Depression, anxiety, post-traumatic stress disorder andhealth-related quality of life and its association with socialsupport in ambulatory prostate cancer patientsecc_1117 736..745

A. MEHNERT, phd, Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martin-istr., Hamburg, C. LEHMANN, doctoral student, Department of Medical Psychology, University MedicalCenter Hamburg-Eppendorf, Martinistr., Hamburg, M. GRAEFEN, md, Martini-Clinic, Prostate Cancer Center,University Medical Center Hamburg-Eppendorf, Martinistr., Hamburg, H. HULAND, md, Department of Urology,University Medical Center Hamburg-Eppendorf, Martinistr., Hamburg, & U. KOCH, phd, md, Department ofMedical Psychology, University Medical Center Hamburg-Eppendorf, Martinistr., Hamburg, Germany

MEHNERT A., LEHMANN C., GRAEFEN M., HULAND H. & KOCH U. (2010) European Journal of CancerCare 19, 736–745Depression, anxiety, post-traumatic stress disorder and health-related quality of life and its association withsocial support in ambulatory prostate cancer patients

The aim of this study is to identify anxiety, depression and post-traumatic stress disorder in prostate cancerpatients and to investigate the association with social support and health-related quality of life. A total of 511men who had undergone prostatectomy were surveyed during ambulatory follow-up care for an average of 27months after surgery using standardised self-report measures (e.g. Hospital Anxiety and Depression Scale,Posttraumatic Stress Disorder Checklist – Civilian Version, Illness-Specific Social Support Scale, Short-FormHealth Survey). Seventy-six per cent of patients evaluated their disease as ‘not’ or a ‘little threatening’. Thecancer diagnosis and uncertainty were most frequently reported as ‘distressing’, while medical treatment anddoctor–patient interaction were most frequently evaluated as ‘most helpful’. The number of patients reportingincreased levels of psychological distress was 16%, with 6% demonstrating signs of having severe mentalhealth problems’. No higher levels of anxiety and depression were observed in cancer patients compared withage-adjusted normative comparison groups. Lack of positive support, detrimental interactions and perceivedthreat of cancer were found to be predictors of psychological co-morbidity (P < 0.001). Lack of positive support,detrimental interactions, threat of cancer, disease stage and age significantly predicted mental health (P <0.001), whereas the impact of social support on physical health was rather weak. Findings emphasise the needfor routine psychosocial screening.

Keywords: prostate cancer, quality of life, psychological, social.

INTRODUCTION

Prostate cancer is one of the most prevalent male cancersin Germany and western developed countries with an

estimated annual incidence of 58 000 new cases inGermany and of 678 000 new cases worldwide (Parkinet al. 2005; Rohde et al. 2007; Robert Koch-Institut &Gesellschaft der epidemiologischen Krebsregister in Deut-schland 2008). Despite a comparatively good prognosisand less invasive treatments in the majority of prostatecancer patients, considerable psychosocial distress,anxiety and depression are though evident throughout thecourse of the illness in this patient population (Eton &Lepore 2002; Penson et al. 2003; Bloch et al. 2007).

Correspondence address: Anja Mehnert, Research staff, Department ofMedical Psychology, University Medical Center Hamburg-Eppendorf, Mar-tinistr. 52-S35, 20246 Hamburg, Germany (e-mail: mehnert@uke.uni-hamburg.de).

Accepted 18 January 2009DOI: 10.1111/j.1365-2354.2009.01117.x

European Journal of Cancer Care, 2010, 19, 736–745

Original article

© 2009 The AuthorsEuropean Journal of Cancer Care © 2009 Blackwell Publishing Ltd

According to a systematic literature review by Daleet al. (2005), anxiety has been identified in 10–36% ofshort- and long-term prostate cancer survivors. Tworecent studies in ambulatory prostate cancer patients andpatients with localised prostate cancer following surgeryor radiotherapy demonstrated high degrees of anxiety in13% and 15% of men (Roth et al. 2006; Namiki et al.2007). Similar results were found for depression. Previousstudies found between 13% and 27% of prostate cancerpatients to have major depressive disorder or clinicallysignificant levels of depression (Kornblith et al. 1994; Pirlet al. 2002; Korfage et al. 2006). Pirl et al. (2008) showedthat rates of depressive symptoms ranged from 10% to16% in men with locally advanced prostate cancer receiv-ing hormone therapy.

A further number of studies assessing psychological dis-tress indicate that 13–53% of prostate cancer patientssuffer from distress at different time points during thecourse of the illness (Roth et al. 1998; Zabora et al. 2001;Bisson et al. 2002; Balderson & Towell 2003; Mehnertet al. 2007). Specific cancer-related health anxiety such asworries about cancer recurrence or future diagnostic testswere prevalent in between 36% and 39% of prostatecancer patients (Deimling et al. 2006). Moreover, post-traumatic stress disorder (PTSD) has been increasinglydiagnosed in cancer populations, because life-threateningillness has been included as a potential traumatic event inthe Diagnostic and Statistical Manual of Mental Disorders– Fourth Edition (DSM-IV) in 1994 (American PsychiatricAssociation 1994). PTSD is characterised by the experi-ence of a traumatic life event and an individual stressresponse including intense fear, helplessness, or horror.Specific PTSD symptom clusters are trauma-related intru-sive cognitions, avoidance and hyperarousal. The preva-lence of cancer-related PTSD ranges from 0% to 32%(Kangas et al. 2002; Akechi et al. 2004; Palmer et al. 2004;Mehnert & Koch 2008; Shelby et al. 2008). Research alsoindicates that a substantial number of patients, up to 48%,are likely to encounter individual PTSD symptoms fol-lowing cancer (Kangas et al. 2002; Matsuoka et al. 2002;Akechi et al. 2004; Mehnert & Koch 2008). Studies on theprevalence of PTSD in adult cancer patients, however,predominantly focus on breast cancer patients with earlyand mixed tumour stages. There is little knowledge so farabout the prevalence of PTSD and specific PTSD symp-toms in prostate cancer patients.

Lack of family or social support, the presence of physi-cal and functional impairments such as urinary and bowelsymptoms, younger age at diagnosis, cancer recurrence,high or unstable prostate-specific antigen (PSA) test levels,as well as avoidance coping styles appear to be important

for the prediction of distress in men with prostate cancer(Bisson et al. 2002; Perczek et al. 2002; Balderson &Towell 2003; Roesch et al. 2005; Namiki et al. 2007). Inparticular, social support has been widely demonstrated topromote mental as well as physical health, and to act as abuffer against distress and cancer-related burden. On thecontrary, social isolation, lack of support or detrimentalinteractions have been found to have an adverse effect onemotional well-being (Helgeson & Cohen 1996; Bottom-ley & Jones 1997; Baider et al. 2003; Trunzo & Pinto 2003;Kroenke et al. 2006; Roberts et al. 2006; Northouse et al.2007).

The objectives of the study were to examine the subjec-tive threat of prostate cancer and perceived distress as wellas supporting events, and to identify the prevalence ofanxiety, depression and PTSD in ambulatory prostatecancer patients during follow-up care. Group comparisonswith population-based normative values for anxiety anddepression were conducted. Furthermore, we investigatedhealth-related quality of life (HRQOL) in this sample ofshort- and long-term prostate cancer survivors, and therole of social support in preventing the occurrence of psy-chological co-morbidity in these patients. As the stressbuffering role of social support has been emphasised inother cancer populations, we hypothesised that positivesocial support as well as inversely detrimental interac-tions will act as significant predictors of psychologicalco-morbidity and HRQOL.

METHODS

Participants

Patients were recruited with a clinical diagnosis of pros-tate cancer who had received a radical prostatectomybetween 1992 and 2003. Patients scheduled for follow-upcare at the University Medical Center’s Department ofUrology between November 2003 and December 2004were consecutively asked to complete a set of self-reportquestionnaires during waiting time at the outpatientclinic. The study protocol had been approved by the ethicscommittee of the local chamber of physicians. A sample ofn = 511 patients gave informed consent to participate inthe study. The participation rate was 70%. Table 1 pre-sents the demographic and clinical characteristics of thesample. The mean age of participants was 64 years.Eighty-eight per cent of men were married, 66% hadjunior high school or lower education and the majority ofpatients (68%) were retired. Seventy-one per cent were atdisease stage pT2. The average time since surgery (pros-tatectomy) was 27 months, ranging from 2 weeks to 141

Depression and anxiety in prostate cancer

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months; 81% of patients had nerve-sparing surgery. Infor-mation about the non-participants was not available.

Measures

Clinical information was collected for each patient usingmedical charts. Demographic data were obtained using astandardised questionnaire. Patients were asked to answerwritten questions about stressful, distressing and support-ive events during the course of their cancer experience.Furthermore, the current threat of the prostate cancerdisease was assessed using a 5-point Likert item (1 = ‘notat all threatening’ to 5 = ‘very much threatening’). Per-ceived distressing and supporting events were assessedusing open ended questions. The German version of theHospital Anxiety and Depression Scale (HADS) is a vali-dated screening instrument for anxiety and depression insomatically ill patients (Herrmann et al. 1995). The item

scores range from 0 (no distress) to 3 (maximum distress).According to the German HADS Manual, a score of 0–7 iscategorised as normal, a score of 8–10 is considered toindicate a possible anxiety or depressive disorder (moder-ate levels of anxiety/depression), and a score of 11 or aboveis considered to indicate a probable anxiety or depressivedisorder (high levels of anxiety/depression). Representa-tive population-based standardised values for men atdifferent age groups were computed through regressionanalyses as recommended by Hinz and Schwarz (2001).The following equations were applied: 0.026 ¥ age + 0.69 ¥0 (male gender) + 3.09 for anxiety and 0.079 ¥ age + 0.15 ¥0 (male gender) + 0.73 for depression.

The Posttraumatic Stress Disorder Checklist – CivilianVersion (PCL-C) (Weathers et al. 1991; Teegen 1997)assesses the PTSD symptom criteria intrusion, avoidanceand hyperarousal according to the DSM-IV. Participantsestimate the degree to which they have been concernedabout each symptom during the past month. The term‘distressing event’ was replaced by the term ‘cancer orcancer treatment’. Participants were considered likely tohave PTSD if they meet at least one intrusion, three avoid-ance and two arousal symptoms (rated as ‘moderate’ orabove).

Social Support was assessed using the 24-item Germanversion of the Illness-Specific Social Support Scale (ISSS)(Ramm & Hasenbring 2003) which measures positivesupport (15 items) and detrimental interaction (nineitems). Detrimental aspects of social relationships in thismeasure include over-protective behaviour, dismissive,conflictual behaviour patterns, and pessimism. Items arescored on a 5-point Likert scale ranging from 1 (never) to 5(always).

The Short-Form Health Survey (SF-8) (Ware et al. 1999)was used to assess HRQOL. Each of the eight items mea-sures a different dimension of health: general health,physical functioning, physical role, bodily pain, vitality,social functioning, mental health and emotional role. TheSF-8 provides two summary scores for physical (physicalcomponent summary) and mental health (mental compo-nent summary). Each item score or summary measure-ment ranges from 0 to 100, higher scores indicating betterhealth.

Statistical analysis

Statistical analyses were performed using the StatisticalPackage for the Social Sciences version 15.0. Associationsbetween variables were calculated using Pearson’sProduct-Moment or Spearman’s correlation coefficient.Uni- and multivariate analyses of variance were con-

Table 1. Demographic and medical characteristics (n = 511)

n (%)

Mean age in years 64.3 (�6.0, 38–83)Age distribution

Up to 65 286 56.0Over 65 225 44.0

Marital statusMarried 449 87.9Single/divorced/widowed 62 12.1

Children 412 80.6Level of education

Secondary school 177 34.6Junior high school 162 31.7High school 96 18.8University 76 14.9

Employment statusEmployed 156 30.5Retired 349 68.3Unemployed 6 1.2

Place of residenceBig city 248 48.5City 89 17.4Town 69 13.5Village 105 20.5

Disease stage (TNM)pT2 361 70.7pT3 133 26.0pT4 17 3.3

Mean months since surgery 26.7 (�26.8, 0.5–141.5)Up to 6 months 192 37.6Up to 24 months 97 19.0Up to 36 months 87 17.037 months and more 135 26.4

Type of surgeryNerve-sparing 413 80.8Nerve-damaging 98 19.2

Mean PSA value (ng/mL) 9.58 (�10.7. 0–102.90)

TNM, tumour, node, metastasis; PSA, prostate-specific antigen.

MEHNERT et al.

© 2009 The AuthorsEuropean Journal of Cancer Care © 2009 Blackwell Publishing Ltd

738

ducted for group comparisons in metric data. Group dif-ferences were calculated using t-tests in metric andc2-tests in categorical variables. Logistic regression analy-sis using forward conditional method and linear regressionanalysis were carried out. To provide an estimate of themagnitude of the group differences, Cohen’s standardisedeffect size (r, d, eta2) was calculated. The values r = 0.1, d= 0.2 and eta2 = 0.009 represent the cut-off for a smalleffect size; r = 0.3, d = 0.5 and eta2 = 0.0588 represent thecut-off for a moderate effect size; and r = 0.5, d = 0.8 andeta2 = 0.1379 represent the cut-off for a large effect size.Two-tailed significance tests were conducted using a sig-nificance level of P � 0.05.

RESULTS

Threat of prostate cancer

The majority of patients assessed the current threat of thedisease as ‘not at all’ (35.0%) or ‘a little threatening’(41.1%). Seventeen point two per cent as ‘somewhatthreatening’ and a minority of 6.7% as quite a bit or verymuch threatening (M = 1.97; SD = 0.92). The perceivedthreat of disease was higher in patients 65 years oryounger (P = 0.04) (eta2 = 0.01), in patients with a higherdisease stage (P < 0.001) (eta2 = 0.04) and a longer-timespan since cancer diagnosis (P = 0.001) (eta2 = 0.03). Nointeraction effects were observed (P > 0.34).

Perceived distressing and supporting events

Among the patients, 83.4% (n = 426) experienced at leastone distressing event related to prostate cancer or its treat-ment. The cancer diagnosis (41%) and uncertainty aboutthe future (24%) were most frequently reported as dis-tressing, followed by impotence and sexual problems(11%), and fear of progression (11%) (Table 2).

Eighty-seven per cent (n = 444) of men named support-ing events. Medical treatment (25%) and doctor–patientcommunication (19%) were most frequently reported as

helpful. Sixteen per cent named their partner and 14%their family and friends as supporting others (Table 3).

Psychological co-morbidity and HRQOL

The overall number of patients having increased levels ofpsychological distress or a probable psychiatric disorder isn = 83 (16.2%). The most prevalent probable single diag-nosis is PTSD (4.3%), followed by a probable anxiety(3.3%) and depressive disorder (2.3%) (Table 4). No groupdifferences were found in anxiety, depression and PTSD aswell as HRQOL between patients at different months postsurgery (P > 0.08) and with different tumour stages (P >0.30) (Table 5).

Table 6 shows anxiety and depression in the prostatecancer sample compared with representative population-based standardised values for men at different age groups.We found prostate cancer patients at all age groups atsignificant lower levels of anxiety and depression com-pared with the equivalent group values for the Germannormative sample.

Psychological co-morbidity and HRQOL

Patients with increased levels of psychological distress ora possible psychiatric disorder (n = 83) were found to havea significant lower overall physical (physical componentsummary) (P < 0.001) (eta2 = 0.07) as well as overall mentalquality of life (mental component summary) (P < 0.001)(eta2 = 0.32) as patients with no psychological distress.These significant group differences were also found in allindividual HRQOL dimensions (P < 0.001) (eta2 = 0.39).

Social support

The ISSS mean scores of the total sample were M = 3.2(SD = 0.76) for positive support and M = 0.88 (SD = 0.58) for

Table 2. Type and frequency of distressing events (n = 511)

Distressing events* n (%)

Prostate cancer diagnosis 211 41.3Uncertainty about the future 123 24.1Impotence/sexual problems 58 11.4Fear of progression 52 10.2Incontinence 39 7.6Fear of treatment 29 5.7Other 56 11.2

*Multiple responses; mean number of distressing events M =1.1 (SD = 0.7, range 1–4).

Table 3. Type and frequency of supporting events (n = 511)

Supporting events* n (%)

Medical treatment 126 24.7Doctor–patient communication 97 19.0Partner 83 16.2Family and friends 73 14.3Optimism 55 10.8Good cancer prognosis 44 8.6Cancer rehabilitation 24 4.7Patient–patient interaction 18 3.5Distraction 16 3.1Other 70 13.7

*Multiple responses; mean number of distressing events M =1.2 (SD = 0.7, range 1–3).

Depression and anxiety in prostate cancer

© 2009 The AuthorsEuropean Journal of Cancer Care © 2009 Blackwell Publishing Ltd

739

Tab

le4.

Dep

ress

ion

,an

xiet

yan

dP

TSD

atdi

ffer

ent

mon

ths

post

can

cer

diag

nos

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1)

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agn

osis

P

Tot

alsa

mpl

e(n

=51

1)U

pto

6m

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s(n

=19

2)U

pto

24m

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s(n

=97

)U

pto

36m

onth

s(n

=87

)36

mon

ths

and

mor

e(n

=13

5)

n(%

)n

(%)

n(%

)n

(%)

n(%

)

Dep

ress

ion

†M

(SD

)2.

5(3

.0)

2.6

(3.0

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4(2

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2.4

(2.7

)2.

6(3

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0.85

*N

orm

al47

7(9

3.3)

181

(94.

3)93

(95.

9)82

(94.

3)12

1(8

9.6)

0.54

**M

oder

ate

22(4

.3)

7(3

.6)

2(2

.1)

4(4

.6)

9(6

.7)

Hig

h12

(2.3

)4

(2.1

)2

(2.1

)1

(1.1

)5

(3.7

)A

nxi

ety

M(S

D)†

3.6

(3.3

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4(3

.2)

3.8

(3.4

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0(3

.0)

3.6

(3.7

)0.

59*

Nor

mal

436

(85.

3)16

6(8

6.5)

79(8

1.4)

75(8

6.2)

116

(85.

9)0.

09**

Mod

erat

e58

(11.

4)19

(9.9

)17

(17.

5)11

(12.

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(8.1

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igh

17(3

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7(3

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1(1

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1(1

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8(5

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PT

SD M(S

D)‡

23.6

(8.0

)23

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23.0

(6.9

)24

.2(6

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23.9

(9.9

)0.

67*

Intr

usi

on76

(14.

9)30

(15.

6)12

(12.

4)14

(16.

1)20

(14.

8)0.

88**

Avo

idan

ce46

(9.0

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(6.8

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(10.

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(11.

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43**

Hyp

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(11.

7)22

(11.

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1)0.

79**

PT

SDdi

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osis

22(4

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6(3

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4(4

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3(3

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0.45

**O

vera

lldi

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and

psyc

hol

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alco

-mor

bidi

ty¶

No

dist

ress

428

(83.

8)16

4(8

5.4)

79(8

1.4)

73(8

3.9)

112

(83.

0)0.

55**

Pos

sibl

eps

ych

olog

ical

co-m

orbi

dity

(mod

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edi

stre

ss)

0.31

**A

nxi

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orde

pres

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45(8

.8)

17(8

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10(1

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9(1

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An

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dde

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5(1

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1(0

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1(1

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2(2

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1(0

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Tot

al50

(9.8

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(9.4

)11

(11.

3)11

(12.

6)10

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)P

roba

ble

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31**

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edi

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(an

xiet

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depr

essi

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PT

SD)

21(4

.0)

5(2

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7(7

.2)

2(2

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7(5

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Tw

odi

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(an

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d/o

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Th

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depr

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3(2

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Tot

al33

(6.4

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(5.2

)7

(7.2

)3

(3.4

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*P[M

AN

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†Sca

le0–

21.

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tres

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diso

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10)

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.

MEHNERT et al.

© 2009 The AuthorsEuropean Journal of Cancer Care © 2009 Blackwell Publishing Ltd

740

detrimental interaction. Both scales correlate with r =-0.18 (P = 0.01). No group differences were found for posi-tive support or detrimental interactions in patients’ socio-demographic and medical characteristics except in maritalstatus and level of education. We found married patientsto have significantly higher levels of perceived positivesupport than single, divorced or widowed men (P = 0.002)(eta2 = 0.03). Furthermore, secondary school education wasassociated with higher levels of detrimental interaction (P= 0.002) (eta2 = 0.03). No significant correlation were foundbetween positive support and age (r = 0.00) and time sincesurgery (r = -0.05) as well as between detrimental interac-tions and age (r = -0.05) and time since surgery (r = 0.05).Independently of time since surgery, patients with higherlevels of detrimental interaction experienced their canceras significantly more threatening (P < 0.001).

We found positive support inversely and detrimentalinteractions positively related to anxiety, depression andPTSD symptoms (r > 0.17) (P < 0.001). Positive supportwas associated with better physical and mental HRQOL

(r > 0.10) (P < 0.05) and detrimental interactions werenegatively correlated with mental (P < 0.001), but not withoverall physical HRQOL.

Predictors of psychological co-morbidity and HRQOL

We hypothesised that overall psychological co-morbidity(anxiety/depression cut-off � 8; PTSD) (n = 83) would bepredicted by socio-demographic variables (age, maritalstatus, educational level), cancer/treatment-related vari-ables (time since surgery, tumour stage, surgery, PSAlevel), subjective threat of the disease as well as socialsupport and detrimental interactions. The results of thelogistic regression analysis using the forward conditionalmethod are shown in Table 7. Less social support, a higherlevel of detrimental interactions and subjective threat ofcancer were significant predictors of psychologicalco-morbidity (Nagelkerke’s R2 = 0.36).

Using a multiple regression model to predict overallmental health, we found lack of positive support, detri-

Table 5. HRQOL at different months post cancer diagnosis (n = 511)

Time post diagnosis

P

Total sample(n = 511)

Up to 6 months(n = 192)

Up to 24 months(n = 97)

Up to 36 months(n = 87)

36 months andmore (n = 135)

n (%) n (%) n (%) n (%) n (%)

HRQOL 0.41*PF 47.74 (8.7) 47.95 (7.2) 48.52 (9.0) 48.20 (8.1) 46.56 (10.6)PR 47.74 (9.1) 47.64 (7.8) 48.72 (9.5) 47.75 (8.8) 47.18 (10.5)BP 54.35 (10.9) 55.97 (8.3) 54.77 (11.6) 53.59 (10.9) 52.21 (13.2)GH 48.02 (8.0) 48.82 (7.1) 48.57 (7.5) 47.69 (7.7) 46.71 (9.4)VT 54.15 (9.5) 55.22 (7.6) 53.87 (11.0) 54.03 (8.7) 52.91 (11.1)SF 50.40 (9.2) 51.13 (7.5) 50.66 (9.4) 50.33 (9.4) 49.24 (11.0)ER 47.91 (8.6) 48.69 (6.6) 47.65 (9.4) 48.20 (7.5) 46.81 (11.0)MH 50.25 (10.0) 51.34 (7.9) 50.46 (9.6) 50.40 (8.7) 48.47 (13.0)PCS 60.07 (7.8) 60.16 (6.8) 61.28 (7.0) 59.91 (8.1) 59.19 (9.1)MCS 62.64 (8.8) 63.68 (7.7) 62.55 (8.1) 62.68 (7.9) 61.19 (10.8)

*P[MANOVA].BP, bodily pain; ER, emotional role; GH, general health; HRQOL, health-related quality of life; MANOVA, multiple analysis ofvariance; MCS, mental component summary; MH, mental health; PCS, physical component summary; PF, physical functioning; PR,physical role; SF, social functioning; VT, vitality.

Table 6. Anxiety and depression in prostate cancer patients compared with representative population-based standardised values for menat different age groups (n = 511)

Age group

Anxiety Depression

Prostate cancerpatients

Male normpopulation

P� d

Prostate cancerpatients

Male normpopulation

P�* d†M (SD) M (SD) M (SD) M (SD)

Up to 65 years (n = 286) 4.0 (3.5) 4.7 (3.3) 0.001 0.2 2.8 (3.2) 5.5 (4.0) 0.001 0.866 years and older (n = 225) 3.1 (2.9) 4.9 (3.3) 0.001 0.6 2.1 (2.6) 6.3 (4.0) 0.001 1.3Total (n = 511) 3.6 (3.3) 4.8 (3.3) 0.001 0.4 2.5 (3.0) 5.8 (4.0) 0.001 0.9

*P[t-test].†Effect size d (mean difference/SD in cancer population).

Depression and anxiety in prostate cancer

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mental interactions, subjective threat of cancer, diseasestage and age to be significant predictors of the mentalhealth summary score (R2 = 0.27; F = 13.483; P < 0.001).Lack of positive support and subjective threat of cancerwere found to significantly predict overall physical health;however, the variance explored is very small (R2 = 0.05;F = 3.17; P = 0.005).

DISCUSSION

Despite the high prevalence of prostate cancer, the rela-tively good prognosis, and the marginally less invasivetreatment procedures compared with other cancer types,research has shown significant levels of psychosocial dis-tress in prostate cancer patients. However, studies includ-ing a wide spectrum of short- and long-term survivors aswell as studies on PTSD in prostate cancer patients havebeen relatively rare so far. Furthermore, there have beenonly few studies to date which investigated the role ofsocial support in psychological distress and HRQOL inthis patient population. We therefore attempted toexamine the prevalence of anxiety, depression and PTSD,the character and frequency of perceived support, as wellas distressing events within this study, and to analyse theimpact of positive support and detrimental interactions onpsychological co-morbidity and HRQOL. The strengths ofthis study include the large sample size, the exploration ofPTSD and specific PTSD symptom clusters, and the useof age-adjusted normative comparison groups for anxietyand depression.

Men described the prostate cancer diagnosis and uncer-tainty about the future as the most frequently distressingevents. Similar results have been found in other studiesof prostate cancer patients, but also in patients withother tumour types (Sammarco 2001; Bailey et al. 2004;Mehnert & Koch 2007). In our study, patients reportedmedical treatment and doctor–patient communication tobe most helpful in coping with their illness, and namedtheir partner in third position. It is noteworthy thatmedical treatment – a kind of technical, active problem-solving item – and the probable problem-related commu-nication with a medical expert are perceived as mosthelpful. This can lead to two assumptions: on the one

hand, it is possible that medical treatment and doctor–patient interaction are of very high quality at the depart-ment and the outpatient clinic of urology. On the otherhand, the results lead to the conclusion that practical andproblem-related informational support is of more impor-tance for men than emotional support, or that men, otherthan women, have more difficulties to deal with the emo-tional side of cancer.

A study by Gray et al. (2000) showed that the majorityof prostate cancer patients avoided communication aboutthe cancer and wanted to return to normal life. Reasonsfor this were low levels of perceived social support, fear ofstigmatisation, reduction of horror caused by the diagno-sis, and the fear to be a burden to others. Arrington et al.(2005) investigated prostate cancer survivors and theirwives attending support groups and also found com-munication patterns that inhibited emotional support.However, we found married men to have significantlyhigher levels of positive support than single men. Thisfinding indicates that living with a partner could have asupporting effect for these patients – even if they do notname it in particular. Independently of time since surgery,patients with higher levels of detrimental interactionexperienced their cancer as significantly more threaten-ing. As these were men with a significantly higher diseasestage, this finding suggests that detrimental interactionshave a particular adverse effect in men with cancer pro-gression that might lead to higher levels of anxiety anddistress.

The findings of this study indicate that a relativelysmall proportion of patients suffer from PTSD, anxiety ordepression in comparison with other patients with othercancer sites. The levels of anxiety and depression areslightly lower than those reported in other studies (Daleet al. 2005; Roth et al. 2006) which might be due to a goodprognosis and less invasive treatments such as nerve-sparing surgery in the majority of our prostate cancersample. We furthermore found the study participants atall age groups at significant lower levels of anxiety anddepression compared with the equivalent group values forthe German normative sample. However, psychologicaldistress was observed in 16% of all patients. Given therelatively wide time range between surgery and time of

Table 7. Predictors for psychological co-morbidity (n = 511)

b SEOddsratio

95% confidenceinterval P�

Social support -0.69 0.21 0.50 0.33–0.76 0.001Detrimental interactions 1.38 0.27 4.00 2.33–6.77 0.001Subjective threat of cancer 1.15 0.19 3.16 2.17–4.62 0.001

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assessment, it is noteworthy that time since surgery hadno significant impact on psychological co-morbidity.Although the time span between prostate cancer surgeryand the psychosocial assessment in this study varies sig-nificantly between patients, from the perspective ofhealthcare research, it is important to provide data aboutthe prevalence of psychosocial distress in a specific timeand setting (Koch 2008). The identification of psychologi-cal distress in cancer survivors within primary cancerhealthcare settings and institutions, and the use of appro-priate screening measures will in a medium-term perspec-tive allow a better psychosocial healthcare planning andan early assignment and referral of patients with specificneeds to support offers. With regard to the appropriatenessof the PTSD diagnosis in cancer populations, events expe-rienced as most distressful such as feelings of uncertainty,impotence, incontinence and sexual problems as well asfear of progression can be critically discussed given thedefinition of a traumatic event in the DSM-IV.

In order to understand which factors play the mostimportant part in the occurrence of psychological distressas well as HRQOL we calculated a logistic and a linearregression analysis. Results clearly point out that largelyindependent of patients’ medical situation and socio-demographic factors, the lack of positive support and det-rimental interaction as well as perceived threat of thedisease are significant predictors of psychological distress.However, although the impact of social support onHRQOL is significant, it is still considered to be ratherweak due to the large sample size, in particular withregard to the physical health sum scale. It is likely thatother factors such as general physical co-morbidity due tothe age of patients or other medical factors contributesignificantly more to HRQOL than social support. Thedimensions of social support that could more likely influ-ence physical quality of life might also include aspects ofthe mobilisation, and the planning of exercises and healthbehaviours together with a partner, family members orfriends, aspects that were not measured by the instrumentwe used. It is also possible that patients with a betterphysical quality of life would perceive themselves ashaving a better level of social support (Knoll et al. 2007).

Our study has certain weaknesses. First of all, despitethe large sample size and the acceptable response rate, wecould not conduct non-responder analyses nor gain infor-mation about a possible bias of our sample due to organi-sational reasons. Furthermore, it would have been helpfulfor the interpretation of these findings to have informa-tion on the quality of and satisfaction with personalrelationships, doctor–patient communication and aboutpatients’ needs for professional psychosocial support. In

sum, this study points out that prostate cancer patientsvalue medical treatment and doctor–patients interactionas sources of support to be more important than emotionalsupport from partners. However, similar to many otherstudies in different cancer populations, lack of positivesupport or detrimental interactions are significantly asso-ciated with high levels of psychological distress. Thesefindings emphasise the need to detect patients with psy-chosocial distress and low social support on the basis ofdoctor–patient communication and/or cancer specific andprostate cancer screening instruments (Roth et al. 2006)that include the patient’s need for various dimensions ofsupport from an early stage. Socio-demographic character-istics can serve as an indication of a possible lack ofsupport, but are not sufficient. In addition, as it has beenfound in other studies (Lintz et al. 2003) that it is evi-dently necessary to provide professional psychosocialsupport that meets the needs of those patients.

ACKNOWLEDGEMENT

This research has been supported by the Astrid-Haugstrup-Sörensen-Gedächtnisstiftung (No. T 100 –13.496) within the Donors’ Association for the Promotionof Sciences and Humanities in Germany, Essen,Nordrhein-Westfalen, Germany.

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