Impact of prostate cancer screening on health-related quality of life in at-risk families

The half-painted picture: Reviewing the mental health impacts of cancer screening

Cancer screening is recommended for select cancers worldwide. Cancer screening has become increasingly effective and accessible and often increases overall survival. However, the mental health effects of cancer screening, such as its impact on depression, anxiety, and post-traumatic stress disorder, are largely unknown. Conflicting available literature indicates the negative, neutral, and positive mental health effects of cancer screening across cancer types. There are a limited number of randomized controlled trials measuring the mental health effects of cancer screening. Overall, the more negative and life-threatening the screening results, the greater the mental health effects. Screening for cancer without a known precursor, for example, due to family history, can have positive impacts such as decreased worry and increased quality of life. However, receiving a cancer diagnosis often has negative mental effects that increase with the life-threatening potential of malignancy. In this study, we review the existing literature and provide recommendations for future research to determine if and when cancer screening is the best practice.

Patient-reported outcomes associated with cancer screening: a systematic review

Background

Multi-cancer early detection tests have been developed to enable earlier detection of multiple cancer types through screening. As reflected by patient-reported outcomes (PROs), the psychosocial impact of cancer screening is not yet clear. Our aim is to evaluate the impact of cancer screening through PRO assessment.

Methods

A systematic review was conducted using MEDLINE, EMBASE, and reference lists of articles from January 2000 to August 2020 for relevant publications assessing the psychosocial impact of cancer screening before and within 1 year after screening in the general asymptomatic population, including following receipt of results. Studies focused on diagnostic evaluation or involving patients previously diagnosed with cancer were excluded.

Results

In total, 31 studies (12 randomized controlled trials; 19 observational studies) were included, reflecting PRO assessments associated with lung, breast, colorectal, anal, ovarian, cervical, and prostate cancer screening procedures. The most commonly assessed construct was symptoms of anxiety, using the State-Trait Anxiety Inventory. Cancer-specific distress and worry were also assessed using a broad range of measures. Overall, individuals tolerated screening procedures well with no major psychosocial effects. Of note, increases in symptoms of anxiety and levels of distress and worry were generally found prior to communication of screening results and following communication of indeterminate or positive results that required further testing. These negative psychosocial effects were, however, not long-lasting and returned to baseline relatively soon after screening. Furthermore, individuals with higher cancer risk, such as current smokers and those with a family history of cancer, tended to have higher levels of anxiety and distress throughout the screening process, including following negative or indeterminate results.

Conclusions

The psychosocial impact of cancer screening is relatively low overall and short-lived, even following false-positive test results. Individuals with a higher risk of cancer tend to experience more symptoms of anxiety and distress during the screening process; thus, more attention to this group is recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09261-5.

Disutility associated with cancer screening programs: A systematic review

OBJECTIVES

Disutility allows to identify how much population values intervention-related harms contributing to knowledge on the benefits/harms ratio of cancer screening programs. This systematic review evaluates disutility related to cancer screening applying a utility theory framework.

METHODS

Using a predefined protocol, Embase, Medline Ovid, Web of Science, Cochrane, Google scholar and supplementary sources were systematically searched. The framework grouped disutilities associated with breast, cervical, lung, colorectal, and prostate cancer screening programs into the screening, diagnostic work up, and treatment phases. We assessed the quality of included studies according to the relevance to target population, risk of bias, appropriateness of measure and the time frame.

RESULTS

Out of 2840 hits, we included 38 studies, of which 27 measured (and others estimated) disutilities. Around 70% of studies had medium to high-level quality. Measured disutilities and Quality Adjusted Life Years loss were 0-0.03 and 0-0.0013 respectively in screening phases. Both disutilities and Quality Adjusted Life Years loss had similar ranges in diagnostic work up (0-0.26), and treatment (0.09-0.27) phases. We found no measured disutilities available for lung cancer screening and-little evidence for disutilities in treatment phase. Almost 40% of the estimated disutility values were above the range of measured ones.

CONCLUSIONS

Cancer screening programs led to low disutities related to screening phase, and low to moderate disutilities related to diagnostic work up and treatment phases. These disutility values varied by the measurement instrument applied, and were higher in studies with lower quality. The estimated disutility values comparing to the measured ones tended to overestimate the harms.

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.

Does personality affect health-related quality of life? A systematic review

Background

Health-related quality of life (HRQOL) is increasingly measured as an outcome for clinical and health services research. However, relatively little is known about how non-health factors affect HRQOL. Personality is a potentially important factor, yet evidence regarding the effects of personality on HRQOL measures is unclear.

Methods

This systematic review examined the relationships among aspects of personality and HRQOL. Eligible studies were identified from Medline and PsycINFO. The review included 76 English-language studies with HRQOL as a primary outcome and that assessed personality from the psychological perspective. Individuals with various health states, including ill (e.g., cancer, cardiovascular disorders), aging, and healthy, were included in this review study.

Results

Some personality characteristics were consistently related to psychosocial aspects more often than physical aspects of HRQOL. Personality characteristics, especially neuroticism, mastery, optimism, and sense of coherence were most likely to be associated with psychosocial HRQOL. Personality explained varying proportions of variance in different domains of HRQOL. The range of variance explained in psychosocial HRQOL was 0 to 45% and the range of explained variance in physical HRQOL was 0 to 39%.

Conclusions

Personality characteristics are related to HRQOL. Systematic collection and analysis of personality data alongside HRQOL measures may be helpful in medical research, clinical practice, and health policy evaluation.

Similar perspectives on prostate cancer screening value and new guidelines across patient demographic and PSA level subgroups: A qualitative study

BACKGROUND

In 2012, the United States Preventive Services Task Force (USPSTF) recommended against prostate-specific antigen (PSA)-based prostate cancer screening for all men.

OBJECTIVE

To inform educational materials addressing patient questions and concerns about the 2012 USPSTF guidelines, we sought to: (i) characterize patient perceptions about prostate cancer screening benefits, harms and recommendations against screening, and (ii) compare perceptions across race, age and PSA level subgroups.

METHODS

We conducted qualitative interviews with a sample of 26 men from the Minneapolis Veterans Affairs Health Care System, stratified by race (African American, other), age (50-69, 70-84) and PSA level (documented PSA level ≥4 in Veterans Health Administration electronic medical records vs no such documentation). We used an inductive approach informed by grounded theory to analyse transcribed interviews.

RESULTS

Most men in all subgroups expressed misperceptions about the benefits of prostate cancer screening and had difficulty identifying harms associated with screening. In all subgroups, reactions to recommendations against screening ranged from unconditionally receptive to highly resistant. Some men in every subgroup initially resistant to the idea said they would accept a recommendation to discontinue screening from their provider.

CONCLUSIONS

Given the similarity of perceptions and reactions across subgroups, materials targeted by race, age and PSA level may not be necessary. Efforts to inform decision making about prostate cancer screening should address misperceptions about benefits and lack of awareness of harms. Provider perspectives and recommendations may play a pivotal role in shaping patient reactions to new guidelines.

The psychological impact of undergoing genetic-risk profiling in men with a family history of prostate cancer

BACKGROUND

The ability to identify men at genetically high-risk of prostate cancer (PrCa) would enable screening to be targeted at those most in need. This study explored the psychological impact (in terms of general and PrCa-specific worry and risk perceptions) on men with a family history of PrCa, undergoing prostate screening and genetic-risk profiling, within a research study.

METHODS

A prospective exploratory approach was adopted, incorporating a sequential mixed-method design. Questionnaires were completed at two time points to measure the impact of undergoing screening and genetic-risk profiling. In-depth interviews were completed in a subgroup after all study procedures were completed and analysed using a framework approach.

RESULTS

Ninety-five men completed both questionnaires, and 26 were interviewed. No measurable psychological distress was detectable in the group as a whole. The interview findings fell into two categories: 'feeling at risk' and 'living with risk'. The feeling of being at risk of PrCa is a part of men's lives, shaped by assumptions and information gathered over many years. Men used this information to communicate about PrCa risk to their peers. Men overestimate their risk of PrCa and have an innate assumption that they will develop PrCa. The interviews revealed that men experienced acute anxiety when waiting for screening results.

CONCLUSIONS

Personalised genetic-risk assessments do not prevent men from overestimating their risk of PrCa. Screening anxiety is common, and timeframes for receiving results should be kept to a minimum. Methods of risk communication in men at risk of PrCa should be the subject of future research.

Impact of lung cancer screening results on participant health-related quality of life and state anxiety in the National Lung Screening Trial

BACKGROUND

Low-dose computed tomography (LDCT) lung screening has been associated with a 20% reduction in lung cancer mortality. A major barrier to the adoption of lung screening is the potential negative psychological impact of a false-positive (FP) screen, occurring in 20% to 50% of those screened. The objective of this study was to assess the impact of abnormal findings on health-related quality of life (HRQoL) and anxiety in the American College of Radiology (ACRIN)/National Lung Screening Trial (NLST).

METHODS

The NLST was a randomized screening trial comparing LDCT with chest X-ray screening (CXR). This study was part of the original protocol. A total of 2812 participants at 16 of 23 ACRIN sites who had baseline HRQoL assessments were asked to complete the Short Form-36 and the State Trait Anxiety Inventory (form Y-1) questionnaires to assess short-term (1 month) and long-term (6 months) effects of screening. FP were lung cancer-free at 1 year, and true-positives (TP) were not.

RESULTS

Of the total participants, 1024 (36.4%) participants were FP, 63 (2.2%) were TP, 344 (12.2%) had significant incidental findings (SIFs), and 1381 (49.1%) had negative screens. Participants had been randomized to LDCT (n = 1947) and CXR (n = 865). Short-term and long-term HRQoL and state anxiety did not differ across participants with FP, SIF, or negative screens. Short-term and long-term HRQoL were lower and anxiety was higher for TP participants compared to participants with FP, SIF, and negative screens.

CONCLUSIONS

In a large multicenter lung screening trial, participants receiving a false-positive or SIF screen result experienced no significant difference in HRQoL or state anxiety at 1 or at 6 months after screening relative to those receiving a negative result.

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.

Association of healthcare barriers with prostate-specific antigen screening among African-American and Afro-Caribbean men

OBJECTIVE

To evaluate the association between the barriers to healthcare access and prostate-specific antigen (PSA) screening practices among African-American and Afro-Caribbean men.

METHODS

Stratified cluster sampling of census tracts in Brooklyn, New York yielded 533 men, aged 45-70 years. The men were classified into the following groups: U.S.-born white, U.S.-born African-American, Jamaican, and Trinidadian/Tobagonian. The subjects completed a written 6-item survey assessing the healthcare barriers.

RESULTS

Overall, 27% of men reported never having had a PSA test and 28% reported that they had received annual PSA screening. On multivariate analysis, those who viewed the healthcare system as convenient were more likely to report an initial PSA test (odds ratio 1.8, P < .05). Those who perceived difficulty in accessing reliable care were less likely to ever have had a PSA test (odds ratio 0.6, P < .05). Subjects who had not had a comprehensive discussion with their physician about prostate cancer were less likely to have had an initial PSA test and more likely to have maintained annual PSA screening (odds ratio 0.3 and 1.7, respectively, P < .05).

CONCLUSION

We identified 2 novel perceived barriers to prostate cancer screening: men who experience the healthcare system as inconvenient were less likely to initiate PSA testing, and those who found it difficult to obtain quality care were less likely to ever have had a PSA test. The perceived system barriers were more closely linked to PSA screening behavior than were the measures assessing perceptions of self-efficacy. Our results suggest that a broader discussion by physicians that addresses the perceptions regarding the healthcare system might enhance the understanding of, and increase the use of, prostate cancer screening among higher risk minority men.

A review of prostate-specific antigen screening prevalence and risk perceptions for first-degree relatives of men with prostate cancer

First-degree relatives of men with prostate cancer have a higher risk of being diagnosed with prostate cancer than men without a family history. The present review examines the prevalence and predictors of testing in first-degree relatives, perceptions of risk, prostate cancer knowledge and psychological consequences of screening. Medline, PsycInfo and Cinahl databases were searched for articles examining risk perceptions or screening practices of first-degree relatives of men with prostate cancer for the period of 1990 to August 2007. Eighteen studies were eligible for inclusion. First-degree relatives participated in prostate-specific antigen (PSA) testing more and perceived their risk of prostate cancer to be higher than men without a family history. Family history factors (e.g. being an unaffected son rather than an unaffected brother) were consistent predictors of PSA testing. Studies were characterized by sampling biases and a lack of longitudinal assessments. Prospective, longitudinal assessments with well-validated and comprehensive measures are needed to identify factors that cue the uptake of screening and from this develop an evidence base for decision support. Men with a family history may benefit from targeted communication about the risks and benefits of prostate cancer testing that responds to the implications of their heightened risk.

Anxiety associated with prostate cancer screening with special reference to men with a positive screening test (elevated PSA) - Results from a prospective, population-based, randomised study

Levels of anxiety were assessed through questionnaires completed by 1781 screen-positive (PSA > or = 3 ng/mL) men attending the European Randomised Study of Screening for Prostate Cancer in Gothenburg, Sweden. During the first visit (clinical examination, including biopsies), no anxiety whilst awaiting the PSA test results was reported by 66% and 2% reported high levels of anxiety. A multinomial logistics model for repeated measurements, adjusted for age, PSA level, heredity, biopsy finding and urinary symptoms, revealed that anxiety awaiting the PSA was only influenced (increased) by the existence of previously elevated PSA tests (p<.0001). No anxiety associated with biopsy was reported by 45%, while 6% experienced high levels of anxiety. Levels of anxiety decreased significantly with subsequent rounds of examinations (p<0.0001) and with increasing age (p=0.0016). Anxiety associated with prostate cancer screening in general is low to moderate, even in men with elevated PSA, and severe anxiety affects a smaller group of susceptible men.

Colonoscopic screening for colorectal cancer improves quality of life measures: a population-based screening study

BACKGROUND

Screening asymptomatic individuals for neoplasia can have adverse consequences on quality of life. Colon cancer screening is widespread but the quality of life (QOL) consequences are unknown. This study determined the impact of screening colonoscopy on QOL measures in asymptomatic average-risk participants.

METHODS

Asymptomatic male and female participants aged 55-74 years were randomly selected from the Australian Electoral Roll or six primary care physicians' databases. Participants completed the Short-Form (SF-36) Quality of Life Assessment at baseline and at a mean of 39 days after colonoscopy. Outcome measures were (i) significant changes in raw scores in any of the eight SF-36 domains assessed following colonoscopic screening and (ii) improvements or declines in previously validated categories, representing clinically significant changes, within any of the eight SF-36 domains.

RESULTS

Baseline QOL measures were similar to those of a matched general population sample. Role Limitations due to Emotions, Mental Health and Vitality raw scores significantly improved following colonoscopy (P < 0.05, 2-tailed t-test). Health ratings according to Category were similar (same clinical status) in the majority of participants. However, 30% participants recorded clinically significant improvement in the Mental Health and Vitality domains (P < 0.05, Wilcoxon Signed-Ranks test). This improvement was not offset by declines in other domains or in other participants. Improvement in QOL was not related to colonoscopy results.

CONCLUSION

Average-risk persons benefit significantly from colon cancer screening with colonoscopy, improving in Mental Health and Vitality domains of Quality of Life. This improvement is not offset by declines in other domains.

The role of anxiety in prostate carcinoma: a structured review of the literature

Although the impact of anxiety on patients with some types of cancer is well recognized, to the authors knowledge its impact on patients with prostate carcinoma has not been studied as thoroughly. The authors conducted a systematic review of the medical literature for high-quality articles that quantified anxiety levels in men with prostate carcinoma and identified 29 articles. Using the clinical timeline of prostate carcinoma to organize the articles, cross-sectional studies that reflected anxiety prevalence in populations and longitudinal studies that reflected changes in anxiety over time were identified. Anxiety appeared to fluctuate over the clinical timeline in response to stressors and uncertainty (such as at the time of screening and/or biopsy), rising before these times and falling afterward. Although anxiety levels in men age > 55 years who were at risk for prostate carcinoma were modest (10-15%), multiple studies found that these levels were substantially higher in men who presented for screening (> 50%), and "seeking peace of mind" was the motivation cited most frequently for pursuing screening. Most studies demonstrated a significant decrease in anxiety levels after a normal screening or biopsy result, although the proportion of men who remained anxious afterward did not fall to baseline levels (20-36%). Men who presented for prostate-specific antigen monitoring after treatment had elevated anxiety levels at the time of testing (23-33%). Many years after therapy for localized disease, anxiety levels were lower after prostatectomy (23%) compared with the levels after watchful waiting (31%).

Knowledge of the Limitations Associated With Prostate Cancer Screening Among Low-income Men

This correlational pilot study measured limitations of prostate cancer screening, using a revised Knowledge of Prostate Cancer Questionnaire. Knowledge in 81 low-income men is reported. The Knowledge About Prostate Cancer Screening Questionnaire consists of 12 questions, with scores ranging from 0 to 12. Concepts measured include limitations, symptoms, risk factors, and screening age guidelines. The Total Knowledge Score had a mean of 6.60, with a standard deviation of 3.00, indicating that knowledge was low. Half of the men knew that "some treatments for prostate cancer can make it harder for men to control their urine." More than half of the men knew that, "some treatments for prostate cancer can cause problems with a man's ability to have sex." Married men, low-income men, and Caucasian men had significantly lower Total Knowledge Scores than unmarried, higher income, and African American men. Implications for practice and research are discussed.

Adherence to an annual PSA screening program over 3 years for brothers and sons of men with prostate cancer

OBJECTIVE

To assess the adherence to an annual PSA screening program conducted over 3 years in first-degree relatives of a sample of men with prostate cancer, and to identify characteristics of men who failed to undergo the full screening process.

PATIENTS AND METHODS

Out of 747 candidates that were eligible for the screening program (asymptomatic brothers and sons aged between 40 and 70 years of men diagnosed with prostate cancer) 640 were contacted. The screening program entailed annual serum PSA testing over a 3-year period, during which every candidates attendance was recorded. At the outset, each candidate was requested to complete a questionnaire regarding their socio-professional characteristics, their level of anxiety and their attitude towards genetic susceptibility.

RESULTS

442 (69%) candidates agreed to enter the study and 420 filled out the questionnaire. During the 3-year period, 50 candidates (12%) who had accepted the first year screening refused to undergo subsequent PSA tests. These men were younger ( p=0.015), more anxious (p=0.037 ) and to have more than one affected first-degree relative ( p=0.028 ).

CONCLUSIONS

The crucial and challenging step in the adherence to a screening program was the initial recruitment. Once recruited, adherence rate after 3 years was very high (88%). Identifying factors that help predict men who might leave the screening process may provide us means of improving their compliance in the future.

Short-term impact of cancer prevention and screening activities on quality of life

PURPOSE

There are few data on the short-term effects of participating in cancer prevention activities, undergoing genetic risk assessment, or having routine screening. The objective of this article is to systematically review existing research on short-term effects of prevention, genetic counseling and testing, and screening activities on quality of life.

METHODS

We conducted a MEDLINE search for original research studies that were published between January 1, 1985, and December 31, 2002, and conducted in North America or Western Europe. Data were abstracted and summarized using a standardized format.

RESULTS

We reviewed 210 publications. Most studies focused on psychological states (anxiety, depression), symptoms, or general health status. One hundred thirty-one studies used 51 previously validated noncancer instruments. Many researchers (12.6%) also added cancer-specific measures, such as perceived cancer risk or symptom indices. Only one study measured satisfaction or quality of provider-client communication. While one report examined lost workdays, no other economic consequences of short-term outcomes were evaluated. Among seven studies that assessed short-term outcomes preferences, only four specifically used time trade-off or linear rating scale methods. No study used standard gamble or willingness-to-pay methods. The overwhelming majority of research indicated that short-term effects were transient. Only two studies linked short-term effects to long-term cancer-related health behaviors such as repeat screening.

CONCLUSION

There is considerable heterogeneity in short-term outcome measurement. Clinicians need to be aware of potential for short-term, transient adverse effects. The impact of short-term experiences should to be linked to long-term health status and use of services.