Cross‐sectional study of psychosocial well‐being among lesbian, gay, bisexual, and heterosexual gynecologic cancer survivors

Abstract Background Delays in care and increased risk for mental health diagnoses put individuals identifying as a sexual minority with cancer at risk for decreased quality of life. Aim To assess psychosocial health among sexual minority gynecologic cancer survivors, we compared self‐reported quality of life and psychosocial measures between individuals diagnosed with gynecologic cancers identifying as lesbian/gay/bisexual (LGB) and heterosexual. Methods and Results English‐speaking adults with gynecologic cancers were invited to participate in an ongoing cohort survey study. Quality of life and psychosocial measures included the Functional Assessment of Cancer Therapy‐General, Distress Thermometer (distress), Patient Health Questionnaire‐8 (depression), General Anxiety Disorder‐7 (anxiety), and Post‐traumatic Stress Disorder Checklist for DSM‐5 (post‐traumatic stress disorder; PTSD). Measures were compared by self‐reported sexual orientation (heterosexual vs. LGB) using descriptive statistics (frequencies and means) and linear and logistic regression models, adjusting for college education. Of 814 patients invited, 457 enrolled (56.1%) and 401 (92.6%) completed the survey and provided information on their sexuality. All but one self‐identified as cisgender women and 22 (5.5%) as LGB. LGB participants were more likely to have completed college (68.2% vs. 40.1%, p = .009) but were otherwise similar across demographic and clinical characteristics. Quality of life and distress scores were similar between groups. LGB participants, compared to heterosexual, reported higher rates of depression (31.8% vs. 10.6%, adjusted odds ratio [OR] = 4.1 [95% confidence interval [CI]: 1.6–11.0], p = .004), anxiety (25.0% vs. 7.1%, adjusted OR = 5.4 [95% CI: 1.7–16.7], p= .004), and PTSD (13.6% vs. 3.5%, adjusted OR = 4.2 [95% CI: 1.1–16.3], p = .04). Conclusion LGB participants reported poorer emotional health following a gynecologic cancer diagnosis than heterosexual participants. Our data suggest this population may need additional resources and support during and after their cancer diagnosis. Future work is needed to identify additional risk factors and the underlying sources of these disparities in order to improve patient care and wellness in this population.

diagnosis. Future work is needed to identify additional risk factors and the underlying sources of these disparities in order to improve patient care and wellness in this population. Individuals who belong to societally marginalized populations are at increased risk for adverse health outcomes, as described in The Health Equity Promotion Model and Minority Stress Theory. 2,3 Discriminatory or stigmatized experiences within one's family and community, re-experienced in clinical settings may impact one's mental and physical health. Multiple studies suggest that individuals belonging to sexual minority populations have a higher prevalence of gynecologic cancers due to increased prevalence of risk factors such as smoking and obesity, as well as decreased likelihood of cancer screening. [4][5][6][7][8][9][10][11][12][13][14] Furthermore, disparities in the rates of depression, anxiety, and substance abuse have previously been shown between sexual minority individuals and their heterosexual counterparts. Rates of mental health disorders are estimated to be approximately 2-3 times higher in the sexual minority population compared to that of the general population. 15,16 Both the increased rate of substance abuse and increased rates of mental health disorders in this population are likely influenced by prejudice and discrimination. 17 Despite a higher prevalence of cancer-related risk factors, individuals belonging to a sexual minority group have greater delays to diagnosis and treatment. Decreased rates of health insurance, poorer access to healthcare and financial barriers leading to unmet medical care have been suggested as inciting factors. 6,[17][18][19] Furthermore, there continues to be a need for increased medical education among practitioners and nursing staff on the topic of sexual minority health, potentially contributing to disparities in quality of care received by members of this community. [20][21][22][23][24][25][26][27][28] Lack of access to adequate healthcare and insurance, stigmatization and increased prevalence for mental health diagnoses prior to cancer diagnosis put this population of cancer survivors at particular risk for poorer outcomes and QOL following a cancer diagnosis. However, evidence on psychosocial outcomes among this population of gynecologic cancer survivors is limited with inconsistent findings. [29][30][31] Given the potential impact of gynecologic cancer on psychosocial health outcomes in general, and the greater prevalence of clinical risk factors among sexual minority populations specifically, further identifying disparities among subgroups of survivors is necessary to identify highest risk individuals for worse outcomes. 32,33 We sought to compare self-reported QOL and psychosocial measures between heterosexual and sexual minority gynecologic cancer survivors.

| METHODS
The Gynecology Oncology-Life after Diagnosis (GOLD) cohort study prospectively assesses QOL and long-term social, emotional, and physical sequelae of cancer in gynecologic cancer survivors. Study methods have been published elsewhere. 34  The primary outcomes for this exploratory cross-sectional analysis were self-report measures of QOL and emotional health at the time of study entry. Cancer-related QOL was measured using the Functional Assessment of Cancer Therapy-General (FACT-G); higher scores indicate greater QOL. 35,36 Cancer-related distress was measured using the National Comprehensive Cancer Network Distress Thermometer, version 2.2016, with higher scores indicating greater distress; a score of 4 or greater was considered clinically relevant distress. 37 Depression was measured using the Patient Health Questionnaire-8 (PHQ-8) score; higher scores indicate greater depression symptoms; a score of 10 or greater was considered potentially clinically relevant depression symptoms. 38 Generalized anxiety was measured using the General Anxiety Disorder-7 (GAD-7), with higher scores indicating greater anxiety severity and a score of 10 or greater was considered potentially clinically relevant anxiety symptoms. 39 Symptoms of post-traumatic stress disorder (PTSD) were measured using the Post-traumatic Stress Disorder Checklist for DSM-5, with higher scores indicating greater PTSD symptoms and a score of 33 or greater considered potentially clinically relevant. 40 Sexual orientation was self-reported by participants (heterosexual, lesbian, gay, bisexual, or other). Due to the small sample size, participants who identified as lesbian, gay, bisexual were categorized as LGB for analysis purposes. No participants reported "other." Additional self-reported data collected via the survey included demographic variables, which were categorized for analyses as follows: age (continuous, years), gender (male, female, transgender, other), race/ethnicity (non-Hispanic white, other), education (no college degree, at least a college degree), income (annual household income <$50 000, $50 000-$99 999, ≥$100 000, prefer not to say), marital status (partnered/married, widowed/divorced/never mar- In a supplemental analysis, we reviewed the medical records of all LGB participants and of heterosexual participants with elevated anxiety or depression scores for mental health disorders diagnosed prior to their cancer. Individuals with missing outcome data were excluded from analyses related to just that outcome measure. Data were analyzed using SAS version 9.4 software (SAS Institute Inc., Cary, North Carolina), and p-values less than .05 were considered statistically significant.

| RESULTS
A total of 814 individuals were invited to participate in this study; 457 participants enrolled (56.1% total response rate; 252 of 590 (42.6%) via mail and 205 of 224 (91.5%) in clinic). Of these, 421 completed the survey and 401 (92.6%) provided information on their sexual orientation and were included in this analysis.
Participants were on average 60.0 ± 11.0 years old and 2.1 ± 2.0 years from diagnosis. Most were non-Hispanic white (97.4%) and had not completed college education (60.0%). The majority were diagnosed with ovarian (42.7%) or endometrial (39.6%) cancer, with the remaining 11.9% and 5.8% having cervical or vaginal/vulvar cancers, respectively. Demographic and clinical variables were generally similar between groups; however, LGB participants were more likely to have completed a college education (68.2% vs. 40.1%, p = .009; Table 1).
Rates of potentially clinically relevant depression (31.8% vs.

| DISCUSSION
As the number of gynecologic cancer survivors increases, identification of risk factors associated with poorer outcomes and QOL is crucial for providing comprehensive care. Our findings suggest that individuals who identify as LGB are at risk for poorer emotional health following a gynecologic cancer diagnosis, specifically with regard to anxiety, depression, and PTSD. We did not observe significant differences in QOL by sexual identity group. While the FACT-G captures overall emotional QOL and has demonstrated reliability for examining general QOL, the PHQ-8, and GAD-7 questionnaires assess specific mental health concerns and are accepted clinical tools with known cutoffs relevant for identifying depression and anxiety. [42][43][44][45] The American Cancer Society estimated that 107 290 individuals would be diagnosed with gynecologic cancers in 2020. 46 Conservatively, 1.2%-12% of the US population is estimated to identify as belonging to a sexual and/or gender minority group. 48 Although epidemiologic data on the number of individuals with gynecologic cancers who identify as a sexual minority are lacking, extrapolating from the reports above, we can conservatively estimate that at least 1300 sexual and/or gender minority individuals will be diagnosed with a gynecologic cancer each year. Evidence suggests lesbian women are at increased risk for breast cancer, 9 and bisexual individuals may be at increased risk for cervical cancer 4 ; this is likely due at least in part to lower rates of cervical and breast cancer screening among the sexual minority population. 23  their sexual orientation, and concerns about disclosure of sexual orientation. 52 As previously mentioned, these stressors, discriminatory experiences, and microaggressions experienced with a societally marginalized identity may impact health. 2 Even if the emotional health of individuals identifying as a sexual minority was poor before their cancer diagnosis, the frequent clinical contact that comes with a cancer diagnosis presents a window of opportunity to identify and address emotional health, which may also impact the individual's ability to cope with the diagnosis. The interplay between preexisting and cancer-related factors should be the focus of future studies.
It has also been shown that patients with poor access to care describe worse emotional health. 31 In a recent study, Boehmer et al, showed that sexual minority female cancer survivors had significantly lower access to care compared to their heterosexual counterparts, and this was associated with poor physical and mental QOL. 31 The underlying risk of poor mental health, combined with lower access to care, and unease regarding provider knowledge and trust makes the sexual minority cancer survivor population at specific risk for poorer mental QOL. This is exacerbated by poor ascertainment of gender identity and sexual orientation as part of oncology care. 53   LGB participants is reflective of the population. We did not perform a power analysis prior to proceeding with the study. The sample size did not allow for adjustment for other factors, or the ability to examine different sexual minorities separately, or intersectionality of multiple social constructs that likely create unique and group-specific experiences of discrimination and impact clinical care, such as race, ethnicity, socioeconomic class, or among specific sexual and gender minority subgroups (ie, lesbian, bisexual, gay, queer, transgender). The tools used to examine anxiety, depression, and distress should be further examined among sexual and gender minority individuals as the validity and reliability of these tools were likely established among largely cisgender, heterosexual populations. We also did not measure insurance status, which also may have been related to the outcomes.
While we recognize the importance of addressing discrimination and stigmatization to reduce disparities, we did not assess these factors and were unable to address these factors in this study. Future studies should examine these factors that may lead to differences in psychosocial outcomes with intervention studies to guide reduction of disparities as outlined by the minority stress and health equity promotion models. 2,3 Participants in this study were diagnosed and treated for gynecologic cancers at a single academic institution in Minnesota and were primarily non-Hispanic white, thus our findings may not be generalizable. Finally, given the nature of the study and nonresponse rate, there may be response bias.

| CONCLUSION
Our data highlight that LGB gynecologic cancer survivors may need additional, specific, and alternative resources and support following a cancer diagnosis. This is exacerbated by the lack of policies for patient-centered care of sexual minority populations in cancer centers. 23 forms for study participation and abstraction of clinical data from the electronic health record.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.