The role of socioeconomic status in adjustment after ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is a noninvasive breast cancer that constitutes between 12% and 15% of breast cancers.1 Although the biological characteristics and treatment options of DCIS have been the subject of growing research over the past several decades, only a small number of studies have examined the psychosocial sequelae of a DCIS diagnosis.2–6 In addition, no research has been conducted to identify socioeconomic subgroups of women who might be vulnerable to psychological morbidity after a DCIS diagnosis. Research on the psychosocial sequelae of a DCIS diagnosis is warranted for several reasons. First of all, DCIS is generally not life-threatening. When treated with standard therapy, the majority of cases will not result in local or systemic recurrence.1,7 Yet, similar to invasive breast cancer, the primary treatment for DCIS is surgery, with 30% of women undergoing mastectomy and 60% undergoing a breast-conserving procedure.1 Consequently, women with DCIS may experience many of the same psychosocial issues as women who are treated for invasive breast cancer, such as anxiety,8–10 depression, sexual problems, and negative body image.9 In fact, the limited research that has directly compared women with DCIS to women with invasive breast cancer has found no difference in their levels of psychological symptoms (ie, difficulty sleeping, anxiety, and depression),2 quality of life, and overall well-being.3 However, women with DCIS may experience fewer physical symptoms, better general health, and a less negative impact on their sex life and interpersonal relationships than women with invasive breast cancer.3 The word carcinoma and the surgical treatments for DCIS suggest a level of disease severity, and the distinction between invasive and noninvasive cancer can be confusing for many patients.4,5 In addition, women report being frustrated by the lack of available information about their DCIS.4,5 A shortage of information may leave women with DCIS unaware of their true breast cancer risk. For example, research suggests that women with DCIS do not differ from women with invasive breast cancer in their perceived risk of local or distant recurrence or distant metastases2 or of dying from their disease.3 Furthermore, between 54% and 61% of women perceived at least a moderate risk for disease recurrence,6,11 and 39% perceived at least a moderate risk for invasive cancer in the next 5 years.6 These risk perceptions are inaccurate, as true risk for local recurrence in the form of DCIS or invasive breast cancer after modern therapy ranges approximately 1% to 7%.12–14 Prior work from our group suggests that distress may contribute to inaccurate risk perceptions. For example, women with elevated DCIS-related intrusive or avoidant thoughts were more likely to overestimate their risk of metastasis, whereas women with elevated anxiety were more likely to overestimate their risk of a DCIS or invasive breast cancer recurrence and of developing invasive breast cancer in their lifetime.6 To effectively address the psychosocial needs of women with DCIS, it is important to consider that the incidence and prevalence of distress after DCIS may not be equal across all women, but instead may vary by socioeconomic status (SES). SES is inversely associated with psychological morbidity after an invasive cancer diagnosis.15–22 In addition, SES dictates access to important resources such as money, knowledge, and social connections/support that could be used to minimize the impact of a major health crisis such as a cancer diagnosis.23–29 Women with low SES may not have the same financial and psychosocial resources to cope with their DCIS; thus, this population may be vulnerable to anxiety and depression after their diagnosis. The extent to which SES affects distress after a DCIS diagnosis has not been previously addressed. The authors conducted a prospective longitudinal observational study to examine the psychosocial impact of a DCIS diagnosis.6 The current paper analyzes a subset of these data to examine whether SES was associated with anxiety and depression in these women. Because social support is inversely associated with distress across populations,30,31 and social support is positively associated with SES,24–28 this paper also explores whether the association between SES and distress was explained by differences in social support (mediation) and whether social support buffered against distress among women with low SES (moderation). We hypothesized that 1) women’s distress (anxiety and depression) would be inversely associated with their SES (education and financial status) at baseline and at the 9-month follow-up; 2) SES would predict a change in distress from baseline to the 9-month follow-up; and 3) social support would mediate and moderate the association between SES and anxiety and depression.