Extending the validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) at the time of prostate biopsy in a racially-mixed population

The psychosocial impact of prostate cancer screening for BRCA1 and BRCA2 carriers

OBJECTIVES

To report the long-term outcomes from a longitudinal psychosocial study that forms part of the 'Identification of Men with a genetic predisposition to ProstAte Cancer: Targeted Screening in men at higher genetic risk and controls' (IMPACT) study. The IMPACT study is a multi-national study of targeted prostate cancer (PrCa) screening in individuals with a known germline pathogenic variant (GPV) in either the BReast CAncer gene 1 (BRCA1) or the BReast CAncer gene 2 (BRCA2).

SUBJECTS AND METHODS

Participants enrolled in the IMPACT study were invited to complete a psychosocial questionnaire prior to each annual screening visit for a minimum of 5 years. The questionnaire included questions on sociodemographics and the following measures: Hospital Anxiety and Depression Scale, Impact of Event Scale, 36-item Short-Form Health Survey, Memorial Anxiety Scale for PrCa, Cancer Worry Scale, risk perception and knowledge.

RESULTS

A total of 760 participants completed questionnaires: 207 participants with GPV in BRCA1, 265 with GPV in BRCA2 and 288 controls (non-carriers from families with a known GPV). We found no evidence of clinically concerning levels of general or cancer-specific distress or poor health-related quality of life in the cohort as a whole. Individuals in the control group had significantly less worry about PrCa compared with the carriers; however, all mean scores were low and within reported general population norms, where available. BRCA2 carriers with previously high prostate-specific antigen (PSA) levels experience a small but significant increase in PrCa anxiety (P = 0.01) and PSA-specific anxiety (P < 0.001). Cancer risk perceptions reflected information provided during genetic counselling and participants had good levels of knowledge, although this declined over time.

CONCLUSION

This is the first study to report the longitudinal psychosocial impact of a targeted PrCa screening programme for BRCA1 and BRCA2 carriers. The results reassure that an annual PSA-based screening programme does not have an adverse impact on psychosocial health or health-related quality of life in these higher-risk individuals. These results are important as more PrCa screening is targeted to higher-risk groups.

The Development of iManage-PC, an Online Symptom Monitoring and Self-management Tool for Men With Clinically Localized Prostate Cancer

BACKGROUND

Prostate cancer (PC) often impacts 4 major aspects of health-related quality of life (HRQL): urinary, sexual, and bowel dysfunction, and anxiety. Online tools may be helpful in supporting the development of self-management skills that can improve HRQL.

OBJECTIVE

The aim of this study was to develop and pilot-test an online symptom monitoring and self-management program, iManage-PC.

METHODS

A literature search, input from experts, and feedback from patients were used to develop iManage-PC. A 4-week, single-arm pilot study was conducted with 96 men with prostate cancer. We evaluated system usability, acceptance, and satisfaction and examined preliminary effects on patient-reported outcomes.

RESULTS

Rates of retention (94.8%) and adherence to symptom monitoring (95.0%-97.0%) were high. Most participants rated the tool as satisfactory and acceptable (81.2%-94.3%). Related-samples Wilcoxon signed rank tests revealed that participants reported increased self-efficacy related to their ability to manage their adverse effects (T = 1772.0, P < .001, r = 0.39), physical discomfort (T = 1259.0, P < .001, r = 0.40), and stress and worry (T = 1108.5, P = .001, r = 0.34). Global mental and physical health also improved (T = 1322.0, P = .032, r = 0.23, and T = 1409.0, P = .001, r = 0.35, respectively).

CONCLUSIONS

Future research with such tools should examine the potential role of cut-score-derived management interventions to improve engagement, symptom management self-efficacy, and HRQL.

IMPLICATIONS FOR PRACTICE

Our findings are consistent with a growing body of literature that supports the feasibility and acceptability of remotely delivered interventions.

Prevalence of Anxiety and Depression in Prostate Cancer Patients and Their Spouses: An Unaddressed Reality

Objectives

To estimate the prevalence of unsuspected anxiety or depression in prostate cancer patients and their spouses, as well as factors involved in its onset. Materials and Methods. A prospective study of 184 patients and 137 spouses evaluated in our hospital during 2019 using the Memorial Anxiety Scale for Prostate Cancer (MAX-PC), Hospital Anxiety and Depression Scale (HADS) and Patient Health Questionnaire depression module (PHQ-9). This study provides an internal validity assessment of the scales and their correlation (alpha and rho coefficients; index r). The contributions of age, education level, months after diagnosis, pain, prostate-specific antigen (PSA) level, stage of the disease and treatment performed to the positivity of the questionnaires were studied using the Wilcoxon–Mann–Whitney and chi-square tests.

Results

The prevalence of anxiety was 10.9% (MAX-PC) and 28.3% (MAX-PC-PSA). The HADS-A questionnaire indicated pathology in 14.1% of the patients and 16.05% of the spouses. Depression was detected in 7% (HADS-D) and 9.2% (PHQ-9) of patients as well as in 8.8% (HADS-D) and 16.05% (PHQ-9) of their spouses. The greatest concordance between men and women was with the PHQ-9 (Spearman's rho: 0.78; p = 0.01). Education level is significantly related to the presence of anxiety and depression, regardless of the questionnaire applied. The probability of detecting pathology in the MAX-PC varied from 6% in patients with elementary education to 23.5% in university students (p = 0.04). The greatest differences were detected when applying the PHQ-9 to patients (4% pathological, elementary education vs. 35.3% pathological, university education). Our study confirms the lack of a relationship between rates of anxiety and depression and factors such as PSA level, age of the patient and number of comorbidities.

Conclusion

There is a high prevalence of unsuspected anxiety and depression in patients with prostate cancer and their wives. Education level correlates with such prevalence.

Psychosocial impact of undergoing prostate cancer screening for men with BRCA1 or BRCA2 mutations

OBJECTIVES

To report the baseline results of a longitudinal psychosocial study that forms part of the IMPACT study, a multi-national investigation of targeted prostate cancer (PCa) screening among men with a known pathogenic germline mutation in the BRCA1 or BRCA2 genes.

PARTICPANTS AND METHODS

Men enrolled in the IMPACT study were invited to complete a questionnaire at collaborating sites prior to each annual screening visit. The questionnaire included sociodemographic characteristics and the following measures: the Hospital Anxiety and Depression Scale (HADS), Impact of Event Scale (IES), 36-item short-form health survey (SF-36), Memorial Anxiety Scale for Prostate Cancer, Cancer Worry Scale-Revised, risk perception and knowledge. The results of the baseline questionnaire are presented.

RESULTS

A total of 432 men completed questionnaires: 98 and 160 had mutations in BRCA1 and BRCA2 genes, respectively, and 174 were controls (familial mutation negative). Participants' perception of PCa risk was influenced by genetic status. Knowledge levels were high and unrelated to genetic status. Mean scores for the HADS and SF-36 were within reported general population norms and mean IES scores were within normal range. IES mean intrusion and avoidance scores were significantly higher in BRCA1/BRCA2 carriers than in controls and were higher in men with increased PCa risk perception. At the multivariate level, risk perception contributed more significantly to variance in IES scores than genetic status.

CONCLUSION

This is the first study to report the psychosocial profile of men with BRCA1/BRCA2 mutations undergoing PCa screening. No clinically concerning levels of general or cancer-specific distress or poor quality of life were detected in the cohort as a whole. A small subset of participants reported higher levels of distress, suggesting the need for healthcare professionals offering PCa screening to identify these risk factors and offer additional information and support to men seeking PCa screening.

Assessing anxiety in Black men with prostate cancer: further data on the reliability and validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC)

PURPOSE

The National Cancer Institute has highlighted the need for psychosocial research to focus on Black cancer patients. This applies to Black men with prostate cancer, as there is little systematic research concerning psychological distress in these men. This study was designed to validate the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) in Black men with prostate cancer to help facilitate research within this group.

METHODS

At three institutions, Black men with prostate cancer (n = 101) completed the MAX-PC, the Hospital Anxiety and Depression Scale (HADS), the Functional Assessment of Cancer Therapy (FACT) Quality of Life Questionnaire, and the Distress Thermometer.

RESULTS

The average age of the 101 men was 66 (SD = 10) and 58 % had early-stage disease. The MAX-PC and its subscales (Prostate Cancer Anxiety, PSA Anxiety, and Fear of Recurrence) produced strong coefficient alphas (0.89, 0.88, 0.71, and 0.77, respectively). Factor analysis supported the three-factor structure of the scale established in earlier findings. The MAX-PC also demonstrated strong validity. MAX-PC total scores correlated highly with the Anxiety subscale of the HADS (r = 0.59, p < 0.01) and the FACT Emotional Well-Being subscale (r = -0.55, p < 0.01). Demonstrating discriminant validity, the correlation with the HADS Depression subscale (r = 0.40, p < 0.01) and the CES-D (r = 0.42, p < 0.01) was lower compared to that with the HADS Anxiety subscale.

CONCLUSIONS

The MAX-PC is valid and reliable in Black men with prostate cancer. We hope the validation of this scale in Black men will help facilitate psychosocial research in this group that is disproportionately adversely affected by this cancer.

Health-Related Quality of Life, Psychological Distress, and Sexual Changes Following Prostate Cancer: A Comparison of Gay and Bisexual Men with Heterosexual Men

INTRODUCTION

Decrements in health-related quality of life (HRQOL) and sexual difficulties are a recognized consequence of prostate cancer (PCa) treatment. However little is known about the experience of gay and bisexual (GB) men.

AIM

HRQOL and psychosexual predictors of HRQOL were examined in GB and heterosexual men with PCa to inform targeted health information and support.

METHOD

One hundred twenty-four GB and 225 heterosexual men with PCa completed a range of validated psychosexual instruments.

MAIN OUTCOME MEASURE

Functional Assessment of Cancer Therapy-Prostate (FACT-P) was used to measure HRQOL, with validated psychosexual measures, and demographic and treatment variables used as predictors.

RESULTS

GB men were significantly younger (64.25 years) than heterosexual men (71.54 years), less likely to be in an ongoing relationship, and more likely to have casual sexual partners. Compared with age-matched population norms, participants in both groups reported significantly lower sexual functioning and HRQOL, increased psychological distress, disruptions to dyadic sexual communication, and lower masculine self-esteem, sexual confidence, and sexual intimacy. In comparison with heterosexual men, GB men reported significantly lower HRQOL (P = .046), masculine self-esteem (P < .001), and satisfaction with treatment (P = .013); higher psychological distress (P = .005), cancer related distress (P < .001) and ejaculatory concern (P < .001); and higher sexual functioning (P < .001) and sexual confidence (P = .001). In regression analysis, psychological distress, cancer-related distress, masculine self-esteem, and satisfaction with treatment were predictors of HRQOL for GB men (R2Adj = .804); psychological distress and sexual confidence were predictors for heterosexual men (R2Adj = .690).

CONCLUSION

These findings confirm differences between GB and heterosexual men in the impact of PCa on HRQOL across a range of domains, suggesting there is a need for GB targeted PCa information and support, to address the concerns of this "hidden population" in PCa care.

A Longitudinal Study of Predictors of Sexual Dysfunction in Men on Active Surveillance for Prostate Cancer

Aim

The aim of this study was to examine the relationship between sexual dysfunction, repeat biopsies and other demographic and clinical factors in men on active surveillance (AS).

Methods

Patient-reported outcomes (PROs) measures were administered at enrollment and every 6 months to assess quality of life (QOL), psychosocial and urological health outcomes. Using mixed-effects models, we examined the impact of repeat biopsies, total number of cores taken, anxiety, age, and comorbidity on sexual function over the first 24 months of enrolling in AS.

Main Outcome Measures

PROs included the Expanded Prostate Cancer Index Composite-26 (EPIC-26) Sexual Function (SF) subscale, the American Urological Association-Symptom Index (AUA-SI), and the Memorial Anxiety Scale for Prostate Cancer (MAX-PC).

Results

At enrollment (n = 195), mean age was 66.5 ± 6.8 with a mean EPIC-26 SF score of 61.4 ± 30.4. EPIC-26 SF scores steadily decreased to 53.9 ± 30.7 at 24 months (P < 0.01). MAX-PC scores also progressively decreased over time (P = 0.03). Factors associated with lower EPIC-26 scores over time included age, unemployed status, diabetes, coronary artery disease, and hypertension (all P < 0.05). Higher prostate-specific antigen (PSA) was associated with a more rapid decline in EPIC-26 SF over time (P = 0.03). In multivariable analysis, age, diabetes, and PSA × time interaction remained significant predictors of diminished sexual function. Anxiety, number of biopsies, and total cores taken did not predict sexual dysfunction or change over time in our cohort.

Conclusions

Men on AS experienced a gradual decline in sexual function during the first 24 months of enrollment. Older age, PSA × time, and diabetes were all independent predictors of diminished sexual function over time. Anxiety, AUA-SI, the number of cores and the number of biopsies were not predictors of reduced sexual function in men in AS.

Assessment of patient-reported symptoms of anxiety

Patient self-reported symptoms are of crucial importance to identify anxiety disorders, as well as to monitor their treatment in clinical practice and research. Thus, for evidence-based medicine, a precise, reliable, and valid (ie, “objective”) assessment of the patient's reported “subjective” symptoms is warranted. There is a plethora of instruments available, which can provide psychometrically sound assessments of anxiety, but there are several limitations of current tools that need to be carefully considered for their successful use. Nevertheless, the empirical assessment of mental health status is not as accepted in medicine as is the assessment of biomarkers. One reason for this may be that different instruments assessing the same psychological construct use different scales. In this paper we present some new developments that promise to provide one common metric for the assessment of anxiety, to facilitate the general acceptance of mental health assessments in the future.

Anxiety and health-related quality of life (HRQL) in patients undergoing active surveillance of prostate cancer in an Australian centre

OBJECTIVE

To assess anxiety, health-related quality of life (HRQL) and understanding of active surveillance (AS) in a cohort of patients enrolled in AS of prostate cancer in an Australian setting.

PATIENTS AND METHODS

Survey of 61 men currently enrolled in AS for prostate cancer, which included validated measures of sexual function using the International Index of Erectile Function (IIEF-5), voiding using the International Prostate Symptom Severity Score (IPSS) and the Memorial Anxiety Scale for Prostate Cancer (MAX-PC), a measure of prostate cancer specific anxiety. Three novel questions to assess patients' Understanding of AS (UAS). IIEF-5 and IPSS scores obtained through the present survey were compared with patients' scores at initiation of AS.

RESULTS

In all, 47 of 61 (77%) patients responded to the survey. There was no significant difference in patients' IIEF-5 and IPSS scores at commencement of AS compared with the survey results. Our patients' on AS MAX-PC scores were consistent with other published cohorts and did not suggest high rates of clinically significant anxiety amongst this cohort. Most (89%) of the patients' responses to the UAS indicated a correct understanding of AS.

CONCLUSION

Our patients on AS maintained their HRQL with low levels of anxiety, which did not differ from those reported in other groups of men with prostate cancer and most had an appropriate understanding of AS. This study represents one of the first Australasian investigations on HRQL and anxiety in men on AS of prostate cancer.

Prevalence and predictors of cancer specific distress in men with a family history of prostate cancer

OBJECTIVE

To examine prevalence and predictors of cancer-specific distress in undiagnosed men with and without a family history of prostate cancer, and to examine the contribution of perceptions of an affected relative's cancer experience on the distress of unaffected male relatives.

METHODS

Men with a first degree relative with prostate cancer (n = 207) and men without a family history (n = 239) from Australia completed a Computer Assisted Telephone Interview. Participants completed the Prostate Cancer Anxiety Subscale of the Memorial Anxiety Scale for Prostate Cancer, measures of perceived risk, and socio-demographic information. Men with a family history provided details about their family history (number of relatives diagnosed with and dead from prostate cancer, relationship to affected relative, months since diagnosis) and reported their perceptions of their affected relative's prostate cancer experience including perceptions of threat related to the relative's diagnosis and perceived treatment phase and prognosis.

RESULTS

Cancer-specific distress was low for all men and there was no significant difference in the distress experienced by men with and without a family history. Regression analyses showed that for all men, cancer-specific distress increased with urinary symptoms and decreased in those with higher education and in older participants. For men with a family history, having a relative who died from prostate cancer and perceiving greater threat from a relative's diagnosis was associated with greater cancer-specific distress.

CONCLUSIONS

Interventions would benefit from examining appraisals of familial risk and examining prospective assessments of distress in the unaffected male relatives of men with prostate cancer over the course of the cancer trajectory.

Evaluation of the association of prostate cancer-specific anxiety with sexual function, depression and cancer aggressiveness in men 1 year following surgical treatment for localized prostate cancer

BACKGROUND

Cancer-specific anxiety (CSA) can affect treatment decisions and is common in men following surgery for prostate cancer (PCa). We hypothesized that CSA is also associated with factors affecting quality of life. Herein, we examine the association of CSA with psychosocial factors and PCa aggressiveness in a cohort of men 1 year after prostatectomy for localized PCa.

METHODS

From our prospective PCa Registry, we identified 365 men who underwent prostatectomy for localized PCa who completed the Memorial Anxiety Scale for Prostate Cancer (MAX-PC) and Expanded Prostate Cancer Index Composite at 1-year follow-up. We evaluated the association of scores on the MAX-PC with demographics, clinicopathologic features, sexual function, and depression scores using Wilcoxon Rank Sum and Kendall's tau correlation tests.

RESULTS

Higher scores on the MAX-PC (i.e., higher anxiety) are associated with younger age (p < 0.01) and non-Caucasian race (p < 0.01). Men with higher MAX-PC scores also reported poor sexual satisfaction/function (p < 0.01) and increasing depressive symptoms (p < 0.01). Finally, although higher anxiety is associated with several pathologic features of aggressiveness (stage, positive margins, PSA at 1 year; all p-values < 0.01), we noted several men with clinically indolent disease who reported significant anxiety.

CONCLUSIONS

Our data suggest that higher levels of CSA are associated with poor sexual function and increased depressive symptoms 1 year after prostatectomy. Moreover, we noted demographic and pathologic features associated with higher CSA as well. If confirmed, our data support development of models to predict men at high risk of CSA following PCa surgery and targeted referral for additional counseling.

African American men significantly underestimate their risk of having prostate cancer at the time of biopsy

BACKGROUND

Guidelines for prostate cancer (PCa) screening recommend physicians to have an informational discussion with patients. At the time of biopsy, patients should be informed of their heightened PCa risk, particularly African Americans (AA) who have significantly higher diagnostic and mortality risk. We tested predictors of patients' estimation of their likelihood of having PCa at the time of biopsy.

METHODS

A convenience sample of AA (n = 207) and white (n = 271) biopsy patients was surveyed at the time of prostate biopsy. Participants gave likelihood estimations of having PCa and data on their socio-demographics, health, clinical status, and general and PCa-specific anxiety. Binary logistic regressions tested for predictors of the patients' estimations and biopsy results.

RESULTS

Fifty-one percent of AA men answered that they had a '0%' likelihood of having PCa versus 19% of whites, whereas 57% of AA men had abnormal biopsies compared with 42% of whites. In logistic regressions, predictors of patient answers of 0% chance of PCa were AA ethnicity (OR = 4.50; p < 0.001), lower cancer-specific anxiety (OR = 0.93; p < 0.01), less education (OR = 2.38; p < 0.05), and less urinary disturbance (OR = 0.70; p < .05). In a second regression, AA patients trended towards higher positive biopsy rates (OR = 1.43; p = 0.17).

CONCLUSIONS

At biopsy, AA more often estimated their likelihood of PCa as 0%, despite higher risks. Reasons for these low estimates and their potential contribution to poor treatment outcomes of AA patients require further investigation.

Screening for emotional distress in cancer patients: a systematic review of assessment instruments

Screening for emotional distress is becoming increasingly common in cancer care. This systematic review examines the psychometric properties of the existing tools used to screen patients for emotional distress, with the goal of encouraging screening programs to use standardized tools that have strong psychometrics. Systematic searches of MEDLINE and PsycINFO databases for English-language studies in cancer patients were performed using a uniform set of key words (eg, depression, anxiety, screening, validation, and scale), and the retrieved studies were independently evaluated by two reviewers. Evaluation criteria included the number of validation studies, the number of participants, generalizability, reliability, the quality of the criterion measure, sensitivity, and specificity. The literature search yielded 106 validation studies that described a total of 33 screening measures. Many generic and cancer-specific scales satisfied a fairly high threshold of quality in terms of their psychometric properties and generalizability. Among the ultrashort measures (ie, those containing one to four items), the Combined Depression Questions performed best in patients receiving palliative care. Among the short measures (ie, those containing five to 20 items), the Center for Epidemiologic Studies–Depression Scale and the Hospital Anxiety and Depression Scale demonstrated adequate psychometric properties. Among the long measures (ie, those containing 21–50 items), the Beck Depression Inventory and the General Health Questionaire–28 met all evaluation criteria. The PsychoSocial Screen for Cancer, the Questionnaire on Stress in Cancer Patients–Revised, and the Rotterdam Symptom Checklist are long measures that can also be recommended for routine screening. In addition, other measures may be considered for specific indications or disease types. Some measures, particularly newly developed cancer-specific scales, require further validation against structured clinical interviews (the criterion standard for validation measures) before they can be recommended.

Prostate cancer-specific anxiety in Dutch patients on active surveillance: validation of the memorial anxiety scale for prostate cancer

Purpose

Men with prostate cancer (PC) may show specific disease-related anxiety. We evaluated the psychometric properties of the Dutch adaptation of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC).

Methods

The MAX-PC was translated using standardized forward–backward procedures. Patients (N = 150) on active surveillance, a strategy of initially withholding active therapy, for recently diagnosed early PC were mailed a questionnaire. Internal consistency was estimated using Cronbach’s alpha. The scale structure was analyzed using confirmatory factor analysis (CFA). Construct validity was evaluated by Pearson’s correlations between MAX-PC scores and scores on decisional conflict (DCS), generic anxiety (STAI), depression (CES-D), and general mental health (SF-12 MCS).

Results

Data from 129 respondents were used (response rate 86%). Cronbach’s alpha for the total score and the three subscales were 0.77, 0.91, 0.64, and 0.85, respectively. CFA largely confirmed the three-factor structure as used in the original publication (model fit: χ² 149, P = 0.051). The patterns of directions and sizes of the correlations (r = 0.36–0.66) between MAX-PC scale scores and the other variables were in accordance with a priori hypotheses, except for the prostate-specific antigen anxiety subscale. The relatively poor performance of this scale in the original version was replicated.

Conclusions

The structure and validity of the MAX-PC to quantify PC-specific anxiety were largely confirmed in Dutch patients.

Patient anxiety about prostate cancer independently predicts early initiation of androgen deprivation therapy for biochemical cancer recurrence in older men: a prospective cohort study

PURPOSE

Androgen deprivation therapy (ADT) is first-line therapy for patients with prostate cancer (PCA) who experience biochemical recurrence (BCR). However, the optimal timing of ADT initiation is uncertain, and earlier ADT initiation can cause toxicities that lower quality of life (QOL). We tested the hypothesis that elevated cancer anxiety leads to earlier ADT initiation for BCR in older men.

PATIENTS AND METHODS

We conducted a prospective cohort study of older patients with BCR of PCA (n = 67). Patients completed questionnaires at presentation and each follow-up visit until initiation of ADT. PCA-specific anxiety was measured with the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Other collected data included demographics, clinical information, and general anxiety information. Treating oncologists were surveyed about their recommendations for ADT initiation. The primary outcome was the time to ADT initiation. Univariate, multivariate logistic regression, and time-to-event analyses were conducted to evaluate whether cancer anxiety was a predictor of earlier initiation of ADT.

RESULTS

Thirty-three percent of patients initiated ADT at the first or second clinic visit. Elevated PCA anxiety (MAX-PC > 16) was the most robust predictor in multivariate analyses of early initiation (odds ratio [OR], 9.19; P = .01). PSA also independently correlated with early initiation (OR, 1.31; P = .01). PSA did not correlate with MAX-PC.

CONCLUSION

Cancer anxiety independently and robustly predicts earlier ADT initiation in older men with BCR. For older patients with PCA, earlier ADT initiation may not change life expectancy and can negatively impact QOL. PCA-specific anxiety is a potential target for a decision-making intervention in this setting.

Psychological Distress among Prostate Cancer Patients: Fact Or Fiction?

Although the detrimental effect upon psychological well-being of receiving a diagnosis of, or treatment for, cancer has been demonstrated across many different types of cancer, three recent reviews of the psychological health of prostate cancer patients have produced contradictory conclusions. In order to elucidate the reasons for these apparent different conclusions, each of these reviews is described, with principal methods and findings summarised. Actual data, methodology used to select/reject research studies for inclusion in reviews, plus the validity of strict methodological culling of some research studies are discussed. Several extra studies and commentaries are also described, and a resolution of the apparent contradictory review conclusions is offered.

Determinants of treatment regret in low-income, uninsured men with prostate cancer

OBJECTIVES

The regret of a prostate cancer treatment choice, a significant dimension of health-related quality of life, has not been well-characterized. Little is known about its association with the fear of cancer recurrence or spirituality.

METHODS

We drew subjects from a men's health study composed of a clinically heterogeneous sample of subjects enrolled from a statewide, publicly funded assistance program that provided free prostate cancer treatment for uninsured, low-income men in California. We included men who completed a telephone interviews and self-administered questionnaires at study enrollment and at 6 months of follow-up. Using validated instruments, we measured regret, health-related quality of life, fear of cancer recurrence, and spirituality through telephone interviews and self-administered questionnaires.

RESULTS

Of the 195 men, 90 underwent radical prostatectomy (46%), 50 underwent external beam radiotherapy (28%), and 51 underwent hormonal therapy (26%). Of these 195 men, 36 (18%) regretted their treatment choice. Multivariate analyses revealed that nonwhite men were more likely than white men to experience decisional regret (odds ratio [OR] range 7.27 to 12.26). Conversely, men confident of cancer cure (OR 0.19, 95% confident interval 0.04 to 0.86), men with greater spirituality (OR 0.91, 95% confidence interval 0.87 to 0.96), and men with acute treatment effects (OR 0.34, 95% confidence interval 0.12 to 0.93) were less likely to regret their treatment decisions.

CONCLUSIONS

In our study, a fear of cancer recurrence, less spirituality, a longer interval since treatment, and nonwhite race were associated with treatment regret in low-income, underserved men with prostate cancer. Attempts to decrease anxiety and enhance spirituality in men treated for prostate cancer might diminish treatment regret. Additional studies in racially diverse cohorts are needed to examine the association of regret with race.