Elsevier

The Lancet Oncology

Volume 12, Issue 13, December 2011, Pages 1240-1248
The Lancet Oncology

Articles
Psychological morbidity and quality of life of ethnic minority patients with cancer: a systematic review and meta-analysis

https://doi.org/10.1016/S1470-2045(11)70212-1Get rights and content

Summary

Background

Ethnic minority is associated with higher cancer incidence and poorer survival than is being in the majority group. We did a systematic review and meta-analysis to assess whether psychological morbidity and health-related quality of life (HRQoL) were affected by minority status.

Methods

We searched Medline, AMED, PsycINFO, Embase, CENTRAL, CINAHL, PubMed, Sociological Abstracts, and Web of Science for English-language articles published between Jan 1, 1995, and October, 2009. Articles were eligible if they reported original data on anxiety, depression, distress (for psychological morbidity), or HRQoL in minority and majority cancer patients or survivors. Minority status was defined as being an immigrant or having an ethnic, linguistic, or religious background different to the majority of the population in the country where the research was done. We excluded African Americans and indigenous groups. Eligible articles were rated for quality of reporting, external validity, internal validity, sample size, and power. Each quality criterion was rated independently by two reviewers until inter-rater reliability was achieved. In a meta-analysis we compared mean scores adjusted for socioeconomic status and other sociodemographic and clinical variables, where available. Effect sizes greater than 0·5 and 95% CI that included 0·5 or −0·5 were deemed clinically important, with negative values indicating worse outcomes in minority patients. We assessed publication bias by estimating the number of potential unpublished studies and the number of non-signficant studies with p=0·05 required to produce a non-significant overall result.

Findings

We identified 21 eligible articles that included 18 datasets collected in the USA and one in each of Canada, Romania, and the UK. Ethnic minority groups were Hispanic, Asian or Pacific Islander, or Hungarian (one dataset). Overall, we found minority versus majority groups to have significantly worse distress (mean difference −0·37, 95% CI −0·46 to −0·28; p<0·0001), depression (−0·23, −0·36 to −0·11; p=0·0003), and overall HRQoL (−0·33, −0·58 to −0·07; p=0·013). Further analyses found disparities to be specific to Hispanic patients in the USA, in whom poorer outcomes were consistent with potentially clinically important differences for distress (effect size −0·37, 95% CI −0·54 to −0·20; p<0·0001), social HRQoL (−0·45, −0·87 to −0·03; p=0·035), and overall HRQoL (−0·49, −0·78 to −0.20; p=0·0008). Results were significantly heterogeneous for overall HRQoL and all domains. Tests for interaction, for adjusted versus unadjusted and comparisons of high-quality, medium-quality, and low-quality articles, were generally non-significant, which suggests no bias. We found no evidence of any substantive publication bias.

Interpretation

Hispanic cancer patients in the USA, but not other ethnic minority groups, report significantly worse distress, depression, social HRQoL, and overall HRQoL than do majority patients, of which all but depression might be clinically important. Heterogeneous results might, however, have limited the interpretation. Data for other minority groups and for anxiety are scarce. More studies are needed from outside the USA. Future reports should more clearly describe their minority group samples and analyses should control for clinical and sociodemographic variables known to predict outcomes. Understanding of why outcomes are poor in US Hispanic patients is needed to inform the targeting of interventions.

Funding

Prince of Wales Hospital, Sydney, Australia.

Introduction

Disparities associated with cancer incidence and survival between minority and majority groups have been the focus of substantial research and policy making in many developed countries.1, 2 Reasons are thought to include culturally determined lifestyle and beliefs, and practical barriers to care, such as lack of language proficiency, unfamiliarity with health systems, discrimination, and poor cultural competence among providers.3 Importantly, lower socioeconomic status is also associated with poorer outcomes. The contribution of minority versus socioeconomic variables, however, is poorly understood.4

The growing numbers of minorities in developed countries demand attention to clinical and patient-reported outcomes, such as health-related quality of life (HRQoL) and psychological distress, which provide insight into how the disease and treatment affect daily life.3 Three previous reviews of psychological morbidity among minority cancer patients concluded that disparities exist, but they did not assess the degree of difference for specific minority groups.5, 6, 7 We did a systematic review and meta-analysis to investigate further which minority patients are most at risk.

Section snippets

Data selection

In October, 2009, we searched Medline, AMED, PsycINFO, Embase, CENTRAL, CINAHL, PubMed, Sociological Abstracts, and Web of Science for English-language, full-text articles published in peer-reviewed journals from Jan 1, 1995, onwards, on any cancer type or stage (including disease free) in people of any age. We chose to keep the range of publication years narrow because of the dynamic nature of migratory patterns and cultural contexts.8 We used the following subject terms and keywords in

Results

We screened 1378 potentially relevant, non-duplicate articles. The κ score for concordance between reviewers rating the articles was 0·61–0·75. The final number of papers included in the meta-analysis was 21 (figure 1), which reported on 18 distinct datasets.19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39 Of these, ten included among their main objectives comparisons of psychological morbidity between minority and majority groups.19, 21, 22, 24, 27, 29, 30, 35

Discussion

Our analysis indicates that distress, depression, and overall HRQoL are significantly worse in patients from minority groups than in those from the majority. Overall, disparities seem to be driven by differences between Hispanic and majority patients in the USA. The effect sizes for distress, social HRQoL, and overall HRQoL suggested that these features might be clinically important. Heterogeneity between results for social and overall HRQoL, however, limits the interpretability of these

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