Illness perceptions and emotional well-being in men treated for localized prostate cancer☆
Introduction
Prostate cancer (PC) survivors comprise 42% of the five million male cancer survivors in the U.S. [1]. The growing number of long-term survivors and the physical and psychological sequelae of PC emphasize the importance of research on the factors that influence quality of life (QOL) outcomes during the posttreatment phase.
Radical prostatectomy (RP) and external beam radiation (EBR) are the most common treatment options for localized (Stage I or II) PC. Both can cause chronic adverse effects on sexual and urinary function [2], [3] that are greater than declines observed in the general older male population [4]. While the effects of treatment on urinary function may be time-limited [5], erectile dysfunction (ED) present at 1 year after treatment can be considered permanent for some men [2].
While concern about disease-specific problems tends to persist years after treatment [3], [4], research is more equivocal about whether general emotional well-being is impacted in the long-term [6], [7]. Treatment for PC may reduce the distress caused by diagnosis [2], [8]. Alternatively, survivorship has been described as a long-term process of responding to changes following both diagnosis and treatment [9]. As treatment side effects can be chronic [3], [10] and insidious (e.g., long-term microvessel and neural damage may cause sexual function to be affected much later after EBR) [11], cumulative experiences may continue to impact emotional well-being. Individual variance in general QOL further indicates that certain factors may place subsets of PC survivors at risk for poorer psychosocial outcomes.
Limited research in different cancer populations suggests that post-treatment emotional well-being may be influenced by cancer beliefs and expectations. Of note, the most common concerns of breast cancer patients have been shown to be pain, financial burden, and recurrence and/or death; these concerns have predicted greater emotional distress in the months after surgery [12]. While cancer recurrence is also a central concern among men with PC [13], most reports of QOL in PC have focused on the persistence of bother over treatment-related side effects [3], [4], [14]. Few, if any, studies have comprehensively explored how PC survivors perceive their overall illness experience.
Research based on the Self-Regulatory Model (SRM) indicates that one's cognitive representation of any health threat comprises a cluster of perceptions which affect behavioral and emotional responses to diagnosis and treatment [15]. These perceptions include: the label applied to the illness and the symptoms associated with it; perceived illness duration; beliefs about the causes of the illness; perceived consequences of the illness on one's personal life; and beliefs about the extent to which the illness can be controlled by oneself or one's treatment [16]. Numerous studies support these dimensions [17] and demonstrate that they are germane to different illnesses [18]. Little research, however, has tested this framework with post-treatment cancer patients.
Across disease groups, illness perceptions as conceptualized by the SRM have been linked to several QOL outcomes [19], [20], [21]. Generally, perceptions of controllability are positively related to adaptive outcomes and negatively related to psychological distress, while perceptions of negative consequences are related to poorer outcomes. Of note, only perceived controllability has been related to objective disease state [22].
Among PC survivors, perceptions about treatment-related side effects are important predictors of well-being [14], [23]. QOL is also influenced, however, by cancer concerns (e.g., financial burden) that are not limited to physical symptoms [12]. For instance, at 6 months post treatment, men who perceived that their illness was disruptive to significant others and imposed hardship on them were more likely to report poorer general QOL [24]. As indicated by the SRM, patients may develop an overarching cognitive representation of their illness that subsumes specific symptom concerns and that influences coping and QOL outcomes.
An assumption of the SRM is that cognitive and emotional responses to illness develop in parallel and interact with each other [25]. While the emotional constructs of this theory have generally received less research attention, the concept of parallel processing nevertheless provides a route through which illness perceptions may influence emotional well-being. Limited evidence suggests that if PC survivors are unable to adjust to new limitations following treatment, they may be at risk for greater perceived hardship [26]. A comprehensive approach to studying illness perceptions among men with PC may thus lead to a more global understanding of survivor concerns, facilitate identification of distorted cognitions that may influence emotional well-being, and provide mechanisms for reducing distress.
Prior work in other chronic illness populations suggests that disease factors may influence the relationship between illness perceptions and emotional well-being [27], [28]. For instance, among patients with severe renal disease, belief in personal control was related to greater depression in patients who had previously experienced a failed renal transplant, and to lower depression for those who had not [27]. In the context of PC, severe illness perceptions may therefore be more salient predictors of poor emotional well-being for men who are experiencing greater post-treatment sexual problems.
Men with elevated life stress also may be at particular risk for decrements in QOL following PC treatment. Although not well documented in PC, stress has been shown to exacerbate the relationship between perceived control and emotional well-being in cardiac patients [29]. Results emphasize the importance of including general life stress in models of illness perceptions and emotional well-being.
The current study explored whether illness perceptions were related to emotional well-being in posttreatment PC patients. Specifically, we hypothesized that the following illness perceptions would be associated with poorer emotional well-being: greater perceived negative consequences of PC, greater belief in personality and behavioral causes of PC, lower perceived personal and treatment control over PC, and lower perceived comprehension of one's condition. We also hypothesized that these relationships would be stronger for (1) men with greater sexual dysfunction and (2) men with greater life stress.
Section snippets
Participants
Participants were recent PC survivors who provided baseline (i.e., preintervention) data for a randomized controlled psychosocial intervention trial. Upon study entry, men were required to have undergone treatment (RP, EBR, or brachytherapy) for localized (i.e., Stage I or II) PC within the past 18 months.
To create a homogenous sample with regard to biobehavioral factors, participants were excluded if they were under age 50 years, were currently receiving hormone treatment, had a history of
Sample characteristics
Participants were an ethnically diverse group of 214 older men (mean age=64.9, S.D.=7.4) who underwent surgery (49.5%) or completed radiation treatment (50.5%) for localized PC within the past 18 months. See Table 1 for sample characteristics.
Covariates of emotional well-being
More years of education (r=.17, P<.02) and higher income (r=.12, P=.07) were both associated with greater EWB. Also, both non-Hispanic Whites and African Americans reported greater EWB than Hispanic men (F=8.35, P<.01; mean non-Hispanic White=21.58,
Discussion
The prevalence of PC and its treatment-related challenges collectively underscore the importance of identifying predictors of post-treatment QOL. Prior work across diverse chronic illness populations has shown that general QOL domains are influenced by illness perceptions [22]. Most studies of cancer perceptions have focused on peritreatment breast cancer patients [44], [45]. Growing research in PC, however, has emphasized the role of perceived bother over treatment-related side effects such as
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This study was supported by National Cancer Institute grants 1P50CA84944 and U01CA861.