The association between patient characteristics, psychological distress, and coping in the diagnostic phase of prostate cancer - A cross-sectional multicenter study

PURPOSE

This study aims to investigate the associations between patient characteristics, psychological distress, and coping in the diagnostic phase of prostate cancer.

METHODS

A cross-sectional multicentre study was conducted from 2017 to 2019. A total of 250 patients were recruited from three hospitals in western Norway. The patients completed a questionnaire while awaiting their prostate biopsy. Patient characteristics were collected, and the Hospital Anxiety and Depression Scale and the Revised Ways of Coping Checklist were used to measure psychological distress and evaluate coping strategies and primary appraisal, respectively.

RESULTS

Approximately 15% and 5% of the patients experienced symptoms of anxiety and depression, respectively. Younger age and poorer self-reported health were associated with higher anxiety levels. Anxiety was associated with all five coping strategies but showed the strongest correlation with wishful thinking. The patients who appraised their situation as a threat experienced more symptoms of both anxiety and depression and used more wishful thinking and avoidance than did the patients who appraised their situation as a challenge or benign.

CONCLUSION

A subgroup of patients experiences psychological distress during diagnostic evaluation of prostate cancer. Age, self-reported health, and primary appraisal may contribute to the development of psychological distress. Identification of patient characteristics associated with higher levels of psychological distress may guide nurses in implementing early interventions aimed at supporting beneficial coping and enhancing well-being.

Comparison of procedural anxiety and pain associated with conventional transrectal ultrasound prostate biopsy to magnetic resonance imaging-ultrasound fusion-guided biopsy: a prospective cohort trial

BACKGROUND

Prostate cancer (PCa) diagnosis relies on biopsies, with transrectal ultrasound (TRUS) biopsies being common. Fusion biopsy (FB) offers improved diagnostic accuracy, but the pain and anxiety experienced by patients during biopsies is often overlooked. This study aims to compare pain and anxiety levels between standard TRUS-guided biopsy (STB) and systematic plus MRI/US fusion biopsy (STB + FB).

MATERIALS AND METHODS

The study involved adult men undergoing biopsies, receiving identical peri-procedural care, including 2% lidocaine jelly in the rectum and subsequent 1% lidocaine injections (10cc per side) into the prostate-seminal vesicle junction and prostatic apical areas bilaterally. The biopsy technique was chosen based on clinical and imaging findings. Pre- and post-biopsy anxiety levels were assessed using the State-Trait Anxiety Inventory (STAI) questionnaire, categorized as mild (20-37), moderate (38-44), or severe (45-80). Post-biopsy pain was evaluated on a numerical rating scale, ranging from 0 to 10.

RESULTS

Of the 165 patients, 99 underwent STB, and 66 underwent STB + FB. No significant differences were observed in age, race, prostate-specific antigen, prostate volume, or prior biopsies between the groups. The STB + FB group had more biopsy cores taken (16.2 vs. 12, p = 0.001) and a longer procedure time (23 vs. 10 min, p = 0.001). STB biopsy patients experienced lower post-procedural anxiety compared to STB + FB, with a mean difference of -7 (p = 0.001, d = 0.92). In the STB + FB group, 89% experienced severe post-procedural anxiety compared to 59% in STB (p = 0.002). There was no significant difference in post-procedural pain (p = 0.7). Patients with prior biopsies had significantly higher STAI(S) anxiety scores (p = 0.005), and the number of prior biopsies correlated with anxiety severity (p = 0.04) in STB + FB group.

CONCLUSION

In summary, STB + FB group demonstrated higher post-procedural anxiety levels than the STB group, with no difference in pain levels. Additionally, patients with a history of repeat biopsies were more likely to exhibit higher STAI(S) anxiety scores.

Attitudes and health behaviors of middle-aged and older adults with elevated tumor markers in China

Objectives

To understand the attitudes and health behaviors of middle-aged and older adults in China after receiving elevated results of tumor markers (TMs) test in the annual health examinations (AHEs) and explore the influencing factors.

Methods

A three-section online questionnaire survey was conducted from March 1 to April 30, 2020 in Hangzhou, China, to people who were aged 45 and older and had at least one elevated result of TMs test. Clinical information was collected from the online survey and medical records. Descriptive statistics were carried out followed by regression analyses.

Results

Of 380 participants, 76.1% were unwilling to quit the TMs test in AHEs, whereas 75.3% would take the doctor's advice and quit unnecessary TMs test; 67.4% felt stressed about their TMs. Among participants with elevated TMs, 76.8% changed lifestyle to keep healthy, 74.2% sought health information, 58.9% requested a TMs retest, and 50.3% did further tests to confirm a diagnosis. Family history of cancer was associated with lifestyle changing; education level, area of residence and health insurance were associated with health information seeking; comorbidity were associated with retests and sequential confirming tests.

Conclusion

The application of the TMs test in AHEs among Chinese people may lead to positive and negative behavioral consequences and psychological distress. Doctors have a significant impact on patients' health behaviors. Accurate indications and adequate communication with patients before and after the TMs test are in great need.

Evolution of anxiety management in prostate biopsy under local anesthesia: a narrative review

INTRODUCTION AND METHODS

Prostate biopsy (PB) is an essential step in the diagnosis and active surveillance of prostate cancer (PCa). Transperineal PB (TP-PB) is now the recommended approach and is mostly conducted under local anesthesia. However, this procedure can potentially cause anxiety for patients, given the oncological context and the fear of peri-procedural pain and complications. The objective of this narrative review is to summarize the currently available tools for the management of peri-interventional anxiety during TP-PB, with a particular emphasis on the potential role of virtual reality (VR) in this setting.

RESULTS

In TP-PB, preoperative anxiety can lead to increased pain perception, longer procedure time, and decreased patient satisfaction. Pharmacological and non-pharmacological approaches have been explored to reduce anxiety, such as premedication, deep sedation, education, relaxation techniques, hypnosis, and music therapy, albeit with mixed results. VR has recently emerged in the technological armamentarium for managing pain and anxiety, and the efficiency of this technology has been evaluated in various medical fields, including pediatrics, gastroenterology, urology, gynecology, and psychiatry.

CONCLUSION

Despite the paucity of available data, VR appears to be a safe and effective technique in reducing anxiety in many procedures, even in frail patients. No studies have evaluated the role of VR in TP-PB. Future research should thus explore the optimal way to implement VR technology and any potential benefits for TP-PB patients.

Encouraging Patients to Ask Questions: Development and Pilot Testing of a Question Prompt List for Patients Undergoing a Biopsy for Suspected Prostate Cancer

This study assessed the acceptability and feasibility of a question prompt list (QPL) to facilitate informed treatment decision-making in men with suspected localised prostate cancer, which involves values-based choices between options with similar efficacy but different side effects. The QPL was developed through iterative consultation with consumers, clinicians and researchers. Acceptability was assessed using study-specific questions regarding QPL satisfaction and usefulness and qualitative interviews. Feasibility was determined via the proportion of men given the QPL according to medical records and the completion of standardised measures of decisional outcomes. Quantitative data were analysed using descriptive and univariate statistics. Qualitative data were thematically analysed. Fifty-two men consented; 34 provided data for analysis. The QPL recipients reported moderate-high content satisfaction (70.6%) and perceived usefulness in guiding appointments when receiving biopsy results (64.7%). Two main qualitative themes also indicated the QPL acceptability: (1) the freedom to ask-acceptable timing, flexible usage and usefulness of the QPL, and (2) satisfaction with the QPL content. However, only 18.4% of eligible men received the QPL, indicating limited feasibility. The QPL is safe and acceptable, but further research is needed regarding how to facilitate the uptake of the question prompt list in clinical practice.

Men's perception of information and psychological distress in the diagnostic phase of prostate cancer: a comparative mixed methods study

BACKGROUND

Previous studies indicate that men experience frustration and uncertainty when confronted with an elevated prostate specific antigen (PSA) test and during further diagnostics for prostate cancer. The novel Stockholm3 test is an algorithm-based test that combines plasma protein biomarkers, genetic markers and clinical variables in predicting the risk of PCa. The test was introduced in a western part of Norway as a new tool for detecting prostate cancer. This study aimed to explore and compare men's perception of information and possible experience of distress between a PSA group and a Stockholm3 group during the diagnostic phase of prostate cancer.

METHODS

This study is a part of the trailing research evaluating the impact of the change from PSA to Stockholm3. It is a multicenter study using a comparative mixed method design. Data were collected in a PSA group (n = 130) and a Stockholm3 group (n = 120) between 2017 and 2019. Quantitative data were collected using questionnaires and qualitative data were collected using semi-structured interviews (n = 20). The quantitative and qualitative data were analysed and compared separately and then merged in a side-by-side discussion. The study adheres to the GRAMMS guidelines for reporting mixed-methods research.

RESULTS

Compared with the PSA group, men in the Stockholm3 group reported that the information from the general practitioners was better. Similarly, men in the Stockholm3 group were more likely to indicate that they had received sufficient information regarding how examinations would be conducted. No differences were found between the groups regarding waiting time and distress. Three themes emerged from the qualitative analysis of the two groups: "Information affects the experience of comprehension", "Stepping into the world of the healthcare system", and "Periodically feelings of distress".

CONCLUSION

The Stockholm3 test may facilitate the provision of information to patients. However, some patients in both groups experienced distress and would benefit from more information and additional support from healthcare professionals. Routines that ensure sufficient information from the interdisciplinary healthcare team should be of priority during the diagnostic phase of prostate cancer in order to provide patients with predictability and to avoid unnecessary distress.

Utility of serum biomarkers for predicting cancer in patients with previous negative prostate biopsy

PURPOSE

To review the role of serum biomarkers: prostate-specific antigen (PSA), PSA density (PSAD), free:total PSA ratio, prostate health index (PHI) and PHI density (PHID), along with magnetic resonance imaging (MRI) for identification of clinically significant prostate cancer (PCa), comparing their utility in patients with persistently raised PSA levels after a prior negative prostate biopsy (PNB).

METHODS

In this single-centre prospective observational study conducted from September 2015 to October 2020, patients underwent a saturation biopsy via the transperineal route. If a Prostate Imaging Reporting and Data System version 2 (PIRADS) 3 and above lesion was seen on MRI, targeted biopsies were also obtained. Information on clinical history, lesion characteristics, PIRADS classification and follow-up was collected. The sensitivity, specificity and area under curve (AUC) for each of the biomarkers were calculated.

RESULTS

351 men underwent saturation biopsy with or without targeted biopsies. 103 patients had a PNB. Among this PNB cohort, 43 (41.7%) men had a benign outcome, while 60 (58.3%) men had histopathologically diagnosed PCa, of which 41 (39%) were clinically significant. All patients underwent multiparametric MRI scans prior to biopsy. Within this cohort, PHI and PHID had the best abilities to predict for clinically significant PCa with an AUC of 0.73 and 0.70 respectively, compared to 0.65 for PSAD, 0.34 for free:total PSA and 0.56 for PSA.

CONCLUSION

A significant proportion of patients are diagnosed with PCa after a PNB. This study shows that PHI and PHI densities may be suitable adjuncts predicting for clinically significant PCa in patients with PNB.

Psychological distress among patients awaiting histopathologic results after prostate biopsy: An unaddressed concern

BACKGROUND

Prostate cancer is the most commonly diagnosed neoplasm in men. From the introduction of PSA testing, an increasing number of men undergoes prostate biopsy (PBX). While the physical side effects of PBx have been well investigated, its psychological impact has been under-evaluated.

AIM

The aim of our study is to investigate the presence of psychological distress (anxiety and depression) in patients waiting for histopathological results after prostate biopsy (PBx).

METHODS

From February to April 2019, 51 consecutive patients undergoing prostate biopsies at our institution were included. Age, PSA, DRE, familiarity for prostate cancer, number of previous biopsies, type of anesthesia, number of cores were recorded. All patients filled the Hospital Anxiety and Depression Scale (HADS), a psychometric Likert-scale questionnaire, before receiving the histopathological results of their PBx.

RESULTS

The prevalence of psychological distress among patients awaiting histopathologic results is 41% (21/51 patients), with anxiety being the main component of their distress. On multivariate analysis, PSA, family history, and repeat biopsy were significantly associated with anxiety and depression.

CONCLUSION

Patients undergoing PBx experience a burden of psychological distress waiting for histopathologic results, especially anxiety. Appropriate counseling should be offered to patients at high risk of developing psychological distress after PBx. Future goals would include technological improvements to shorten the time between biopsy and definitive results.

Deterioration in Sleep Quality Affects Cognitive Depression in Prostate Cancer Patients

Men who suffer from prostate cancer (PCa) need to make important decisions regarding their treatment options. There is some evidence that these men may suffer from sleep difficulties due to their cancer or its diagnosis and treatment. Although sleep difficulties have been associated with cognitive depression in other samples of men, they have not been examined in PCa patients, despite the importance of decision-making for these men. This study was designed to investigate the association between sleep difficulties and cognitive depression in PCa patients. A sample of 96 PCa patients completed a background questionnaire, the Zung Self-Rating Depression Scale, and the Insomnia Severity Index. Comparison was made between sleep difficulty scores from before the patients received their diagnosis of PCa to the time of survey, allowing use of a “retrospective pretest” methodology. Just over 61% of the sample reported a deterioration in sleep quality, and this was significantly associated with cognitive depression (r = .346, p = .007). At the specific symptom level, having a clear mind significantly contributed to the variance in difficulty falling asleep (R² change = .140, F for change = 9.298, p = .003). Sleeping difficulties, particularly falling asleep, are common and associated with depression-related to ability to think clearly in PCa patients. This has potentially adverse effects upon the ability of men with PCa to understand their treatment options and make decisions about them.

Anxiety and depression associated with a positive prostate biopsy result: A comparative, prospective cohort study

Purpose

To investigate the course of anxiety and depression before and after transrectal ultrasound-guided prostate biopsy (TRUS-Bx) and in the postoperative 1st month when the histopathological biopsy result was obtained.

Methods

In between June 2017- January 2019, 204 patients who underwent TRUS-Bx and completed the questionnaires assessing anxiety and depression were included in the study. Questionnaires were completed immediately before the biopsy, immediately after the biopsy and at the end of the first month when the histopathological biopsy results were given. State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS) and perceived stress scale (PSS) forms were used to assess anxiety and depression. After the histopathological examination patients were divided into two groups as patients without cancer (Group 1) and with cancer (Group 2). Data was compared between the groups.

Results

PSA level was negatively correlated with STAI TX-1 scores of the patients immediately after TRUS-Bx, whereas it was positively correlated with STAI TX-1 and TX-2 30 days after the TRUS-Bx. PSA level was positively correlated with HADS-A and HADS-D scores immediately before and 30 days after TRUS-Bx. Biopsy results showed a significant difference in 30 day post-biopsy related data. STAI TX-1, STAI TX-2, HADS-A, HADS-D and PSS scores were higher in Group 2 compared with Group 1.

Conclusions

Pre-biopsy anxiety disappeared after bx, but there was a significant increase in anxiety and depression in patients after the diagnosis of malignancy. Patients were seriously concerned about the diagnosis of prostate cancer.

Depression and prostate cancer: implications for urologists and oncologists

Many patients with prostate cancer experience severe levels of depression, which can negatively affect their treatment and disease course. Some prostate cancer treatments can increase the severity of a patient's depression, for example, by increasing anhedonia and erectile dysfunction. Depression is often thought of as a unitary phenomenon, but multiple subtypes can be distinguished. This variety of manifestations challenges the successful application of universal antidepressant treatment options and argues for a multi-symptom assessment process that considers a patient's disease burden and their particular form of depression. Inclusion of screening and detailed diagnosis of depression can be argued to be part of good practice, and clinicians are urged to consider when and how this might be accomplished within their urological practice.

Effect of Diaphragmatic Breathing on Procedural Anxiety During Transrectal Prostate Biopsy

OBJECTIVE

To improve the tolerability of transrectal ultrasound guided prostate biopsy through use of diaphragmatic breathing.

METHODS

Forty-seven patients, aged 52-79 years, who were scheduled for a transrectal ultrasound guided prostate biopsy with or without MRI guidance, were recruited at a single Veterans Affairs medical center for the diagnosis or evaluation of prostate cancer. Patients either met with a health psychologist for a 1-time, diaphragmatic breathing intervention immediately prior to their biopsy, or received usual care. All biopsies were performed using local anesthetic without sedation or anxiolytic therapy. The primary outcome was the difference in self-reported procedural situational anxiety as measured with the State Trait Anxiety Inventory, assessed both pre- and post-transrectal ultrasound guided prostate biopsy. We also examined secondary outcomes including physiological parameters (heart rate and blood pressure).

RESULTS

There were no significant differences in preprocedural anxiety or physiological parameters between patients who received the intervention and those who received usual care. Patients who received the intervention had a significantly larger decrease in situational anxiety from pre- to postprocedure (M = 14.15, SD = 6.64) compared with those who received usual care (M = 3.45, SD = 9.97); t (38) = -4.0, P <.000; d = 1.26. Patients who received the intervention had a significantly larger decrease in heart rate (bpm) from pre- to postprocedure (M = 10.63, SD = 12.21) compared with those who received usual care (M = 0.07, SD = 9.25); t (31) = 2.75 P = 0.010; d = 0.97.

CONCLUSION

A guided diaphragmatic breathing intervention reduced procedural anxiety during prostate biopsy and improved patient experience.

Patient-reported pain, discomfort, and anxiety during magnetic resonance imaging-targeted prostate biopsy

INTRODUCTION

The addition of targeted prostate biopsy to systemic biopsy impacts patient experience. We examined patient-reported pain, discomfort, anxiety, and tolerability among men undergoing magnetic resonance imaging (MRI)-targeted prostate biopsy in addition to transrectal ultrasound-guided systematic biopsy compared to those undergoing systematic biopsy alone.

METHODS

All patients underwent transrectal systematic 14-core biopsies. Patients with regions of interest on MRI underwent additional targeted biopsies. All patients received equivalent periprostatic nerve block. Four single-item, standard, 11-point numerical rating scales evaluating pain, discomfort, anxiety, and tolerability were completed immediately after biopsy. Differences in means were compared using t-tests. Correlation between rated domains was tested using Spearman's correlation coefficient.

RESULTS

Of 273 consecutive patients, 195 (71%) underwent targeted biopsy and 188 (69%) had undergone prior biopsy. In all men, the median score for pain and tolerability was 3, while the median score for discomfort and anxiety was 4. Pain was rated at 7 or above by 15% of patients. Moderate correlation between pain, discomfort, anxiety, and tolerability of repeat biopsy was observed (Spearman's ρ between 0.48 and 0.76). Compared to patients undergoing systematic biopsy alone, men who received both targeted and systematic biopsies reported higher anxiety scores (difference 1.2; 95% confidence interval [CI] 0.4-2.0; p=0.004) and discomfort (difference 1.0; 95% CI 0.3-1.7; p<0.001).

CONCLUSIONS

Patients undergoing targeted and systematic biopsies report more discomfort and anxiety than patients undergoing systematic biopsies alone. Absolute differences are small, and patients are willing to undergo repeat biopsy if advised. Interventions to reduce biopsy-related anxiety are needed.

A narrative review and update on management following negative prostate biopsy

PURPOSE OF REVIEW

Prostate cancer has traditionally been diagnosed using systematic transrectal ultrasound-guided biopsy. However, given the inherent nature of sampling, a negative biopsy does not exclude clinically significant prostate cancer (csPCa), and continued controversy exists in the optimal management following initial biopsy. Numerous avenues for evaluation include multiparametric MRI (mpMRI), use of molecular biomarkers, repeat biopsy, and observation.

RECENT FINDINGS

mpMRI has shown promise in guiding further biopsy management: for individuals with identified target lesions, increased accuracy and detection using combination targeted and systematic sampling has been repeatedly demonstrated in the literature as an effective strategy. For those with negative MRIs and/or negative biomarker (blood, urinary, tissue) studies, increasing evidence has suggested that these individuals may be able to avoid biopsy altogether, albeit at a small risk of missing csPCa. Observation should be based on an individual's risk of csPCa versus their competing health risks, and saturation biopsy reserved for rare cases with high clinical suspicion.

SUMMARY

Management following an initial negative prostate biopsy requires careful discussion with the patient, their risk tolerance, and threshold for intervention. Although subject to availability, mpMRI and molecular biomarkers may better risk stratify patients, identify target lesions, and in certain cases, spare biopsy altogether.