Special Edition: Junior Clinical Research (2023), Vol. 3 No. S2 https://doi.org/10.47488/dhrp.v3iS2.83 DHR Proceedings ǀ http://dhrproceedings.org 19 2023, Vol. 2 No. S2 19-23 COMMENTARY How Breast Cancer Treatments Affect Hispanic Psychologically Post-Treatment Samantha N. Espinoza1,2, Elise Hernandez1,3, Fernando Saucedo Jr.1,3, Estevan Bonilla1,3, Natasha Perez1,4, Julian Gonzalez Jr.1,4, Abigail Herrera1,2, Savannah N. Puente1,2, Faith L. Perez1,4, Iliana Rios1,4 1 3rdAnnual Junior Clinical Research Internship, South Texas Academy for Education & Training in Research, DHR Health Institute for Research and Development 2 Weslaco High School, TX 3 Harlingen High School, TX 4 Santa Rosa High School, TX Received: June 16, 2023 Accepted for publication: October 25, 2023 Published: November 16, 2023 Introduction In the United States, breast cancer accounts for nearly 30% of all new cancer cases each year.1 It is the primary cause of cancer death among Hispanic women and the second highest cause of cancer death among all females.2 According to the Breast Cancer Research Foundation, Hispanic women are more likely to experience an earlier onset of an aggressive illness such as triple-negative breast cancer.3 In the United States, every year, about 264,000 women are diagnosed with breast cancer. Among these women, around 39% reported non-specific distress, 34% experienced anxiety, 31% reported symptoms of post- traumatic stress, and 20% experienced depression following their diagnosis.4 Awareness of a cancer diagnosis can cause severe emotional distress, creating a psychological imbalance among patients, subsequently affecting their quality of life. Following a patient’s diagnosis, there are many factors that contribute to adverse psychological effects related to therapies and treatment such as chemotherapy, hormonal therapy, medical menopause, and hypothyroidism.5 In addition to this, therapies themselves can cause patients to experience common side effects such as fatigue, nausea/vomiting, diarrhea, constipation, pain, arm swelling, shortness of breath, and skin irritation.6 In addition to the conflicting symptoms and effects one may experience during surgery, an entire new set of complications derive from previous treatments, further advancing one's psychological state. Surgeries such as lumpectomies and mastectomies can also affect the quality of life of patients as it alters their body, leading to loss of self- confidence. The physical side effects of breast cancer treatment can include altered body shape, hair loss, early menopause, and infertility.7 The breast is one of the most common symbols of femininity. Thus, the surgical removal of one or both breasts can cause harmful psychological effects on a woman. A woman who has lost a breast may feel self-conscious, insecure, submissive to other women, and less attractive, especially in the eyes of their partner.8 Moreover, the cost to cover respective treatments, surgeries, medications, and doctor visits can be expensive, especially if a patient does not have medical insurance. Even if one does have insurance, certain treatments not covered by insurance and other out-of-pocket costs can result in significant debt, even after treatment has ended. Depending on the severity of their cancer and their health status, patients may not be able to work as much or at all.9 The loss of income can cause significant financial and familial strain, further demonstrating the persisting impacts of breast cancer on patients. Special Edition: Junior Clinical Research (2023), Vol. 3 No. S2 https://doi.org/10.47488/dhrp.v3iS2.83 DHR Proceedings ǀ http://dhrproceedings.org 20 2023, Vol. 2 No. S2 19-23 Hispanic Women Compared to Other Ethnicities Hispanic women, compared to other ethnicities, are at higher risk of going undiagnosed for breast cancer for longer periods of time.10 They are 30% less likely to be diagnosed for the fact that most of them are not exposed to breast cancer screenings or are not aware of its symptoms.3 One of the most effective ways of achieving early identification of breast cancer in women is through routine mammogram screenings. Amongst underserved communities, screenings and informational advertisements about breast cancer may not be promoted by any of their healthcare facilities or public health groups. Providing breast cancer education and adopting risk education measures, in culturally sensitive and dual language situations, could potentially keep incidence and death by cancer low. Within ethnic and racial populations in the United States, differences in the incidence rate, survival rate, and features of the tumor are seen. Epidemiologic studies that mostly included non-Hispanic White women have discovered risks for breast cancer, which limits an understanding of how important these factors are to different ethnic groups.11 Despite Hispanics being around 15% of the population in the United States, which is still currently expanding, only very few studies have examined the thorough effects of breast cancer risk factors in these populations. Less than 3% of individuals involved in clinical trials are Black, 12.7% of Americans have African or Caribbean heritage. In contrast, compared to the prevalence of cancer, Asian communities are typically overrepresented in cancer therapeutic trials.11 Clinical research does not have enough diverse patient populations. It mainly includes non-Hispanic White populations, which restricts our understanding of significant biological and social distinctions that may influence the development of treatments. Body Image “I look in a mirror and the result is deformity. Nothing, but just deformity,” a quote stated by one of many breast cancer survivors.12 Society today tends to portray what the perfect female body should look like. Body image is the depiction of one’s own body in their own mind. Breast cancer survivors suffer with self- confidence and body image due to the fact that they undergo many different treatments that can physically alter their appearance, such as chemotherapy. Chemotherapy is the practical use of powerful chemicals that are inserted through the bloodstream intravenously (IV).13 This treatment destroys both tumor and healthy cells and can result in hair loss. This feminine feature is very significant to women as it plays a part in defining their identity as a woman.8 Mastectomies which are the surgical removal of one or both breasts is another treatment that physically alters the appearance of a woman’s body. Over 100,000 women receive mastectomies annually.14and therefore a large portion of the US female population is affected. A study conducted by Remmers, et.al., surveyed volunteers who participated in a report about the after- thought of themselves being frightened and startled when they first saw the surgical site.15 This can trigger many emotions such as depression, anxiety, and a lack of self-confidence. Because of this, having this form of cancer can leave a heavy toll on the mental and physical state of the human body. Mental Disorders and other Psychological Factors Depression, anxiety, decrease in self- confidence are some of many psychological effects that breast cancer survivors experience during and after their treatments.17 However, in Hispanic households, acknowledgement of mental health issues are either entirely avoided or perceived as non-existent or abnormal.18 Therefore, when they are diagnosed with breast cancer, the psychological effects that come from the diagnosis are generally disregarded since they don’t get the proper information on mental health and that way they won’t be seen as unstable.18 We will go into deeper discussion on how these psychological disorders affect the Hispanics women with the discussion on the two most impacting disorders: depression and anxiety. Depression or major depressive disorder is a mental illness that affects not only your psychological well-being but your physical well-being too.19 It can affect their mental stability which in turn has them not only isolate themselves from others, but also make a simple task seem impossible. For instance, just getting up to shower, brushing their teeth, and keeping up with their hygiene can be hard for someone who is suffering from this condition.20 Others who have not gone through this experience themselves may be quick to judge and think “it’s such a simple task, they're just being lazy” when they don’t even know what it actually feels like to battle yourself within your mind. The fuel that is added to one's depression is also having low self- esteem. Especially since most breast cancer survivors result in getting a mastectomy as previously mentioned. The scarring that comes from the surgical procedure may worsen their isolation from society. One quote that shows this is from a participant from a study on how body image is perceived in women after Special Edition: Junior Clinical Research (2023), Vol. 3 No. S2 https://doi.org/10.47488/dhrp.v3iS2.83 DHR Proceedings ǀ http://dhrproceedings.org 21 2023, Vol. 2 No. S2 19-23 their mastectomies. The quote states “I didn’t want to see the operation area at all; I saw it when I was back home. Before seeing it, I knew that I was going to feel the emptiness but when I saw it, I felt very different (crying), words are never enough to explain”.16 Therefore, insecurity and lack of self-confidence will hold them back from living life and being who they were before the cancer. Anxiety is another mental health illness that can affect many women with breast cancer. In a recent study, 32% of breast cancer patients experienced symptoms of anxiety.21 Having anxiety impacts these women's lives. Anxiety is an emotional disorder which happens because of stress but when it's a disorder it gets worse and doesn't go away.22 For breast cancer survivors it is fearing recurrence, hopelessness, fearing for the worst and uncertainty of the future. Anxiety may affect a patient’s ability to complete daily tasks of everyday life. It can creep up all of a sudden with panic and may go away at any given time. It can affect a person's life by getting in the way of family and friends, job performance, and social skills. Self-confidence is also greatly affected by breast cancer diagnosis and may stop the patient's ability to be around people. Patient’s may get overwhelmed by going out so they usually avoid interacting with others. However, anxiety affects your mental and physical health. Some of the physical effects are being restless, nauseous, light headed or dizzy, and stomachaches.23 You can also get panic attacks when someone or something reminds you of those hard times. People who have experienced anxiety before know the symptoms and how it feels, but those patients who have never experienced anxiety aren't prepared for it. Disturbance in Social Life The way of life, beliefs, and values that are passed down from one generation to the next, also known as culture, can impact how people view and manage their health and well-being, as well as their perception of the world in a situation where something seems unmanageable, like being diagnosed with breast cancer. Along with mental health issues among breast cancer survivors, specifically Hispanic women, there are a variety of social repercussions that affect their quality of life. In a 2011 survey, researchers from Georgetown University found reoccurring themes present throughout the lives of Hispanic women post treatment such as shame, religion, and more which have impacted their standard of living.24 Their social interactions are often limited due to strains on their physical health leading to feelings of isolation, including a sense of burden. Additionally, they may be incapable of performing their assigned familial role leading to further sense of isolation.25 Furthermore, studies on breast cancer survivors exhibit how Hispanic women are especially receptive towards stigmas and responses from family members concerning their illness and how marianismo, a gender role expressing female submissiveness, plays another factor to their social life.26 For instance, some women may feel cultural pressure to remain an all-nurturing figure and even self-sacrificial for the benefit of their husbands. This can also create extensive loneliness as patients refuse to discuss the disease with their spouses. In addition to survivors’ concerns and fears, another notable factor that dictates their quality of life socially is their religion. As for the survey listed above, the majority of Hispanic women put their fears and concerns aside, after their diagnosis, in order to find consolation in God.24 However, that isn’t always the case for all patients. Others have reported their diagnosis and post-treatment complications were a punishment from God, which led them to question their commitment, because most of these patients depended on religious support to determine the bulk of their well-being.27 For instance, solidarity from religion has been linked to higher quality of life for patients suffering with cancer.27 Qualitative studies on this demographic, Hispanic women, propose that cultural components demonstrate a distinct vulnerability throughout their experience of breast cancer from diagnosis, treatment, and to remission. Conclusion Current evidence supports the fact that Hispanic women with breast cancer have a difficult time processing their diagnosis. Once being diagnosed, there are drastic changes to their bodies, body image, mental health, and social life. Once therapy begins, patients' perceptions of their bodies start to change as a result of losing things such as hair, breasts, and self-confidence. Between 40% and 100% patients experience hair thinning, 59.3% reduced in hair volume and 62.5% of patients' hair didn't come back after treatment.28 Mental health issues can have an impact on an individual both during and after treatment, including insomnia, severe anxiety and depression. The rate of breast cancer patients getting depression ranges from 1.5-50% depending on the diagnosis.29 Patients' social lives affect how they interact with their family and friends throughout therapy, and some even start to doubt their religious beliefs and ask God why they were diagnosed. Pooled data from studies showed that 45% reported high levels of social difficulty.30 Therefore, having more awareness and understanding of said issues can tremendously aid the patient's recovery. Special Edition: Junior Clinical Research (2023), Vol. 3 No. S2 https://doi.org/10.47488/dhrp.v3iS2.83 DHR Proceedings ǀ http://dhrproceedings.org 22 2023, Vol. 2 No. S2 19-23 Resources that Hispanic women can use to cope with their diagnosis are Susan G. Komen, HERConnection, 24/7 Cancer helpline, Mary Ann Liebrt, and Patient-Centered Outcomes Research Institute. Acknowledgements Monica Betancourt-Garcia, MD, Program Director; Melissa Eddy, MS, Program Manager Funding Funded by DHR Health Institute for Research & Development; DHR Health; Region One ESC GEARUP College Ready, Career Set!; Region One ESC GEARUP College Now, Career Connected; Region One ESC PATHS; Region One ESC Upward Bound Math & Science; Benavides ISD; and Jubilee Academy-Brownsville References 1. Breastcancer.org. Breast Cancer Facts and Statistics. www.breastcancer.org. Published March 10, 2022. https://www.breastcancer.org/facts-statistics 2. CDC. CDC - Basic Information About Breast Cancer. CDC. 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