 5.834 0.016* 1.423 (1.0691.895)
5469 years 0.321 0.123 5.959 0.015* 1.379 (1.0651.785)
Income \$40,000 0.516 0.109 22.32 0.000** 1.676 (1.3532.076)
Education Without college education -0.041 0.107 0.144 0.705 0.96 (0.7781.185)
Time from
diagnosis
Less than 1 year 0.3 0.136 4.868 0.027* 1.351 (1.0341.764)
13 years 0.152 0.134 1.283 0.257 1.165 (0.8951.516)
Recurrence Yes 0.838 0.12 48.898 0.000** 2.313 (1.8282.924)
Cancer site Haemato/lymphoproliferative 0.533 0.181 8.677 0.003** 1.704 (1.1952.43)
Gynecological 0.025 0.21 0.015 0.904 1.026 (0.681.548)
Digestive/gastrointestinal 0.063 0.197 0.103 0.748 1.065 (0.7241.56)
Other -0.109 0.2 0.296 0.587 0.897 (0.6061.328)
Lung 0.94 0.245 14.674 0.000** 2.56 (1.5834.142)
Head and neck 0.143 0.249 0.331 0.565 1.154 (0.7091.879)
Prostate -0.466 0.222 4.384 0.036* 0.628 (0.4060.971)
EFLc Patient Non-EFLc patient 0.258 0.116 4.987 0.026* 1.294 (1.0321.624)
Depression
Block 1
Gender Male -0.239 0.143 2.79 0.095 0.787 (0.5941.042)
Age \54 years 0.91 0.151 36.333 0.000** 2.484 (1.8483.339)
5469 years 0.465 0.137 11.509 0.001** 1.592 (1.2172.082)
Income \$40,000 0.621 0.111 31.403 0.000** 1.826 (1.4982.313)
Education Without college education 0.077 0.109 0.504 0.478 1.08 (0.8731.337)
Time from
diagnosis
Less than 1 year 0.206 0.138 2.219 0.136 0.1228 (0.9371.61)
13 years 0.185 0.136 1.841 0.175 1.203 (0.9211.573)
Recurrence Yes 0.785 0.121 42.131 0.000** 2.193 (1.732.781)
Cancer site Haemato/lymphoproliferative 0.158 0.182 0.747 0.387 1.171 (0.8191.674)
Gynecological 0.109 0.206 0.278 0.598 1.115 (0.7441.67)
Digestive/gastrointestinal 0.177 0.198 0.802 0.371 1.194 (0.811.761)
Other -0.073 0.2 0.134 0.714 0.929 (0.6281.375)
J Immigrant Minority Health (2009) 11:237248 241
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Table 2 continued
Variable Subgroup b SE Wald (df = 1) P Exp (b) 95% CI for Exp (b)
Lung 0.937 0.243 14.81 0.000** 2.552 (1.5844.114)
Head and neck 0.527 0.249 4.472 0.034* 1.694 (1.0392.761)
Prostate -0.023 0.228 0.01 0.919 0.977 (0.6251.528)
Block 2
Gender Male -0.246 0.144 2.927 0.087 0.782 (0.591.036)
Age \54 years 0.905 0.151 35.823 0.000** 2.472 (1.8383.324)
5469 years 0.465 0.137 11.469 0.001** 1.591 (1.2162.082)
Income \$40,000 0.602 0.111 29.248 0.000** 1.826 (1.4682.271)
Education Without college education 0.058 0.109 0.286 0.593 1.06 (0.8561.313)
Time from
diagnosis
Less than 1 year 0.188 0.138 1.845 0.174 1.207 (0.921.583)
13 years 0.178 0.137 1.686 0.194 1.194 (0.9141.561)
Recurrence Yes 0.79 0.121 42.479 0.000** 2.204 (1.7382.796)
Cancer site Haemato/lymphoproliferative 0.18 0.183 0.972 0.324 1.198 (0.8371.714)
Gynecological 0.108 0.207 0.271 0.603 1.114 (0.7431.67)
Digestive/gastrointestinal 0.185 0.199 0.865 0.352 1.203 (0.8151.776)
Other -0.06 0.2 0.091 0.763 0.941 (0.6361.393)
Lung 0.964 0.244 15.613 0.000** 2.623 (1.6264.231)
Head and neck 0.531 0.25 4.524 0.033* 1.701 (1.0432.775)
Prostate -0.013 0.228 0.003 0.953 0.987 (0.6311.544)
EFLc Patient Non-EFLc patient 0.264 0.117 5.112 0.024* 1.302 (1.0361.637)
Anxiety
Block 1
Gender Male 0.377 0.146 6.681 0.01** 1.458 (1.0951.941)
Age \54 years 0.827 0.142 28.558 0.000** 2.287 (1.683.098)
5469 years 0.466 0.142 10.778 0.001** 1.593 (1.2072.104)
Income \$40,000 0.209 0.113 3.419 0.064 1.232 (0.9881.538)
Education Without college education 0.036 0.111 0.104 0.747 1.036 (0.8341.288)
Time from
diagnosis
Less than 1 year 0.289 0.141 4.222 0.04* 1.335 (1.0131.758)
13 years 0.159 0.14 1.296 0.255 1.172 (0.8921.541)
Recurrence Yes 0.533 0.123 18.666 0.000** 1.703 (1.3382.169)
Cancer site Haemato/lymphoproliferative -0.042 0.189 0.049 0.825 0.959 (0.6651.39)
Gynecological -0.124 0.219 0.32 0.571 0.883 (0.5751.357)
Digestive/gastrointestinal -0.114 0.207 0.303 0.582 0.892 (0.5951.339)
Other -0.128 0.204 0.393 0.531 0.88 (0.591.312)
Lung 0.584 0.243 5.777 0.016* 1.792 (1.1142.885)
Head and neck 0.291 0.251 1.347 0.246 1.338 (0.8182.188)
Prostate -0.457 0.234 3.806 0.051 0.633 (0.41.002)
Block 2
Gender Male 0.373 0.146 6.511 0.011* 1.452 (1.091.933)
Age \54 years 0.823 0.155 28.176 0.000** 2.277 (1.683.085)
5469 years 0.465 0.142 10.74 0.001** 1.593 (1.2062.104)
Income \$40,000 0.192 0.114 2.847 0.092 1.211 (0.9691.513)
Education Without college education 0.021 0.111 0.036 0.85 1.021 (0.8211.271)
Time from Less than 1 year 0.277 0.141 3.865 0.049* 1.319 (1.0011.738)
diagnosis 13 years 0.154 0.14 1.223 0.269 1.167 (0.8881.535)
Recurrence Yes 0.536 0.123 18.865 0.000** 1.709 (1.3422.177)
Cancer site Haemato/lymphoproliferative -0.023 0.19 0.015 0.904 0.977 (0.6741.418)
Gynecological -0.127 0.22 0.336 0.562 0.88 (0.5731.354)
242 J Immigrant Minority Health (2009) 11:237248
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non-EFLc patient predicted a higher Global Severity score
(OR = 1.3, CI = 1.031.63).
The positive and negative predictors of distress by the
BSI scale and subscale scores are summarized in Fig. 2.
Patients below 70 years of age, those with lung cancer and
those with recurrent disease predicted higher Global
Severity, Somatization, Depression and Anxiety scores.
Male patients and those within a year of being diagnosed
predicted higher Global Severity, Somatization and Anxi-
ety scores. Non-EFLc patients and those with low incomes
predicted higher Global Severity, Somatization and
Depression scores. Those with cancer of the prostate
Table 2 continued
Variable Subgroup b SE Wald (df = 1) P Exp (b) 95% CI for Exp (b)
Digestive/gastrointestinal -0.709 0.207 0.276 0.599 0.897 (0.5981.346)
Other -0.118 0.204 0.335 0.563 0.889 (0.5951.326)
Lung 0.604 0.243 6.167 0.013* 1.89 (1.1362.949)
Head and neck 0.295 0.251 1.382 0.24 1.343 (0.8212.195)
Prostate -0.119 0.234 3.674 0.055 0.638 (0.4031.01)
EFLc Patient Non-EFLc patient 0.218 0.119 3.344 0.067 1.243 (0.9841.57)
GSI
Block 1
Gender Male 0.34 0.142 5.907 0.015* 1.411 (1.0691.863)
Age \54 years 0.658 0.147 20.058 0.000** 1.931 (1.4482.575)
5469 years 0.376 0.133 7.978 0.005** 1.457 (1.1221.891)
Income \$40,000 0.482 0.109 19.486 0.000** 1.619 (1.3072.005)
Education Without college education 0.009 0.107 0.007 0.932 1.009 (0.8181.244)
Time from
diagnosis
Less than 1 year 0.406 0.136 8.883 0.003** 1.501 (1.1491.96)
13 years 0.216 0.135 2.56 0.11 1.241 (0.9531.617)
Recurrence Yes 0.878 0.12 53.471 0.000** 2.406 (1.9023.045)
Cancer site Haemato/lymphoproliferative 0.218 0.18 1.469 0.225 1.244 (0.8741.77)
Gynecological -0.012 0.206 0.041 0.84 0.959 (0.641.437)
Digestive/gastrointestinal -0.028 0.196 0.02 0.887 0.973 (0.6631.428)
Other -0.312 0.199 2.456 0.117 0.732 (0.4961.081)
Lung 0.657 0.241 7.437 0.006** 1.93 (1.2033.096)
Head and neck 0.111 0.248 0.202 0.653 1.118 (0.6881.817)
Prostate -0.613 0.224 7.495 0.006** 0.542 (0.3490.84)
Block 2
Gender Male 0.34 0.142 5.745 0.017* 1.405 (1.0641.856)
Age \54 years 0.652 0.147 19.608 0.000** 1.919 (1.4382.56)
5469 years 0.375 0.133 7.914 0.005** 1.455 (1.121.89)
Income \$40,000 0.462 0.11 17.787 0.000** 1.587 (1.2811.968)
Education Without college education -0.009 0.107 0.007 0.934 0.991 (0.8031.223)
Time from
diagnosis
Less than 1 year 0.39 0.137 8.166 0.004** 1.478 (1.131.931)
13 years 0.208 0.135 2.372 0.124 1.232 (0.9451.606)
Recurrence Yes 0.884 0.12 53.938 0.000** 2.42 (1.9123.064)
Cancer site Haemato/lymphoproliferative 0.24 0.181 1.771 0.183 1.272 (0.8931.811)
Gynecological -0.043 0.207 0.043 0.836 0.958 (0.6391.437)
Digestive/gastrointestinal -0.021 0.196 0.011 0.916 0.98 (0.6671.439)
Other -0.301 0.199 2.284 0.131 0.74 (0.51.094)
Lung 0.682 0.242 7.958 0.005** 1.978 (1.2323.177)
Head and neck 0.114 0.248 0.211 0.646 1.121 (0.691.821)
Prostate -0.606 0.224 7.293 0.007** 0.546 (0.3520.847)
EFLc patient Non-EFLc patient 0.259 0.116 5.04 0.025* 1.296 (1.0331.625)
* P\0.05; ** P\0.01
J Immigrant Minority Health (2009) 11:237248 243
1 3
predicted lower Global Severity and Somatization scores.
Patients with hematoproliferative or lymphoproliferative
cancers predicted higher Global Severity scores, while
those with cancers of the head and neck predicted higher
Depression scores.
Discussion
The present report is an in-depth analysis of an earlier
study on a large representative cancer population in an
urban tertiary Canadian cancer centre on the basis of eth-
nicity (using rst language as a surrogate marker) [1]. More
than 25% of those surveyed were patients who identied
themselves to be from non-English rst language countries
(non-EFLc). A caveat is that the classication may not
necessarily reect the patients English communication
skills, which may be an important factor in distress felt in
the health care system in and of itself. Patient ethnicity,
amongst a number of other variables, had an important role
in determining distress levels. Patients who were from
ethnicities other than Canadian or other primarily English
speaking ethnicities including British, American, Austra-
lian, etc., were more likelya 1.3 times increase in risk
to report higher levels of distress. Graphical representation
of distress scores (Fig. 1) reveals the highest levels in
patients from China, India, Korea, Vietnam and South
America, but many of these groups were too small for
formal statistical comparisons. There is research indicating
that people from some ethnicities are less likely to partic-
ipate in cancer screening behavior such as mammography
[20, 23, 25, 26], but they do not investigate whether dis-
tress played a role in the screening behavior.
A few implications could be drawn from the study.
Firstly, in the United States the relationship between
nancial status and disparity in cancer outcomes is
repeatedly underlined [42, 43]. If this was one of the pri-
mary reasons of disparity, then in countries like Canada
with a publicly funded health system [44] or the Canadian
province of Alberta where this is taken a step further with
the elimination of health premiums as of January 2009
[45], disparity should not exist or at least be less obvious.
Therefore the notion that poverty as an ideal indicator of
disparity requires revisiting.
Secondly, Simpson et al. in 2001 [46] identied that use
of psychosocial oncology services provided cost offsets of
up to 22% to the medical system. Therefore in the present
study given that ethnic minority populations are at greater
risk for distress compared to the majority host population,
the converse of the Simpson et al. study could be hypoth-
esizedthat untreated distress in these populations may
inuence a greater uptake of medical services (presentation
at emergency, or repeat hospital visits, etc).
Finally, the role of interventions. Several studies have
indicated the communication pitfalls between the practi-
tioner and general population [4750] as well as in minority
populations [51, 52]. It may inappropriate to say that
translating hospital literature to 52 languages or having a
multicultural staff (which is benecial) or the provision of
professional translators, be a solution in itself. Improvement
of treatment outcomes is the result of improved communi-
cation on the part of the health care provider as well as the
patient. Some examples to this are an agreed-upon man-
agement plan [49], rudimentary training to increase
participation in medical encounters [53], and provision of
printed material to prompt patients to write down questions
Fig. 2 Predictors of BSI scale
and subscale based distress
classication
244 J Immigrant Minority Health (2009) 11:237248
1 3
prior to a visit [54] or patient education videotapes to role-
model active behaviors [55]. It could also be as simple as
being encouraged to bring a companion to important con-
sultations, such as the discussion of potential cancer
diagnosis and treatment [52].
Research Issues Around Measuring Ethnicity
In terms of classication of ethnicity, an overarching
concern exists regarding how well those who self-identify
as Canadian t the non-Hispanic White description of
what is known as the host population in todays multicul-
tural context. They may be predominantly Caucasian but
there are an increasing number of people who are visibly of
a single or mixed ethnic descent, yet identify themselves as
Canadian or part of the host population. Other ques-
tions also intertwined in this conundrum are issues of self-
identication with the adopted or ancestral country, how
this changes over generations after immigration, and its
impact on healthcare behavior, access to healthcare, and
health related decision-making.
For example, the 97 Germans identied in this survey
may be new immigrants who still speak German regularly,
or second or third-generation immigrants who are fully
integrated in the dominant culture and speak awless
English, yet retain pride in their German heritage and
hence self-identify in that manner. They may also be
Caucasian or non-white, but there is no way of knowing
from the self-identication as German. The same prob-
lem exists in interpreting self-identication in many of the
other categories such as American or Canadian.
The other matter of concern stems from research noting
how gradations of English prociency might affect health
status and healthcare access [56]. Ponce et al. [56] postu-
lated that if being English procient could enable the
individual to gain better healthcare access and better health
status, then the outcomes of the English-Procient popu-
lation (those who are uent in English but speak a different
language as their mother tongue) would be comparable to
those of the English-Only population (presumably the host
population). In their study testing this hypothesis, English-
Procient individuals were not found to differ from Eng-
lish-Only individuals on healthcare access or health status,
in contrast to the signicantly worse access to care and
health status of Limited-English-Procient individuals
(those not fully uent in English). Interestingly however,
both Limited-English-Procient and English-Procient
individuals had a statistically higher risk of reporting
poorer emotional health when compared to the English-
Only individuals [56]. This may be mirrored in the present
study, as we can assume that most of the non-English rst
language (non-EFLc) patients, who had higher overall
emotional distress, may have been similar to the English-
Procient group in the Ponce et al. study [56].
To better conceptualize the discussed issues in dening
patient ethnicity, we suggest the following hypothesis. The
two most tangible and easily assessable potential markers
of patients ethnicity that may inuence access and perhaps
utilization of the healthcare system are (1) prociency in
the host language, and (2) physical resemblance to the host
population. Figure 3 is a representation of this hypothesis
and there are two important points. Resembling a non-host
ethnicity/race (quadrant 2) does not preclude individuals
from considering themselves to be part of the host popu-
lation (e.g., a person with an Asian background dening/
categorizing themselves as Canadian or Australian despite
the obvious non-Canadian or non-Australian physical fea-
tures). Also, some individuals in quadrant 3, whose
physical features are compatible with the host population,
may consider themselves of a different race/ethnicity (e.g.,
a cancer patient originally from Finland who speaks uent
English may consider themselves Finnish rst and Amer-
ican second).
Potential patient-related outcomes for the four quadrants
may be the following:
Quadrant 1: English-speaking and seemingly the visible
majority
Patients in this quadrant may consider themselves as
representative of the host population and hence would
have an understanding of the access to and navigation of
care. Given that this quadrant may include up to 80% of
the population, most health status and outcomes research
is based on this group.
Quadrant 2: English-speaking and visible minority
Patients in this quadrant too may consider themselves as
English Only: EO; English Proficient: EP; Limited English Proficiency: LEP
Fig. 3 The population of a multicultural society
J Immigrant Minority Health (2009) 11:237248 245
1 3
members of the host population for several reasons
number of generations that have lived in the country, or
having been born and raised there. They would also have
the required skills to access and navigate the care
system. However, their physical features may cause the
health system to view them as a visible minority. It may
be observed that these patients are often asked inappro-
priate questions (e.g., How long have you been in
Canada/Australia? Do you require a translator when you
are with the doctor?) which may create emotional
distress and feelings of marginalization.
Quadrant 3: Non-English speaking and appears visible
majority
Generally rst generation immigrants who are still
learning to navigate the new health care system, but
would have lesser concerns of marginalization or
exclusion in the host system based on physical appear-
ance. Unless there is a strong accent or a direct request
of help, the health system may assume that this group of
people know or understand the navigation process.
Language issues, though a concern here, may not be to
the extent as it would be for those in Quadrant 4. These
individuals may also experience less stereotyping from
the host health system in comparison to those in
Quadrant 2, and 4.
Quadrant 4: Non-English speaking and visible minority
Patients in this quadrant may generally be rst gener-
ation immigrants from countries that do not have English
as a rst language. Given the immigration process in
most Western countries, a subset of them would be
English-Procient, yet may still experience a degree of
marginalization or exclusion. Navigating a new health
system that is different from they may be accustomed to
may cause them signicant psychological concern.
This classication matrix may be useful in research
investigating the impact of ethnicity, language and race on
cancer patient outcomes in a number of ways. Potential
research questions may tackle the following issues: Do the
four quadrants view the host cancer health system differ-
ently and does the meaning of cancer, the impact of
diagnosis, and the determinants of decision making
(treatment or otherwise) differ between these individuals?
Do these differences translate into or affect psychosocial or
bio-medical outcomes?
Conclusions
Ethnicity as a prognostic variable in cancer care seems to
be a promising area for further research. With its multi-
cultural patient population, and the impetus towards uptake
of emotional distress as the 6th vital sign, this line of
research is relevant in todays multicultural societies, and
requires a systematic interdisciplinary study. The goals of
such a program of research would be to understand the
experience of immigrants and those from diverse ethnic
backgrounds, and ultimately intervene to provide a health
care system that is responsive to the needs of all individ-
uals, regardless of their ethnic background.
Acknowledgements The study was funded from an independent
grant awarded to Drs. Carlson and Bultz from the Zero in on Cancer
Fundraiser, 2002, and the Calgary Satellite Research Centre of the
Sociobehavioral Cancer Research Network, funded by the Canadian
Cancer Society. Dr. Bejoy Thomas is a postdoctoral fellow (2007
2009) funded by the Alberta Heritage Foundation for Medical
Research, Alberta, Canada. Dr. Linda Carlson holds the Enbridge
Endowed Research Chair in Psychosocial Oncology (20072012),
co-funded by the Canadian Cancer Society Alberta/NWT Division
and the Alberta Cancer Foundation. Part of this manuscript was
presented at the 23rd Annual Conference of the Canadian Association
of Psychosocial Oncology (CAPO), Halifax, Canada, 79 May 2008,
the 4th Annual Conference of the American Psychosocial Society
(APOS), Austin, Texas, 14 March 2007, and at the 8th World
Congress on Psycho-Oncology held at Venice, Italy, from 16th to 21st
October 2006.
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