Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel

BACKGROUND

Patients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strain their relationships.

AIM

We convened an international panel with the aim of developing guidelines that will inform clinicians, patients and partners about the impact of prostate cancer therapies (PCT) on patients' and partners' sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship.

METHODS

The guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995-2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment, according to the nomenclature of the American Urological Association (AUA). Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR).

OUTCOMES

Guidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel.

RESULTS

The guidelines account for patients' cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side-effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship.

CLINICAL IMPLICATIONS

The guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer.

STRENGTHS & LIMITATIONS

The strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. Limitation is the variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries.

CONCLUSION

The guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation and outline areas for future research. Wittmann D, Mehta A, McCaughan E, et al. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022;19:1655-1669.

A constructivist grounded theory study on decision-making for treatment choice among Black African and Black Caribbean prostate cancer survivors

OBJECTIVE

Despite Black African (BA) and Black Caribbean (BC) men having a disproportionately high risk (1 in 4) of developing prostate cancer (CaP), there is limited understanding of their decision-making for treatment choice. This study explored decision-making for treatment choice among BA/BC men treated for CaP.

METHODS

Using constructivist grounded theory, face-to-face, Skype and telephone interviews were conducted with 25 Black men (8 BA, 17 BC) recruited in England between October 2016 and March 2018. Data were analysed using constant comparison until saturation was achieved.

RESULTS

Data analysis yielded three broad categories: 'coming to terms with the prostate cancer diagnosis', 'getting empowerment through information-seeking' and 'choosing a treatment option'. Priority for survival substantially motivated BA/BC men to take up radical treatment for their CaP. However, decision-making for a particular treatment option was a more complex process which was shaped by an intersection between biological, behavioural, medical, personal and cultural factors.

CONCLUSIONS

Healthcare providers need to consider the complexity of decision-making process for CaP treatment among BA/BC men and tailor cancer care services to reflect cultural sensitivity and person-centredness. This could potentially minimise treatment decision regrets and improve men's psychological wellbeing along the CaP survivorship pathway.

Experiences of Support for Sexual Dysfunction in Men With Prostate Cancer: Findings From a U.K.-Wide Mixed Methods Study

BACKGROUND

Men with prostate cancer (PCa) often experience sexual dysfunction following diagnosis and treatment, yet little is known about the support they receive to deal with this.

AIM

To explore men's experiences of support for sexual dysfunction following PCa diagnosis.

METHODS

This study included a U.K.-wide survey of men 18-42 months post-diagnosis of PCa, identified through cancer registries. The survey measured sexual function and the extent to which men perceived sexual dysfunction to be a problem (Expanded Prostate Cancer Index Composite-26), access to and experience of medications, devices, and specialist services for sexual dysfunction, and included a free-text question for further comments. Analysis focussed on men who reported poor sexual function, which they considered a moderate or big problem. Descriptive statistics explored the characteristics of men offered intervention and those that found this helpful. Free-text responses were analyzed using thematic analysis.

OUTCOME

The main outcome of this study was to assess access to and experience of medications, devices, and specialist services for sexual dysfunction.

RESULTS

39.0% of all survey respondents (13,978/35,823) reported poor sexual function, which they considered a moderate or big problem. 51.7% of these men were not offered any intervention to aid sexual functioning. 71.9% of those offered an intervention reported trying it, of whom 48.7% found the intervention helpful. Men treated with surgery or brachytherapy were most likely to be offered an intervention. Medication was the most commonly offered intervention and 39.3% of those who tried medication found this helpful. Although offered less often, approximately half of the men who tried devices or attended specialist services found the intervention helpful. Free-text responses indicated that barriers to accessing support included inadequate information and support from healthcare professionals, embarrassment, negative views about treatment options, concerns about side effects and safety, and inconsistencies between secondary and primary care. Barriers to continuing use included limited effectiveness of treatments, inadequate ongoing support, and funding constraints. Drivers of sexual recovery included patient proactivity and persistence with trying different treatment options and ongoing support from health professionals.

CLINICAL IMPLICATIONS

There is an urgent need to ensure that all men are offered, and have equal access to, sexual care support, with referral to specialist services when required.

STRENGTHS & LIMITATIONS

This study presents data from a large, U.K.-wide, population-based study of men with PCa and includes quantitative and qualitative findings. The possibility of non-response bias should, however, be considered.

CONCLUSION

There are significant shortcomings in the support offered to U.K. men with sexual dysfunction following diagnosis and treatment for PCa which need to be addressed. Watson E, Wilding S, Matheson L, et al. Experiences of Support for Sexual Dysfunction in Men With Prostate Cancer: Findings From a U.K.-Wide Mixed Methods Study. J Sex Med 2021;18:515-525.

Quality of life in men living with advanced and localised prostate cancer in the UK: a population-based study

BACKGROUND

Little is known about the health-related quality of life (HRQOL) of men living with advanced prostate cancer. We report population-wide functional outcomes and HRQOL in men with all stages of prostate cancer and identify implications for health-care delivery.

METHODS

For this population-based study, men in the UK living 18-42 months after diagnosis of prostate cancer were identified through cancer registration data. A postal survey was administered, which contained validated measures to assess functional outcomes (urinary incontinence, urinary irritation and obstruction, bowel, sexual, and vitality and hormonal function), measured with the Expanded Prostate Cancer Index Composite short form (EPIC-26), plus questions about use of interventions for sexual dysfunction) and generic HRQOL (assessed with the 5-level EuroQol five dimensions questionnaire [EQ-5D-5L] measuring mobility, self-care, usual activities, pain or discomfort, and anxiety or depression, plus a rating of self-assessed health). Log-linear and binary logistic regression models were used to compare functional outcomes and HRQOL across diagnostic stages and self-reported treatment groups. Each model included adjustment for age, socioeconomic deprivation, and number of other long-term conditions.

FINDINGS

35 823 (60·8%) of 58 930 men responded to the survey. Disease stage was known for 30 733 (85·8%) of 35 823 men; 19 599 (63·8%) had stage I or II, 7209 (23·4%) stage III, and 3925 (12·8%) stage IV disease. Mean adjusted EPIC-26 domain scores were high, indicating good function, except for sexual function, for which scores were much lower. Compared with men who did not receive androgen deprivation therapy, more men who received the therapy reported moderate to big problems with hot flushes (30·7% [95% CI 29·8-31·6] vs 5·4% [5·0-5·8]), low energy (29·4% [95% CI 28·6-30·3] vs 14·7% [14·2-15·3]), and weight gain (22·5%, 21·7-23·3) vs 6·9% [6·5-7·3]). Poor sexual function was common (81·0%; 95% CI 80·6-81·5), regardless of stage, and more than half of men (n=18 782 [55·8%]) were not offered any intervention to help with this condition. Overall, self-assessed health was similar in men with stage I-III disease, and although slightly reduced in those with stage IV cancer, 23·5% of men with metastatic disease reported no problems on any EQ-5D dimension.

INTERPRETATION

Men diagnosed with advanced disease do not report substantially different HRQOL outcomes to those diagnosed with localised disease, although considerable problems with hormonal function and fatigue are reported in men treated with androgen deprivation therapy. Sexual dysfunction is common and most men are not offered helpful intervention or support. Service improvements around sexual rehabilitation and measures to reduce the effects of androgen deprivation therapy are required.

FUNDING

The Movember Foundation, in partnership with Prostate Cancer UK.

Treatment for erectile dysfunction among older men in Northern Ireland

BACKGROUND

Erectile dysfunction is common among older men; however, diagnosis and treatment compared to reported prevalence is low. We aim to identify the degree to which older men are offered treatment for the condition and determine the level of unmet need within Northern Ireland (NI).

METHODOLOGY

Analysis of data collected using a cross-sectional survey was conducted for men aged ≥60 years with data weighted to the NI population by age and deprivation. Respondents answered questions on sociodemographic factors, health-related characteristics, ability to function sexually, level of sexual interest and activity, and any treatment offered to improve erections in the last 3 years. Results are presented as proportions reporting treatment receipt, with differences by respondent characteristics assessed using chi-square tests and multivariable logistic regression.

RESULTS

Among 2597 respondents, 46.5% reported erectile dysfunction. One quarter (25.8%) recalled being offered either medication, devices, or specialised services to improve erections. The offer of treatment was associated with younger age, being separated or divorced, higher number of long-term conditions, and greater interest in sex. Of men reporting erectile dysfunction and offered medication, 28.8% found them helpful and currently use them.

CONCLUSIONS

As a result of not being offered treatment or not finding treatment useful, 93% of men reporting erectile dysfunction have no help with the condition. This is a likely consequence of treatment availability through the NHS in NI, but also suggests that healthcare professionals need to engage more proactively with older men, discussing sexual health routinely and following up those treated for the condition.

"Hard to reach, but not out of reach": Barriers and facilitators to recruiting Black African and Black Caribbean men with prostate cancer and their partners into qualitative research

Access and recruitment barriers may have contributed to the underrepresentation of Black African/Caribbean men and their partners in current psychosocial research related to prostate cancer survivors. Whilst some studies have explored recruitment barriers and facilitators from participants' perspectives, little is known from researchers' point of view. This paper aimed to address this gap in the literature. Recruitment strategies included the following: cancer support groups, researchers' networks, media advertisement, religious organisations, National Health Service hospitals and snowball sampling. Thirty-six eligible participants (men = 25, partners = 11) were recruited into the study. Recruitment barriers comprised of gate-keeping and advertisement issues and the stigma associated with prostate cancer disclosure. Facilitators which aided recruitment included collaborating with National Health Service hospitals, snowball sampling, flexible data collection, building rapport with participants to gain their trust and researcher's attributes. Findings highlight that "hard to reach" Black African/Caribbean populations may be more accessible if researchers adopt flexible but strategic and culturally sensitive recruitment approaches. Such approaches should consider perceptions of stigma associated with prostate cancer within these communities and the influence gatekeepers can have in controlling access to potential participants. Increased engagement with healthcare professionals and gatekeepers could facilitate better access to Black African/Caribbean populations so that their voices can be heard and their specific needs addressed within the healthcare agenda.

"…It might not have occurred to my husband that this woman, his wife who is taking care of him has some emotional needs as well…": the unheard voices of partners of Black African and Black Caribbean men with prostate cancer

PURPOSE

Evidence suggests that partners of men with prostate cancer (CaP) experience greater psychosocial distress compared with men themselves. However, the experiences of partners of high-risk (1 in 4) Black African (BA) and Black Caribbean (BC) men with CaP remain poorly understood as existing research has predominantly focused on Caucasian populations. This study aimed to address this gap by exploring partners' experience and support needs as influenced both by the specific impacts of CaP, treatment side effects and socio-cultural context.

METHODS

Using a constructivist grounded theory approach, eight face-to-face, two Skype and one telephone interviews were conducted with eligible partners (n = 11). The interviews were analysed using constant comparison following key stages of open, focused and theoretical coding.

RESULTS

Three broad categories emerged which described participants' experiences: 'partner in the passenger seat', 'care-giving on an isolating journey', and 'coping as a partner'. Findings showed that BA and BC cultural marital context influenced how partners experienced and traversed the CaP journey. Peripheral involvement in decision-making, communication restrictions, limited access to support and lack of recognition for their experiences and needs further contributed to partners' psychological and emotional distress.

CONCLUSIONS

Cultural beliefs, behaviours and values should be taken into account when developing psychosocial support for partners and their men with CaP. Specifically providing information focused on partners and including them in the CaP care pathway could help ensure that partners' needs are recognised and improve marital communications. This could potentially help partners and their men to identify acceptable ways of supporting each other throughout the CaP experience.

Urinary, bowel and sexual health in older men from Northern Ireland

Objectives

To provide data on the prevalence of urinary, bowel and sexual dysfunction in Northern Ireland (NI), to act as a baseline for studies of prostate cancer outcomes and to aid service provision within the general population.

Subjects and Methods

A cross‐sectional postal survey of 10 000 men aged ≥40 years in NI was conducted and age‐matched to the distribution of men living with prostate cancer. The EuroQoL five Dimensions five Levels (EQ‐5D‐5L) and 26‐item Expanded Prostate Cancer Composite (EPIC‐26) instruments were used to enable comparisons with prostate cancer outcome studies. Whilst representative of the prostate cancer survivor population, the age‐distribution of the sample differs from the general population, thus data were generalised to the NI population by excluding those aged 40–59 years and applying survey weights. Results are presented as proportions reporting problems along with mean composite scores, with differences by respondent characteristics assessed using chi‐squared tests, analysis of variance, and multivariable log‐linear regression.

Results

Amongst men aged ≥60 years, 32.8% reported sexual dysfunction, 9.3% urinary dysfunction, and 6.5% bowel dysfunction. In all, 38.1% reported at least one problem and 2.1% all three. Worse outcome was associated with increasing number of long‐term conditions, low physical activity, and higher body mass index (BMI). Urinary incontinence, urinary irritation/obstruction, and sexual dysfunction increased with age; whilst urinary incontinence, bowel, and sexual dysfunction were more common among the unemployed.

Conclusion

These data provide an insight into sensitive issues seldom reported by elderly men, which result in poor general health, but could be addressed given adequate service provision. The relationship between these problems, raised BMI and low physical activity offers the prospect of additional health gain by addressing public health issues such as obesity. The results provide essential contemporary population data against which outcomes for those living with prostate cancer can be compared. They will facilitate greater understanding of the true impact of specific treatments such as surgical interventions, pelvic radiation or androgen‐deprivation therapy.

Evaluating a psychosocial intervention for men with prostate cancer and their partners: Outcomes and lessons learned from a randomized controlled trial

AIM

This study evaluated the process and outcome of a psychosocial intervention for men with prostate cancer and their partners. As more men survive prostate cancer, they and their partners need help and support to help them cope with the physical and psychosocial effects of the disease and treatment. There is a lack of psychosocial interventions for men with prostate cancer and their partners.

METHODS

A randomized controlled trial was conducted with 34 participants to measure the effects of the intervention on selected psychosocial outcomes, post-intervention and at one month' follow-up. The nine-week program (CONNECT) consisted of three group and two telephone sessions. It focused on symptom management, sexual dysfunction, uncertainty management, positive thinking and couple communication. The outcomes, measured by validated tools were: self-efficacy, quality of life, symptom distress, communication, uncertainty and illness benefits.

RESULTS

The men in the intervention group did better on two outcomes (communication and support) than controls. Partners in the intervention group did better than controls on most outcomes. Less participants than expected participated in the trial. The reasons for non-participation included partners not wishing to participate, men not interested in group work, and not understanding the core purpose of the intervention. The cost of training facilitators and for delivering the intervention appeared to be low.

CONCLUSION

The knowledge generated from this study will be beneficial for all those grappling with the challenges of developing, implementing and evaluating complex psychosocial interventions. This study has also highlighted the difficulties in recruiting men and their partners in clinical trials.

Online support groups for women with breast cancer

BACKGROUND

Survival rates for women with a diagnosis of breast cancer continue to improve. However, some women may experience physical, psychological and emotional effects post diagnosis, throughout treatment and beyond. Support groups can provide opportunities for people to share their experiences and learn from others. As the number of online support groups increases, more and more women with breast cancer will likely access them.

OBJECTIVES

To assess effects of online support groups on the emotional distress, uncertainty, anxiety, depression and quality of life (QoL) of women with breast cancer.

SEARCH METHODS

We searched for trials in the Cochrane Breast Cancer Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 4), MEDLINE, Embase and PsycINFO on 2 May 2016, and we handsearched journals and reference lists. We also searched the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP) search portal and clinicaltrials.gov on 2 May 2016.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing effects of online support groups on women with a diagnosis of breast cancer and women who have completed breast cancer treatment. We included studies comparing online support groups with a usual care group, and studies comparing two or more types of online support groups (without a usual care group).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. We presented outcome data using mean differences (MDs) and standardised mean differences (SMDs) along with 95% confidence intervals (CIs), and we used the fixed-effect model when appropriate. We assessed the quality of the body of evidence using the GRADE approach.

MAIN RESULTS

We included six studies (492 women) that assessed online support groups for women with breast cancer. Online support groups in these six trials lasted from six to 30 weeks. Women participated in these groups between 1.5 and 2.5 hours per week, and investigators conducted all studies in the USA. Participants were predominantly white and well educated and were moderate to high earners. Four studies compared an online support group versus a control group, and the other two compared a 'moderated' versus a 'peer-led' online support group, and a 'standard' versus an 'enhanced' online support group, respectively.None of the included studies measured 'emotional distress' or uncertainty. One study (78 women) for which data for analysis were missing reported no positive effects of online support on 'distress' and 'cancer-specific distress' versus support provided by a control group. Two studies measured anxiety: One study (72 women) found no difference in anxiety at the end of the intervention between the online support group and the control group (MD -0.40, 95% CI -6.42 to 5.62; low-quality evidence), and the second study (184 women) reported a reduction in anxiety levels at the end of the intervention when comparing the 'standard' support group (run by participants without prompting from health professionals) versus an 'enhanced' online support group (in which participants were specifically asked by the researcher to respond to one another's need for support).Five studies (414 women) measured depression. Three studies compared depression in the online support group with depression in the control group. Pooled data from two studies (120 women) showed a small to moderate reduction in depression in the online support group compared with control groups at the end of the intervention (SMD -0.37, 95% CI -0.75 to 0.00; very low-quality evidence). The third study, a pilot study (30 women), provided no data for analysis but reported no difference in depression between participants in support and control groups at the end of the intervention. Of the remaining two studies that measured depression, one study (60 women) provided no extractable data for comparison but reported no difference in depressive symptoms between a 'moderated' and a 'peer-led' support group; the other study (184 women) reported greater reduction in depression in the 'standard' support group than in the 'enhanced' online support group.Three studies measured quality of life. One pilot study (30 women) provided limited data for analysis but reported no change in quality of life at the end of the intervention. Only two studies (140 women) provided data for pooling and showed no positive effects on quality of life at four months post intervention compared with controls (SMD -0.11, 95% CI -0.47 to 0.24; very low-quality evidence). At 12 months post intervention, one study (78 women) reported that the intervention group did not attain better quality of life scores than the control group (MD -10.89, 95% CI -20.41 to -1.37; low-quality evidence).We found no data for subgroup analyses on stage of disease, treatment modality and types and doses of interventions. No studies measured adverse effects.

AUTHORS' CONCLUSIONS

This review did not find the evidence required to show whether participation in online support groups was beneficial for women with breast cancer, because identified trials were small and of low or very low quality. Large, rigorous trials with ethnically and economically diverse participants are needed to provide robust evidence regarding the psychosocial outcomes selected for this review.

Fathers' experiences of living with cancer: a phenomenological study

There is a paucity of knowledge about fathers' experiences of cancer. This study explored the experiences of fathers diagnosed and living with cancer while also having parental responsibility for children. A hermeneutic phenomenological approach guided the study. Data were generated through 22 in-depth interviews with 10 fathers throughout Northern Ireland. The findings evidenced that fathers' identities are challenged and frequently re-shaped by the cancer experience, in many cases leading to an improved lifestyle behaviour. Heightened engagement with their children can provide a protective effect from the illness. On the other hand a lack of involvement led to frustration and low mood. The findings also demonstrated that father/child relationships were adversely affected by the social complexities that exist in the variances and diversity of fathers parenting roles and status. This knowledge contributes to our understanding of the complex relationships of fathers in non-traditional roles. It extends our understanding of how, when stereotyped gendered roles are ascribed to fathers it can impact on a fathers' ability to fulfil the traditional breadwinner's role. This is knowledge that will inform health care professionals and enable them to provide gendered-sensitive care that takes account of the masculine psychological responses that can shape the cancer experience.

The experience and perceptions of men with prostate cancer and their partners of the CONNECT psychosocial intervention: a qualitative exploration

AIM

To explore the experience of prostate cancer survivors and their partners of the CONNECT psychosocial intervention.

BACKGROUND

There is a scarcity of evidence relating to interventions to help men and their partners cope with the after affects of prostate cancer treatment.

DESIGN

This study employed a qualitative design for in depth exploration through couple interviews. The addition of a short process evaluation questionnaire was used to supplement the qualitative data.

METHODS

Semi-structured interviews were conducted between January 2012-October 2012 with a purposive sample of 11 couple dyads who had participated in the CONNECT intervention. Data were analysed using inductive content analysis. Simple descriptive statistics were used to analyse the findings from the questionnaire data.

RESULTS

Couples perceived benefits of participating in the intervention to include: opportunities to share experiences, gain validation, obtain information and engage in couple care. The expertise of the professional facilitator and group dynamics were highlighted as factors influencing the success of the intervention. Potential areas for improvement of the intervention were identified as being: further development of the sexual dysfunction component; incorporation of a partner specific session to better address their needs; determination of optimal delivery format and timing; and further tailoring of the components of the intervention.

CONCLUSION

Although there were areas that could be further improved, this psychosocial intervention was valued by the participants. The insight gained from this qualitative exploration can be used to make the necessary changes before the intervention can be tested in a large randomised controlled trial.

Psychosocial interventions for men with prostate cancer: a Cochrane systematic review

To evaluate the effectiveness of psychosocial interventions for men with prostate cancer in improving quality of life (QoL), self-efficacy and knowledge and in reducing distress, uncertainty and depression. We searched for trials using a range of electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO to October 2013, together with hand searching of journals and reference lists. Randomised controlled trials were eligible if they included psychosocial interventions that explicitly used one or a combination of the following approaches: cognitive behavioural, psycho-educational, supportive and counselling. Interventions had to be delivered or facilitated by trained or lay personnel. Our outcomes were an improvement in QoL, self-efficacy and knowledge and a reduction in distress, uncertainty and depression. Pairs of review authors independently extracted data and assessed risk of bias. We analysed data using standardised mean differences (SMDs), random-effects models and 95% confidence intervals (CIs). In all, 19 studies with a total of 3 204 men, with a diagnosis of prostate cancer, comparing psychosocial interventions vs usual care were included in this review. Men in the psychosocial intervention group had a small, statistically significant improvement in the physical component of general health-related QoL (GHQoL) at end of intervention (SMD 0.12, 95% CI 0.01-0.22) based on low quality evidence. There was no clear evidence of benefit associated with psychosocial interventions for the mental component of GHQoL at end of intervention (SMD -0.04, 95% CI -0.15 to 0.06) based on moderate quality evidence. At end of intervention, cancer-related QoL showed a small improvement after psychosocial interventions (SMD 0.21, 95% CI 0.04-0.39). For prostate cancer-specific and symptom-related QoL, the differences between intervention and control groups were not significant. There was no clear evidence that psychosocial interventions were beneficial in improving self-efficacy at end of intervention (SMD 0.16, 95% CI -0.05 to 0.38) based on very low quality evidence. Men in the psychosocial intervention group had a moderate increase in prostate cancer knowledge at end of intervention (SMD 0.51, 95% CI 0.32-0.71) based on very low quality evidence. A small increase in knowledge with psychosocial interventions was noted at 3 months after intervention (SMD 0.31, 95% CI 0.04-0.58). The results for uncertainty (SMD -0.05, 95% CI -0.35 to 0.26) and distress (SMD 0.02, 95% CI -0.11 to 0.15) at end of intervention were compatible with both benefit and harm based on very low quality evidence. Finally, there was no clear evidence of benefit associated with psychosocial interventions for depression at end of intervention (SMD -0.18, 95% CI -0.51 to 0.15) based on very low quality evidence. The overall risk of bias in the included studies was unclear or high, primarily as the result of performance bias. No data about stage of disease or treatment with androgen-deprivation therapy were extractable for subgroup analysis. Only one study addressed adverse effects. Overall, this review shows that psychosocial interventions may have small, short-term beneficial effects on certain domains of wellbeing, as measured by the physical component of GHQoL and cancer-related QoL when compared with usual care. Prostate cancer knowledge was also increased. However, this review failed to show a statistically significant effect on other domains such as symptom-related QoL, self-efficacy, uncertainty, distress or depression. Moreover, when beneficial effects were seen, it remained uncertain whether the magnitude of effect was large enough to be considered clinically important. The quality of evidence for most outcomes was rated as very low according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system, reflecting study limitations, loss to follow-up, study heterogeneity and small sample sizes. We were unable to perform meaningful subgroup analyses based on disease stage or treatment method. Although some findings of this review are encouraging, they do not provide sufficiently strong evidence to permit meaningful conclusions about the effects of these interventions in men with prostate cancer. Additional well executed and transparently reported research studies are necessary to establish the role of psychosocial interventions in men with prostate cancer.

Maximising survival: the main concern of women with hereditary breast and ovarian cancer who undergo genetic testing for BRCA1/2

PURPOSE

Little is known about how women with hereditary breast and/or ovarian cancer who test positive for a BRCA gene manage the impact of a positive test result on their everyday lives and in the longer term. This study defined the experience and needs of women with hereditary breast and ovarian cancer and a positive BRCA test over time.

METHODS

A grounded theory approach was taken using qualitative interviews (n = 49) and reflective diaries. Data collected from December 2006 until March 2010 was analysed using the constant comparative technique to trace the development of how women manage their concerns of inherited cancer.

RESULTS

A four stage substantive theory of maximising survival was generated that defines the experience of women and how they resolve their main concerns. The process of maximising survival begins prior to genetic testing in women from high risk families as they expect to get a cancer diagnosis at some time. Women with cancer felt they had experienced the worst with a cancer diagnosis and altruistically tested for the sake of their children but a positive test result temporarily shifted their focus to decision-making around their personal health needs.

CONCLUSION

This study adds to clinical practice through raising awareness and adding insights into how women cope with living with inherited cancer risk and the personal and familial ramifications that ensue from it. A clear multi-professional structured care pathway for women from genetic testing result disclosure to undergoing risk-reducing surgery and/or surveillance should be developed.

Psychosocial interventions for men with prostate cancer

BACKGROUND

As the incidence and prevalence of prostate cancer continue to rise, the number of men needing help and support to assist them in coping with disease and treatment-related symptoms and their psychosocial effects is likely to increase.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions for men with prostate cancer in improving quality of life (QoL), self-efficacy and knowledge and in reducing distress, uncertainty and depression.

SEARCH METHODS

We searched for trials using a range of electronic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and PsycINFO to October 2013, together with handsearching of journals and reference lists.

SELECTION CRITERIA

Randomised controlled trials of psychosocial interventions for men at any stage of prostate cancer. We included psychosocial interventions that explicitly used one or a combination of the following approaches: cognitive behavioural, psychoeducational, supportive and counselling. Interventions had to be delivered or facilitated by trained or lay personnel.

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently extracted data and assessed risk of bias. We analysed data using standardised mean differences (SMDs), random-effects models and 95% confidence intervals (CIs).

MAIN RESULTS

Nineteen studies comparing psychosocial interventions versus usual care in a total of 3204 men with prostate cancer were included in this review. All but three of these studies were conducted in the United States.Men in the psychosocial intervention group had a small, statistically significant improvement in the physical component of general health-related quality of life (GHQoL) at end of intervention (1414 participants, SMD 0.12, 95% CI 0.01 to 0.22) based on low-quality evidence. A small improvement in favour of psychosocial interventions (SMD 0.24, 95% CI 0.02 to 0.47) was also seen in the physical component of GHQoL at end of intervention for group-based interventions. No clear evidence of benefit was found for GHQoL scores at end of intervention with individual-based interventions compared with controls. Also, no clear evidence suggested that psychosocial interventions were beneficial in improving the physical component of GHQoL at four to six and at eight to 12 months post-intervention. In addition, no clear evidence showed benefit associated with psychosocial interventions for the mental component of GHQoL at end of intervention (1416 participants, SMD -0.04, 95% CI -0.15 to 0.06) based on moderate-quality evidence. Results for the mental component of GHQoL at four to six and at eight to 12 months post-intervention were compatible with benefit and harm. At end of intervention, cancer-related QoL showed a small improvement following psychosocial interventions (SMD 0.21, 95% CI 0.04 to 0.39), but at eight and 12 months, the effect was compatible with benefit and harm. For prostate cancer-specific and symptom-related QoL, the differences between groups were not significant.No clear evidence indicated that psychosocial interventions were beneficial in improving self-efficacy at end of intervention (337 participants, SMD 0.16, 95% CI -0.05 to 0.38) based on very low-quality evidence in three studies that assessed individual-based interventions. The results for self-efficacy at six to eight and at 12 months post-intervention were compatible with benefit and harm. Men in the psychosocial intervention group had a moderate increase in prostate cancer knowledge at end of intervention (506 participants, SMD 0.51, 95% CI 0.32 to 0.71) based on very low-quality evidence in two studies; this increase was also observed in the subgroups of group-based and individual-based interventions. A small increase in knowledge with psychosocial interventions was noted at three months post-intervention (SMD 0.31, 95% CI 0.04 to 0.58).The results for uncertainty (916 participants, SMD -0.05, 95% CI -0.35 to 0.26) and distress (916 participants, SMD 0.02, 95% CI -0.11 to 0.15) at end of intervention were compatible with both benefit and harm based on very low-quality evidence. No clear evidence suggests that psychosocial interventions were beneficial in reducing uncertainty and distress between groups at six to eight and at 12 months post-intervention. Finally, no clear evidence of benefit is associated with psychosocial interventions for depression at end of intervention (434 participants, SMD -0.18, 95% CI -0.51 to 0.15) based on very low-quality evidence. Individual-based interventions significantly reduced depression when compared with usual care groups. The results for depression at six and at 12 months post-intervention were compatible with benefit and harm.The overall risk of bias in the included studies was unclear or high, primarily as the result of performance bias.No data regarding stage of disease or treatment with androgen deprivation therapy (ADT) were extractable for subgroup analysis. Only one study addressed adverse effects. High attrition could indicate that some participants may not have been comfortable with the interventions.

AUTHORS' CONCLUSIONS

Overall, this review shows that psychosocial interventions may have small, short-term beneficial effects on certain domains of well-being, as measured by the physical component of GHQoL and cancer-related QoL when compared with usual care. Prostate cancer knowledge was also increased. However, this review failed to demonstrate a statistically significant effect on other domains such as symptom-related QoL, self-efficacy, uncertainty, distress or depression. Moreover, when beneficial effects were observed, it remained uncertain whether the magnitude of effect was large enough to be considered clinically important. The quality of evidence for most outcomes was rated as very low according to GRADE, reflecting study limitations, loss to follow-up, study heterogeneity and small sample sizes. We were unable to perform meaningful subgroup analyses based on disease stage or treatment modality. Although some findings of this review are encouraging, they do not provide sufficiently strong evidence to permit meaningful conclusions about the effects of these interventions in men with prostate cancer. Additional well-done and transparently reported research studies are necessary to establish the role of psychosocial interventions in men with prostate cancer.

Psychosocial interventions for patients with head and neck cancer

BACKGROUND

A diagnosis of head and neck cancer, like many other cancers, can lead to significant psychosocial distress. Patients with head and neck cancer can have very specific needs, due to both the location of their disease and the impact of treatment, which can interfere with basic day-to-day activities such as eating, speaking and breathing. There is a lack of clarity on the effectiveness of the interventions developed to address the psychosocial distress experienced by patients living with head and neck cancer.

OBJECTIVES

To assess the effectiveness of psychosocial interventions to improve quality of life and psychosocial well-being for patients with head and neck cancer.

SEARCH METHODS

We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the most recent search was 17 December 2012.

SELECTION CRITERIA

We selected randomised controlled trials and quasi-randomised controlled trials of psychosocial interventions for adults with head and neck cancer. For trials to be included the psychosocial intervention had to involve a supportive relationship between a trained helper and individuals diagnosed with head and neck cancer. Outcomes had to be assessed using a validated quality of life or psychological distress measure, or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data and assessed the risk of bias, with mediation from a third author where required. Where possible, we extracted outcome measures for combining in meta-analyses. We compared continuous outcomes using either mean differences (MD) or standardised mean differences (SMD) and 95% confidence intervals (CI), with a random-effects model. We conducted meta-analyses for the primary outcome measure of quality of life and secondary outcome measures of psychological distress, including anxiety and depression. We subjected the remaining outcome measures (self esteem, coping, adjustment to cancer, body image) to a narrative synthesis, due to the limited number of studies evaluating these specific outcomes and the wide divergence of assessment tools used.

MAIN RESULTS

Seven trials, totaling 542 participants, met the eligibility criteria. Studies varied widely on risk of bias, interventions used and outcome measures reported. From these studies, there was no evidence to suggest that psychosocial intervention promotes global quality of life for patients with head and neck cancer at end of intervention (MD 1.23, 95% CI -5.82 to 8.27) as measured by the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30). This quality of life tool includes five functional scales, namely cognitive, physical, emotional, social and role. There was no evidence to demonstrate that psychosocial intervention provides an immediate or medium-term improvement on any of these five functional scales. From the data available, there was no significant change in levels of anxiety (SMD -0.09, 95% CI -0.40 to 0.23) or depression following intervention (SMD -0.03, 95% CI -0.24 to 0.19). At present, there is insufficient evidence to refute or support the effectiveness of psychosocial intervention for patients with head and neck cancer.

AUTHORS' CONCLUSIONS

The evidence for psychosocial intervention is limited by the small number of studies, methodological shortcomings such as lack of power, difficulties with comparability between types of interventions and a wide divergence in outcome measures used. Future research should be targeted at patients who screen positive for distress and use validated outcome measures, such as the EORTC scale, as a measure of quality of life. These studies should implement interventions that are theoretically derived. Other shortcomings should be addressed in future studies, including using power calculations that may encourage multi-centred collaboration to ensure adequate sample sizes are recruited.

A randomized controlled trial of a self-management psychosocial intervention for men with prostate cancer and their partners: a study protocol

BACKGROUND

Little is known about interventions to help men and their partners cope with the after effects of prostate cancer treatment. The lack of in-depth descriptions of the intervention content is hindering the identification of which intervention (or component of an intervention) works.

AIM

To describe the development and evaluation of the content of a self-management psychosocial intervention for men with prostate cancer and their partners.

DESIGN

A feasibility randomized controlled trial including structure, process, and outcome analysis.

METHODS

This 9-week intervention commences on completion of treatment and consists of three group and two telephone sessions. The intervention focuses on symptom management, sexual dysfunction, uncertainty management, positive thinking and couple communication. Forty-eight couples will be assigned to either the intervention or a control group receiving usual care. Participants will be assessed at baseline, immediately postintervention and at 1 and 6 months postintervention. Outcome measures for patients and caregivers include self-efficacy, quality of life, symptom distress, uncertainty, benefits of illness, health behaviour, and measures of couple communication and support. An additional caregiver assessment will be completed by the partner.

DISCUSSION

The main purpose of this feasibility study is to investigate the acceptability of the CONNECT programme to men with prostate cancer and their partners and to gain feedback from the participants and facilitators to make changes to and enhance the programme. Reasons why men do not want to participate will be collated to enhance recruitment in the future. We will also test recruitment strategies, randomization procedures, and the acceptability of the questionnaires. Ethical approval granted December 2010.

Issues and considerations when researching sensitive issues with men: examples from a study of men and sexual health

This article highlights some ethical considerations and practicalities that arose when conducting research with men in relation to decision making and seeking help for a sexually transmitted infection (STI). The aim of the study was to explore, using a grounded theory approach, the processes involved in making the decision to seek help. The main issues that arose were in relation to seeking permission and gaining approval, obtaining informed consent and susceptibility to harm. The interview itself and the concept of the researcher as a tool of data collection also gave rise to ethical issues. These issues have implications for the conduct of sensitive research with men and highlight the need for more overt reporting of the ethical issues and practical considerations that arise when planning and conducting research.

Changes and challenges to patients' lifestyle patterns following treatment for head and neck cancer

AIM

This paper is a report of a study to explore the changes and challenges to patients' lifestyles following treatment for head and neck cancer.

BACKGROUND

Head and neck cancer affects some of the most basic aspects of daily functioning, such as eating and speaking. There has been a rapid increase in the number of studies on the quality of life for people with head and neck cancer, but most studies have used quantitative methodology.

METHODS

Using a qualitative approach, data were collected in 2004 using semi-structured interviews with a purposive sample of 10 participants who had completed treatment 6-12 months earlier for head and neck cancer. A thematic analysis was employed to interpret the findings.

FINDINGS

Following thematic analysis seven broad themes were identified, five of which covered areas of changes and challenges to participants' lifestyles following treatment. These were: physical changes, concerns about cancer, work and day-to-day tasks, interpersonal relationships and social functioning. The concerns and challenges experienced following treatment were not limited to one aspect of an individual's lifestyle but spanned a number of the themes identified, highlighting the complexity of needs following treatment for head and neck cancer. The other two themes concerned personal attributes that facilitated or inhibited posttreatment coping and specific information needs in the posttreatment period.

CONCLUSION

Specific posttreatment concerns and challenges cannot be viewed as unitary or discrete aspects of life, but should be considered within a biopsychosocial context, to address patients' needs holistically.

Consumers? and professionals? perceptions of a breast cancer review clinic

AIM

This paper is a report of a study to explore the healthcare needs of women attending consultant-led breast cancer review clinics from their own perspectives, how these healthcare needs were being met, and healthcare professionals' perceptions of ways in which the service could be delivered more efficiently and effectively.

BACKGROUND

The value of routine medical follow-up both in terms of detection of recurrence and patient satisfaction has been questioned. However traditional, where routine follow-up continues, there are rising numbers of women with breast cancer attending review clinics.

METHODS

A qualitative approach was adopted, using non-participant observation during seven outpatient oncology/surgical breast review sessions. Interviews were carried out in 2005 with a convenience sample of 21 women clinic attenders, two outpatient nurses, three breast care nurses, four oncologists, three surgeons and an outpatient sister.

FINDINGS

Although women saw themselves as having returned to a precancer state, they still had fears of recurrence and a need for reassurance. This need was generally met through the review clinic but many psychosocial needs were unaddressed. However, nurses seemed to be under-used as a potential source of support. Medical and nursing staff perceived that women needed to be reviewed but acknowledged that appropriately prepared nurses could deliver a more holistic and efficient service.

CONCLUSION

The number of women with breast cancer requiring ongoing review is likely to increase, but the current review service is not meeting all their needs. A nurse-led follow-up service could be an attractive alternative to routine medical follow-up.

Never-ending making sense: towards a substantive theory of the information-seeking behaviour of newly diagnosed cancer patients

AIM

The aim of this paper was to report a study which explored the information-seeking behaviour of patients newly diagnosed with cancer in the immediate postdiagnosis period.

BACKGROUND

Information is an important tool for cancer patients. There is evidence that patients' information needs are not being adequately met and, in many cases, patients often do not recall much information at the time of diagnosis.

METHOD

Using a grounded theory approach, a theoretical sample of 27 newly diagnosed patients was interviewed in their own homes. Data were analysed using grounded theory analysis procedures.

RESULTS

A substantive theory describing the transitions from 'being traumatized' by the diagnosis, through a phase of trying to 'take it on', through to 'taking control' is tentatively offered. It provides a theoretical framework to understand newly diagnosed cancer patients' changing, varied and continuing needs and their efforts to regain some control over their lives. Their information-seeking behaviour seemed a journey of 'never-ending making sense' with ongoing discovery and new information needs as they struggled with the effects of the disease and treatments.

CONCLUSIONS

The processes and stages identified in this study provide nurses with a framework to assess the readiness of patients to receive information and to assist them in their efforts to regain some control over their disease and their lives.

RELEVANCE TO CLINICAL PRACTICE

Health professionals need to be aware of these stages, to be equipped to assess the need of individuals for information and support.

Information-seeking behaviour of men newly diagnosed with cancer: a qualitative study

AIM

This paper reports the findings of a study, which explored the information-seeking behaviour of men newly diagnosed with cancer.

BACKGROUND

There is worldwide recognition that there are significant differences in the way men and women react to and cope with illness, yet there seems to be a lack of research into men's information-seeking behaviours and how they get their information needs met. The needs of men with cancer has so far received less research attention than women.

METHODS

A qualitative approach, consisting of in-depth interviews, was used. A convenient sample of 13 men newly diagnosed with cancer and five healthcare professionals and four lay sources were recruited for this study.

RESULTS

Five themes emerged from the data. These were: 'experiencing discomfort in the healthcare setting', 'reliance on partners as information gatherers', 'reluctance to explore a range of information sources and support', 'unmet information needs' and 'getting back to normal'. Together, they provide a perspective on men's information needs and information-seeking behaviour.

CONCLUSIONS

Healthcare professionals should be aware that there may be gender differences in how patients cope with their cancer, how they seek information and what information needs they have. Further training and preparation in 'men's health' is recommended for all those working with men in cancer care.

RELEVANCE TO CLINICAL PRACTICE

Understanding how, when and in what circumstances men express their information needs will help healthcare professionals to develop strategies to meet these needs and other support needs of men with cancer.

The role of an outreach oncology nurse practitioner: a case study evaluation

Nurses have an extensive input into the care of cancer patients both in hospital and in the community and are central to the current movement to improve and streamline cancer services. Internationally there has been a move to employ highly skilled nurse practitioners in cancer care. This paper describes a single case study evaluating the role and work of an Oncology Nurse Practitioner (ONP). Multiple sources of data were used. Stage One involved collecting descriptive information about the post holder, her role and the types of patients cared for. Stage Two used a qualitative approach to explore how the post was established, its key features, its perceived advantages and disadvantages and the factors influencing its success. Findings show that all participants viewed the post positively and that such nurses can provide high-quality services in remote rural areas. The study found that to be successful the post holder needs appropriate personal attributes such as flexibility and communication skills and the ability to work independently as well as part of a team. The limitations of this study and the implications for the further development of nursing roles in oncology are discussed.

Attitudes to cancer of medical and surgical nurses in a district general hospital

The personal beliefs and attitudes of nurses can have serious implications for their practice. Yet there are a lack of studies on nurses' attitudes to cancer in the UK in general, and in Northern Ireland specifically. The need for such studies is further emphasized by the importance of nurses' role in the Cancer Units of district general hospitals, as proposed by the Calman-Hine Report (Department of Health 1995). The aim of this study was to assess the attitudes to cancer of medical and surgical nurses who care for cancer patients in one district general hospital in Northern Ireland. A questionnaire comprising the Cancer Attitude Scale (Corner 1993) was administered to 106 qualified nurses. The response rate was 68.9% (n=73). Responses to items on the Cancer Attitude Scale show that while generally these nurses held positive attitudes, a high proportion also held negative views about cancer. Of particular concern were their attitudes to the value of active treatments. The implications of these findings are discussed.