Received: 21 September 2018 Revised: 12 February 2019 Accepted: 16 February 2019
PA P E R
Save your time - order a paper!
Get your paper written from scratch within the tight deadline. Our service is a reliable solution to all your troubles. Place an order on any task and we will take care of it. You won’t have to worry about the quality and deadlinesOrder Paper Now
Comparing provider and patient views of issues for low‐ resourced breast cancer patients
Cassandra J. Enzler1 | Shioban Torres2 | Jennifer Jabson3 | Arin Ahlum Hanson4 |
Deborah J. Bowen5
1Public Health Department, UT Health Science
Center at Houston, Houston, Texas
2Community Health Sciences, Boston
University, Boston, Massachusetts
3Department of Public Health, University of
Tennessee, Knoxville, Tennessee
4Living Beyond Breast Cancer, Program
Administration, Bala Cynwyd, Pennsylvania
5Department of Bioethics and Humanities,
University of Washington, Seattle, Washington
Deborah J. Bowen, Department of Bioethics
and Humanities, University of Washington,
1959 NE Pacific Street A204, Seattle, WA
Centers for Disease Control and Prevention,
Grant/Award Number: 1 U58 DP005403
1018 © 2019 John Wiley & Sons, Ltd.
Objective: The purpose of this study was to compare provider and patient views
from the same clinical settings on issues raised by low‐socioeconomic status (SES)
breast cancer survivors.
Methods: We conducted qualitative interviews among two groups: low‐SES breast
cancer survivors (n = 37) and medical personnel (ie, physicians, nurses, and navigators;
n = 8) who interact and serve with these patients from two geographically distinct
low‐resourced clinical settings. These semistructured qualitative interviews used
grounded theory to identify several potential themes, such as finances, resources,
and medical care. Transcripts were coded and summarized into themes.
Results: We analyzed each type of interview data separately then compared
patient and provider perspectives. From these qualitative interviews, we discovered
that low‐SES breast cancer survivors reported many unmet needs, including transpor-
tation, housing, health literacy, and language, among others. Providers reported that
many of these needs are served by the extensive network of supports surrounding
Conclusions: These results illustrate that low‐SES breast cancer survivors have
unique needs that differ from other breast cancer survivors. Many providers feel that
these needs are being met, but patients have more diverse experiences. By better
addressing the links between resource needs and low‐SES breast cancer survivors,
quality of life can be improved.
comparative interviews, low‐resourced settings, patients, poverty, providers
1 | INTRODUCTION
Breast cancer impacts many individuals despite continued research
and development within the scientific field.1,2 In addition to increased
mortality, breast cancer negatively impacts an individual’s quality of
life.3-5 Breast cancer also has a financial impact with some individuals
accruing years of medical debt even after completing treatment.6,7 It is
critical to understand the needs of breast cancer patients, so the most
pressing needs can be addressed efficiently and effectively to support
their quality of life.
There is very little evidence about the unmet needs of low‐
socioeconomic status (SES) breast cancer survivors.8-10 These needs
may differ considerably from the needs of other higher SES women
affected by this disease; correlates of low‐SES include lower educa-
tion, poverty, and poor health, which can impact how low‐SES breast
cancer patients respond to their diagnosis and/or treatment.11-13
ENZLER ET AL. 1019
The aim of this study is to assess the needs of low‐SES breast cancer
patients from the perspective of the patient and the provider. Qualita-
tive interview methods were used to assess resource needs among
low‐SES breast cancer patients in two different low‐resourced sites.
We then interviewed providers from the same two sites who work
with low‐SES breast cancer patients.
2 | METHODS
Patients and providers were recruited from Boston Medical Center
and the University of Tennessee Cancer Institute. These locations
are safety‐net organizations that provide medical care and resources
for the population of interest and areas where living beyond breast
cancer (LBBC) has limited reach with the population. This study
received the Fred Hutchinson Cancer Research Center Institutional
Review Board (IRB) approval (reference number 9511). We focused
on both patient and provider samples for these interviews because
clinical impression provided support for the idea that these perspec-
tives would be different in some key ways that could inform future
intervention efforts. We include a consolidated criteria for reporting
qualitative (COREQ) checklist in the Table S1.
2.1 | Patient recruitment
We recruited 37 cancer patients overall (26 cancer patients, from Bos-
ton, MA and 11 from Knoxville, TN). In Boston, community health
workers from the Boston Public Housing Developments and Survivor-
ship Staff from Boston Medical Center recruited patients via fliers, in
person, or through medical records. Eligibility requirements included a
diagnosis of breast cancer, received or receiving treatment from one
of the medical centers, self‐identified as low income, and having
completed nomore than a high school education or living in public hous-
ing. Interviews were scheduled with patients if they were both eligible
and gave verbal consent to participate in the study. In Knoxville, we
recruited patients by contacting the University of Tennessee Cancer
Institute and local not‐for‐profit organizations, including support groups
that provide resources to low‐income women with breast cancer.
Interviews were scheduled with patients if they were both eligible and
gave verbal consent to participate. Each interview took between 30
and 69 minutes. Authors JJ and ST conducted the reviews.
2.2 | Provider recruitment
We also recruited providers and professionals that worked with low‐
SES breast cancer patients in Boston, MA and Knoxville, TN, including
oncologists, nursing staff, health educators, and patient navigators.
We invited these individuals to share their experiences via a
semistructured telephone interview if they were eligible and gave
verbal consent to participate. We also asked providers to refer us to
other providers or professionals, using snowball sampling, who might
be interested in participating in our study. Providers were eligible to
participate if they had at least 5 hours of interaction with low‐SES
breast cancer patients per week and were employed at either Boston
Medical Center or University of Tennessee Cancer Institute. We
recruited four providers from each institution, resulting in a total of
eight providers included in the study.
2.3 | Theoretical underpinnings
We identified no overarching theory of how low SES potentially
affects patient experiences. Therefore, we used a grounded theory
approach to these interviews, which allowed us to identify elements
of future theoretical models for subsequent research. The patient
interview was semistructured and included topics such as finances,
worries, and support programs and groups, among others. We also
encouraged patients to discuss topics that were not prompted by
the interviewer. We invited patients to share the met and unmet
resource needs that existed during their experiences with or because
of breast cancer. For providers, the interview guide included similar
topics, such as finance, support programs and groups, and medical
treatment, among others, affecting their low‐SES breast cancer
patients; we also encouraged providers to discuss topics that were
unprompted by the interviewer. Interview guides (please see Data
S1 and S2) were reviewed for validity by providers and patients at
each site to improve the quality of the interview guides.
2.4 | Analyses
For both types of interviews, we stopped interviewing when we
approached saturation within the interviews. We developed a draft
coding manual to initiate the process of coding. We then piloted this
manual with pilot interviews conducted for this purpose. We refined
both the guide and the manual and applied it to three of the real inter-
views to finalize it. Interviews were all audio‐recorded and transcribed,
and two coders analyzed each type of transcript separately by hand
using the initial draft of a coding guide, supplemented by codes iden-
tified by coders and investigators during the coding process. The two
coders discussed coding differences and resolved the conflicts until
80% agreement was reached. This was calculated with a simple
miss/hit calculation. We compared rural versus urban and provider
versus patient themes with visual inspection.
3 | RESULTS
Table 1 presents demographic and background data on all patients.
As seen in this table, most patients were women, with a mixture of
ethnic backgrounds. All patients were low income because of eligibility
criteria. Over half were not White, and less than half were married or
partnered. Most (70%) were previously diagnosed with breast cancer.
Table 2 presents a summary of the key themes that were discov-
ered after analyzing the patient and provider transcripts, which are
elaborated below. The key themes focus on finances, emotions,
support groups meeting needs, support groups not meeting needs,
the health care team, and social determinants of health. The key
themes are separated into patient and provider perspectives.
TABLE 1 Demographic characteristics of cancer survivors who par- ticipated in interviews
Characteristics Variables n, %
Gender Male 3 (12)
Female 23 (88)
Race/Ethnicity Black/African American 13 (50)
Hispanic/Latino 3 (12)
Age <40 2 (1)
40‐49 6 (15) 50‐59 9 (24) 60‐69 9 (24) >70 2 (1)
Type of cancer Breast 26 (70)
Cervical 2 (1)
Colorectal 5 (13)
Other 11 (16)
Number of times
diagnosed with cancer
1 31 (84)
2 5 (13)
3 1 (1)
Marital status Married/Domestic Partners 17 (46)
Never Married 7 (19)
Divorced 10 (27)
Widow 3 (8)
Education Less than high school 6 (23)
High school or GED 7 (27)
1‐4 years at university/college 9 (34) Bachelor’s degree 4 (16)
Master’s degree 0
Employment status Full Time 2 (1)
Part Time 17 (46)
Unemployed 18 (49)
Abbreviation: GED, General Education Development.
1020 ENZLER ET AL.
3.1 | Common themes among patients
Many cancer patients expressed difficulties or concerns that medical
costs were a burden. Several patients described having to choose
between medications and living expenses.
“If it gets too bad, where I can’t pay for the medicine,
then I weigh my option as [to] what I can get away
with and what I can’t. Then, I pay for what helps me
more…My finances have drastically changed a lot. That
kinda weighs on me a lot.” ‐Boston BC Patient
Several times, patients stated that a cancer diagnosis negatively
impacted their job or created difficulties in securing employment.
Many patients had difficulty paying daily living expenses.
“Financially, it was just hard, no real money coming in, so
it was just a struggle for everything, food, utilities,
everything that normal people would worry about.” ‐
Knoxville BC Patient
Many patients also expressed how treatment costs affected their
ability to afford adequate housing or provide for their family. Living
expenses that were commonly affected included rent, utilities, gas,
Several patients feared having to choose between living expenses
and meeting treatment recommendations. Some patients mentioned
having anxiety about future appointments because of limited money
for transportation. One patient from Knoxville expressed anxiety
about, “…how we were going to do everything, between the gas and
the medicines and the doctors.”
Some patients mentioned that breast cancer had multiple emo-
tional impacts. One person stated, “I’m a very healthy person other
than of course the cancer. I’ve been healthy my whole life, never
smoked or anything. And you’re just—just sad.” Others mentioned that
they were happy once treatment was over but felt depressed when
thinking of how breast cancer impacted their life. One patient from
Boston stated, “I was happy [after treatment]. I was happy, but I was
also depressed because of what I went through.”
Patients expressed several fears when told their diagnosis. Some of
the patients felt that they did not know, at first, who or where to turn
to for help, or what to expect after diagnosis. Several of the patients
expressed fear of the unknown or experienced anxiety during appoint-
ments. Many patients feared breast cancer recurrence. One patient
stated that their fear of recurrence was, “something black that you
have there. It’s fear that just shows up.” Several other patients worried
about the cancer metastasizing.
Several patients also mentioned that they eventually gathered
strength to accept their diagnosis and move forward with treatment.
One patient expressed, “I just took it as I need to just move forward
with my life.” Other patients mentioned gathering strength by focus-
ing on other health problems or the needs of their family. Some
patients highlighted multiple ways that support groups and programs,
both within the clinic and in the community, met their needs. Many
patients mentioned how support groups provide a social aspect during
their treatment, and several patients mentioned how strongly this
need was met.
“They have a website or a Facebook page where you can
go and talk about your latest problem and they give you
support from other cancer survivors and from nurses and
things like that. It’s very supportive.” ‐ Knoxville BC
Many patients mentioned that the support groups and programs
assisted with financial need. One patient stated, “…we got some finan-
cial help through some of the organizations to help with the gas and
the food.” Many patients also mentioned that the support groups
and programs provide healthy opportunities, such as camping or
white‐water rafting and personal development activities, such as
painting or pottery. Some patients expressed that social support
groups and programs provide opportunities for relaxation, such as
yoga and opportunities to learn more information about breast cancer
and treatment opportunities. A few patients mentioned how support
groups and programs provide emotional support. Overall, many
TABLE 2 Comparison of key themes for patients and providers
Key Themes Patient Perspective Provider Perspective
Patient finances serve as
barrier to high quality
Many patients expressed how cancer affected their ability to
work, which negatively impacted their financial wellbeing.
Many patients also expressed concerns with affording
treatment, housing, and transportation. However, many
patients expressed how resources within and outside of the
hospital provided financial assistance, even if it did not fully
meet their financial needs.
Many Providers mentioned that cancer negatively affected
patients’ finances, impacting rent, living expenses, and
transportation. However, many providers also mentioned
that most patients had insurance and that resources both
within and outside the hospital provided funds to assist
with medication and living expenses.
Several cancer patients expressed happiness when treatment
was over but felt sad when thinking about how much cancer
had impacted their life. Many patients expressed fear or
anxiety about the unknown, recurrence, or knowing what to
do or who to turn to. Several patients expressed gathering
strength and moving on.
Many providers mentioned that patients expressed anxiety
when thinking about paying for treatments and medication
in addition to living expenses.
Support groups available
Many cancer patients expressed how support groups and
resources met several of their needs by offering financial
assistance, emotional support, relaxation opportunities, and
Many providers expressed that support groups and resources
offered patients assistance with living expenses,
transportation, medical expenses and prosthetics, and
social support, as well as providing opportunities for
relaxation and healthy activities.
Support groups are
inadequate to meet all
Several cancer patients expressed how support groups and
resources did not provide emotional support, adequate
transportation options, guidance on what to do or expect
past treatment, or support for family members.
Several providers expressed that some of their patients did
not or could not utilize support groups and resources
offered to them.
Health care team is
important source of
support and resources
Many patients expressed receiving support from their
oncologist and primary care doctor. Several expressed that
the hospitals provided a supportive environment and that
the medical team became like family to them. Several
patients also expressed relying on their doctors for
trustworthy information. However, several patients
expressed feeling uninformed about their health or how to
navigate medical resources. Several others expressed that
they felt the medical team was disconnected and
uncollaborative and that their PCP did not provide adequate
support or information. Many patients felt uninformed
about posttreatment expectations and expressed that their
PCP assumed the patients wants and needs. Additionally,
many patients felt that follow‐up appointments were burdensome either financially or as a time commitment.
Several providers expressed that patients receive information
about medical resources from social workers in the
hospital. Several providers also expressed how the medical
center was the main clinic for surrounding communities
and provided the same quality of care as those received by
higher SES populations.
Social determinants of
health impact care
… Many providers expressed how limited funding constrained resources and that patient financial insecurity also
contributes to inaccessibility of resources. Many providers
expressed how education and wealth causes differences in
health status or resource utilization between low‐SES and high‐SES cancer patients. Additionally, many providers expressed how low‐SES patients have fewer resources and support systems and that stress causes inaccessibility of
resources. Some providers also expressed how the location
of a patient’s residence can cause difficulty in accessing
Abbreviations: SES, low‐socioeconomic status; PCP, primary care provider.
ENZLER ET AL. 1021
patients expressed that nationally recognized cancer organizations
support their needs, although some women felt that these organiza-
tions were not helpful during their treatment.
Patients expressed how participation in support groups and pro-
grams did not meet several of their needs. Several patients mentioned
that resources did not provide emotional support. One patient stated
that support groups needed to provide, “… emotional support like a
psychiatrist that’s available just for cancer patients.” Some patients
also expressed inadequate preparation for what to do beyond
treatment, such as obtaining prosthetics or developing a healthy
lifestyle upon remission. Some patients mentioned that transportation
was inadequate, which resulted in difficulty meeting treatment recom-
mendations without private transportation. Several other patients
mentioned that services did not provide support for families. One
1022 ENZLER ET AL.
patient mentioned that poorly managed family stress made their
quality of life worse rather than better.
“And as much as I feel like we’ve got a lot of family folks
around. I don’t mean to disrespect the family people, but
sometimes I think they make you more sick than what
you are. They make you feel bad about this and that
and you know. Sometimes, I don’t think people heal
properly because of all the heavy stuff that they got on
them.” ‐Boson BC Patient
Patients expressed both negative and positive perspectives of the
medical team during treatment. Many patients expressed that the
oncologist ensured their needs were met, and some patients also felt
that their primary care doctor was supportive during their care.
Several patients felt that the hospital provided a supportive environ-
ment, and some patients viewed the medical team as family. Several
patients mentioned relying on their doctors for trustworthy
Several patients had negative experiences with their primary care
providers (PCPs) or surrounding medical team. Several patients felt
uninformed about their health and how to navigate medical resources;
for example, one patient stated, “And sometimes I felt like I was not
really informed enough about my health and insurance…” In addition,
some patients felt that the medical team was disconnected or that
medical teams in various specialties did not collaborate for the
integrated health of the individual. Several patients felt very strongly
that their PCP did not adequately explain treatments and were
emotionally unavailable and unsupportive.
“But that’s one of the, I guess, worst things. I think also
the breast surgeons can probably be a little more—I
remember that when my breast surgeon called me at
work to tell me that I needed a mastectomy he was so
blunt about it. There was no like not feeling or
anything.” ‐Knoxville BC Patient
Many patients also felt strongly that PCPs did not inform them
about posttreatment expectations. Some patients stated that their
PCP assumed what they needed or wanted, such as prosthetics.
One patient questioned her PCP’s assumptions by saying, “I was like
did I say anything about wanting bigger breasts?” Several patients also
noted that follow‐up appointments were burdensome for them, either
financially or as a time commitment.
3.2 | Common themes among providers
Table 2 presents a comparison between patient and provider themes.
A prominent theme that providers discussed was patient financial
burden. All providers expressed that patients had access to or were
utilizing state sponsored insurance but whether this health coverage
was sufficient for the needs of the patients varied by provider. Several
providers mentioned that patients had adequate insurance while
others felt that patients lacked adequate health coverage. Some
providers stated that insurance did not cover prosthetics needed by
patients, such as lymphedema sleeves or cold caps.
Most providers mentioned that breast cancer negatively affected
patient’s living expenses. Several providers felt that breast cancer
affected transportation. One provider highlighted how difficult it was
for low‐SES breast cancer patients to afford transportation by stating,
“… they can’t afford to either—can’t afford the gas or they can’t pay
someone to bring them.” Many providers also mentioned how difficult
it was for patients to pay rent or mortgage.
“If you’re talking about comparing them to people who
have higher…if you’re really putting your lens on SES
level, those are some of the main challenges I’m seeing.
Like really tangibly difficulties in both finances and in
housing.” ‐Boston BC Provider
Providers expressed several similar perspectives of patient fear
and methods of coping. Almost all providers strongly expressed that
low‐SES patients typically experience more anxiety and fear when
thinking about financing treatment in addition to current living
“I will tell you that patients who come from disparate
backgrounds tend to, in my estimate, in my experience,
tend to worry much more about “How am I gonna pay
for this.” ‐Knoxville BC Provider
Many providers expressed that current support groups and
resources met many of the needs of the low‐SES populations.
All providers mentioned that support programs helped breast cancer
patients with living expenses, such as vouchers or money for food,
utilities, and rent.
“And when those needs were identified, then we provide
things like…essentially cover folks utilities or rent or
support for groceries or gas cards for transportation
needs.” ‐Knoxville BC Provider
All providers also expressed, several of them strongly, that current
resources connected patients with transportation services or offered
financial assistance for transportation. One provider stated that a
transportation method heavily utilized among patients allowed individ-
uals to, “…arrange to have this bus come and pick them up from their
house and bring them in to have their appointment.” Many providers
also mentioned that offered resources addressed needs, including
social support, relaxation, and opportunities for exercise and healthy
living. Several providers stated that patients could access support for
medical expenses and prosthetics through current resources. A few
providers also expressed that church and religious groups were useful
resources for low‐SES patients during treatment.
Providers felt that local and national organizations outside of the
medical center helped address low‐SES breast cancer patient needs.
Many providers said that collaborating with organizations provided
funds and resources that address patient needs. For example, Boston
providers mentioned that the American Cancer Society previously
sponsored a highly utilized event called “Look Good, Feel Better” that
ENZLER ET AL. 1023
helps low‐SES breast cancer patients obtain wigs and improve their
self‐esteem. While many providers felt that patients could utilize
resources and programs outside of the medical center, some providers
felt that low‐SES breast cancer patients did not or were unable to
utilize outside resources.
Providers expressed that most commonly low‐SES breast cancer
patients received information about medical resources and programs
through a social worker within the clinic. Several providers mentioned
that the medical center they worked at was the main clinic for the
surrounding community and region. While these medical centers
typically serve low‐SES populations, a few providers noted that the
medical treatment is the same quality as the care given to higher‐SES
populations. Several providers felt that the health status of low‐SES
populations differed from those classified as higher‐SES; one provider
mentioned that low‐SES individuals may not have access to a primary
doctor, “…so they tend to come in with more advanced cancers.”
Providers gave many reasons as to why low‐SES populations may
have different needs than those with higher SES. Many providers felt
that limited funding constrained current resources. Almost all
providers strongly felt that patient financial insecurity contributes to
inaccessibility of resources.
“Well, I mean I think when you have a higher income, you
don’t have any of the financial challenges that I just sort
of outlined for you with regard to paying for your bills and
having a home. Pay for your medicines, getting private
health insurance, having access to care and usually
having a financial buffer in your ability to take off work
and go get your cancer treated.” ‐Boston BC Provider
Many providers also felt that social determinants of health, such as
education or wealth, cause differences in health status or resource
utilization between low‐SES and high‐SES breast cancer patients. Some
providers mentioned that low‐SES populations have fewer resources
available in the home, such as computers or private transportation
options. Providers also stated that stress causes an inaccessibility of
resources among low‐SES populations. Several providers felt strongly
that low‐SES breast cancer patients have less support systems within
their social network, which creates difficulty in obtaining needed
resources. A few providers also mentioned that an individual’s
location of residence may result in difficult accessing resources.
4 | CONCLUSIONS
We wanted to discover unique needs of low‐SES breast cancer
patients from both an urban and a rural setting by conducting
interviews of these patients at the UT Cancer Institute and Boston
Medical Center. The patient and provider perspectives we captured
elucidated how low‐SES breast cancer patients have unique needs
that differ from those of other breast cancer patients and how views
of those needs differ between providers and patients.
Resources offered at both Boston Medical Center and UT Cancer
Institute were available to meet several low‐SES breast cancer patient
needs, such as living expenses and social support programs. These
resources are critical in providing needed support. However, patients
from both regions also expressed many unmet needs, while many pro-
viders expressed the adequacy of meeting these needs for many
patients. The gaps between providers and patients in perceptions of
these unmet needs highlight a gap in current resource offerings from
both locations. From these, data indicate that the linkages between
patient and resources to meet all the needs are not adequate.
Both low‐SES breast cancer patients and providers from both
regions expressed met and unmet needs that were specific to each
region, which demonstrates that resources are not spread universally
nor are the wants and needs of low‐SES breast cancer patients equal
across the country. As an example, low‐SES breast cancer patients
and providers from Knoxville agreed that transportation was a large
unmet need; however, low‐SES breast cancer patients and providers
from Boston discussed that this was less of an issue for their region.
Low‐SES breast cancer patients and providers from Boston, MA
expressed that housing costs were a large barrier for individuals. While
low‐SES breast cancer patients and providers from Knoxville, TN
mentioned that individuals had financial difficulties, homelessness or
eviction were more commonly expressed by patients from Boston,
MA. These differences could reflect differences in the effects of rural
versus urban poverty or differences in support offered by the institu-
tions or something else entirely. A different assessment of these
issues at multiple institutions might provide insight into the differ-
ences reported here.
There have been very few studies in the literature that focus solely
on the needs of low‐SES breast cancer patients. Studies assessing the
needs of breast cancer patients in the general population of breast
cancer survivors present different themes than those collected by this
study. In the general population of breast cancer patients, survivors
face many needs as well that include psychological care, information
about their disease, and coping mechanisms.14-16 Low‐SES breast
cancer patients in this study expressed some similar needs as those
represented in other studies, but they also had greater pressing needs
that were fundamental, including transportation options, financial
assistance, and posttreatment support. This could suggest that low‐
SES breast cancer patients face more difficulty with basic needs than
higher SES breast cancer patients. This also demonstrates that
national and regional breast cancer nonprofit organizations could fill
this gap in unmet needs and so support patients and providers better.
Future direction should include advocating for increased funding
to reduce resource gaps for low‐SES breast cancer patients and con-
tinuing to research the unmet needs for this population. Providers
need to maintain awareness of the diversity and complexities of needs
for low‐SES patients, as current resource provision does not seem to
cover all needs. As evidenced by this study, different regions may
result in unique needs for low‐SES breast cancer patients. Future stud-
ies should also assess why low‐SES breast cancer patients cannot
access or use existing support programs and services, as these reasons
may elucidate how to better serve this population without increasing
costs. Low‐SES breast cancer patients also have unique and unmet
needs beyond medical treatment. Improving resources outside of
1024 ENZLER ET AL.
medical treatment may allow low‐SES breast cancer patients to better
adhere to treatment or improve their health that has positive implica-
tions for health care expenditures.
4.1 | Clinical implications
These data indicate that there is more to be done to meet the needs of
low‐SES breast cancer patients. But more resources and dollars will
not completely fill the gaps observed. One implication is to better
connect the patients with the resources available, through multiple
communication channels, depending on the population. More long‐
distance resources might be made available for rural women or women
with transportation difficulties. Women at both sites expressed feeling
left out or disconnected from a more human touch. Perhaps peer or
navigator driven resources can be employed to fill that void. Providers
should not assume that because a resource was offered, it will be
perceived by the patients as available, free, and accessible.
4.2 | Limitations
The study had limitations that constrain the generalizability of the
findings. First, it was conducted in two specific geographic locations
that do not represent a population of low‐SES breast cancer patients.
The qualitative nature of the study prohibits us from assessing rates of
distress or concurrence between patients and providers. Finally, we
did not measure these issues over time, and a longitudinal study might
have identified changes that changed with distance from treatment.
Given the target of low‐SES women, we did not think measuring SES
in participants was necessary, but even among these women, it is pos-
sible to imagine variation in SES that could alter responding. All of
these could be addressed through future research.
Numbers do not total 100% because of missing data.
The author(s) declare(s) that there is no conflict of interest.
This journal article was supported by the grant or cooperative agree-
ment number, 1 U58 DP005403, funded by the Centers for Disease
Control and Prevention. Its contents are solely the responsibility of
the authors and do not necessarily represent the official views of
the Centers for Disease Control and Prevention or the Department
of Health and Human Services.
Deborah J. Bowen https://orcid.org/0000-0003-2420-4422
1. Bray F, McCarron P, Parkin DM. The changing global patterns of
female breast cancer incidence and mortality. Breast Cancer Res.
2. McPherson K, Steel CM, Dixon JM. ABC of breast diseases. Breast
cancer‐epidemiology, risk factors, and genetics. BMJ (Clin Res Ed). 2000;321(7261):624‐628.
3. Baqutayan SMS. The effect of anxiety on breast cancer patients.
Indian J Psychol Med. 2012;34(2):119‐123.
4. Burgess C, Cornelius V, Love S, Graham J, Richards M, Ramirez A.
Depression and anxiety in women with early breast cancer: five year
observational cohort study. BMJ. 2005;330(7493):702.
5. Zimmermann T. Intimate relationships affected by breast cancer:
interventions for couples. Breast Care. 2015;10(2):102‐108.
6. Fenn KM, Evans SB, McCorkle R, et al. Impact of financial burden of
cancer on survivors’ quality of life. J Oncol Pract. 2014;10(5):332‐338. https://doi.org/10.1200/JOP.2013.001322
7. Jagsi R, Pottow JAE, Griffith KA, et al. Long‐term financial burden of breast cancer: experiences of a diverse cohort of survivors identified
through population‐based registries. J Clin Oncol Off J Am Soc Clin Oncol. 2014;32(12):1269‐1276.
8. Girgis A, Boyes A, Sanson‐Fisher RW, Burrows S. Perceived needs of women diagnosed with breast cancer: rural versus urban location. Aust
N Z J Public Health. 2000;24(2):166‐173.
9. Park BW, Hwang SY. Unmet needs of breast cancer patients relative to
survival duration. Yonsei Med J. 2012;53(1):118‐125.
10. Todd BL, Feuerstein M, Gehrke A, Hydeman J, Beaupin L. Identifying
the unmet needs of breast cancer patients post‐primary treatment: the Cancer Survivor Profile (CSPro). J Cancer Surviv. 2015;9(2):
11. Bradley CJ, Given CW, Roberts C. Race, socioeconomic status, and
breast cancer treatment and survival. Cancer Spectr Knowledge Environ.
12. Farley TA, Flannery JT. Late‐stage diagnosis of breast cancer in women of lower socioeconomic status: public health implications. Am J Public
13. Thomson CS, Hole DJ, Twelves CJ, Brewster DH, Black RJ, Scottish
Cancer Therapy Network. Prognostic factors in women with breast
cancer: distribution by socioeconomic status and effect on differences
in survival. J Epidemiol Comm Health. 2001;55(5):308‐315.
14. Akechi T, Uchida M, Nakaguchi T, et al. Difference of patient’s
perceived need in breast cancer patients after diagnosis. Jpn J Clin
15. Degner LF, Kristjanson LJ, Bowman D, et al. Information Needs and
Decisional Preferences in Women With Breast Cancer. JAMA.
16. Thewes B, Butow P, Girgis A, Pendlebury S. Assessment of Unmet
Needs Among Survivors of Breast Cancer. J Psychosoc Oncol. 2004;
Additional supporting information may be found online in the
Supporting Information section at the end of the article.
How to cite this article: Enzler CJ, Torres S, Jabson J, Ahlum
Hanson A, Bowen DJ. Comparing provider and patient views
of issues for low‐resourced breast cancer patients. Psycho‐
Oncology. 2019;28:1018–1024. https://doi.org/10.1002/