|Home | About | Journals | Submit | Contact Us | Français|
To develop a better understanding of how men react to being diagnosed with prostate cancer and identify factors that influence these responses, we conducted an observational study to identify sociocultural predictors of men’s psychological reactions.
Participants were 70 African American and 124 white prostate cancer patients who completed a structured telephone interview that evaluated psychological reactions in terms of intrusive thoughts about cancer and attempts to avoid cancer-related thoughts and feelings. Perceptions of disease-specific stress, cultural beliefs and values, and social constraints were also assessed during the interview.
There were no racial differences in men’s reactions to being diagnosed with prostate cancer; however, greater perceptions of disease-specific stress, increasing levels of present temporal orientation, and more social constraints had significant positive effects on avoidant reactions. Greater perceptions of stress also had a significant positive effect on intrusive thoughts.
The results of this study highlight the need for individualized approaches to help men address their thoughts and feelings about being diagnosed with prostate cancer. These efforts should include strategies that help men to communicate more effectively with social support resources and address cultural beliefs and values related to temporal orientation.
Each year thousands of men are diagnosed with prostate cancer; this disease is the leading cause of cancer death among men in the US . Being diagnosed with a life threatening illness such as cancer is a significant stressor; men who were within one year of being diagnosed with prostate cancer reported significantly greater levels of cancer-specific distress compared to survivors who were two to six years post-diagnosis . Previous research has shown that men’s reactions to being diagnosed with prostate cancer are influenced by sociodemographic factors such as race and education. For example, African American men reported lower quality of life than white men at diagnosis and required a longer time to return to baseline levels of functioning following treatment . Similarly, Eton and colleagues  found that after controlling for treatment type, co-morbidities, and age, white men reported significantly higher levels of urinary, bowel, and general physical functioning than African American men. Mental health functioning was also lower among prostate cancer survivors with fewer years of formal education . However, sociodemographic factors may not be the only determinants of reactions to prostate cancer diagnosis; conceptual models of cancer survivorship suggest that psychological factors such as cognitive appraisals (e.g., perceptions of stress) are important to outcomes following diagnosis . Despite this, empirical data are not available on whether or not these factors have a significant effect on reactions to being diagnosed with prostate cancer.
In addition to psychological factors, cultural beliefs and values are important to men’s reactions to being diagnosed with prostate cancer. Culture is defined as a set of shared and socially transmitted ideas about the world that are passed down from generation to generation . The construct of world view is used within the concept of culture to describe beliefs and values regarding the nature of time (e.g., present, future), social relationships, and the presence or absence of natural and supernatural entities that are shared among racial and ethnic group members . Previous research has shown that spiritual beliefs are significant predictors of health-related quality of life in African American and Hispanic cancer patients . Other work has shown that religious activity is associated with lower levels of depressive symptoms among elderly African Americans diagnosed with cancer ; greater spirituality is positively associated with quality of life in men following prostate cancer diagnosis . While religious and spiritual beliefs are important to quality of life following diagnosis, it is likely that other cultural factors influence men’s reactions to being diagnosed. Temporal orientation, or attitudes about specific domains of time, is one of the primary contexts through which individuals understand and give meaning to their experiences . Previous research has shown that having a future temporal orientation is associated with lower distress . However, it is not known if cultural factors such as temporal orientation are associated with reactions to being diagnosed with prostate cancer. Identifying factors that are related to men’s reactions is important to detect those who may be at a greater risk for poorer functioning.
The purpose of the present study was to describe reactions to being diagnosed with prostate cancer among African American and white men who were newly diagnosed and to identify sociodemographic, clinical, psychological, and cultural factors having significant independent associations with these responses. We conceptualized reactions to being diagnosed with prostate cancer in terms of cancer-specific distress because intrusive thoughts and attempts to avoid cancer-related thoughts and feelings are indicators of the extent to which men have processed their experiences with being diagnosed . Based on previous research , we predicted that African American men would report more negative reactions (e.g., greater distress) compared to white men. Since men who are newly diagnosed are likely to be actively processing their clinical experiences, we also hypothesized that cognitive appraisals would have a significant effect on men’s reactions such that those with greater perceptions of stress surrounding their diagnosis (e.g., concerns about recurrence, treatment decision-making) would report more intrusion and avoidance. We also examined the association between cancer-specific distress and religiosity and temporal orientation to develop a better understanding of how cultural beliefs and values are related to men’s reactions. Finally, we examined the relationship between cancer distress and social constraints based on prior research, which has shown that patients who perceived social constraints in terms of talking to their family members and friends reported less effective processing of their diagnosis .
This study was conducted at the University of Pennsylvania and was approved by the Institutional Review Board. Subjects were non-Hispanic African American and white men who were diagnosed with a biopsy confirmed case of prostate cancer during the past two to five months. As in previous research with newly diagnosed cancer patients , the study enrollment rate was 46% among all eligible men who were referred to the study. Only men who completed the baseline telephone interview and had complete clinical data on PSA, stage, and Gleason score at diagnosis were included in the analysis; thus, 194 men were included in the present study.
Eligible subjects were recruited into the study at urology and radiation oncology practices located in the Philadelphia, PA metropolitan area. Recruitment sites (n=13) included community-based urology practices and the urology practices at the University of Pennsylvania Health System (UPHS). Men were recruited into the study by clinic and research staff during a follow-up appointment after they had been diagnosed with prostate cancer (e.g., following disclosure of their biopsy result). It should be noted that some men who were recruited at the UPHS were identified at the radical prostatectomy pre-surgery class and some were being seen for a second opinion and/or treatment. Regardless of recruitment site, eligible men received a verbal and written description of the study and the procedures involved in participation and all men provided written informed consent for study enrollment. At about one to four weeks following provision of informed consent and study enrollment, men were contacted to complete a 30-minute, structured baseline telephone interview that obtained sociodemographics and treatment status and assessed cultural factors, perceptions of social constraints, and cancer-specific distress. The baseline was completed by trained research assistants at the University of Pennsylvania. Men were also contacted for follow-up telephone interviews at 3-, 6-, and 12-months after the baseline. The present study focuses on data collected during the baseline telephone interview because we were specifically interested in men’s reactions to being diagnosed, which represents an important phase in the survivorship trajectory .
Race, age, marital status, education, income, and employment status were obtained during the baseline telephone interview. With the exception of age, these variables were re-coded into dichotomous variables based on the distribution of responses.
PSA, Gleason score, and TNM stage at diagnosis were obtained from medical records at enrollment. Gleason score and stage were re-coded into dichotomous variables (e.g., stage T1 versus T2/T3) based on the distribution of responses. Treatment status was obtained by self-report during the baseline telephone interview by items that asked men if they had received surgical, radiation, or expectant (e.g., watchful waiting) treatment. Men who had completed surgical treatment or had initiated radiation or other types of therapy (e.g., cryosurgery) were categorized as having initiated or completed treatment. Men who had not initiated any treatment were categorized as being pending for treatment.
We adapted items from previous research  to evaluate cognitive appraisals about being diagnosed with prostate cancer. Specifically, men were asked how much stress they had experienced in the following areas: (1) their prostate cancer diagnosis, (2) making decisions about prostate cancer treatment, (3) side effects of prostate cancer treatment, (4) communicating with family members about their diagnosis and treatment, and (5) dealing with the impact of their diagnosis and treatment on family members (1=not at all stressful, 2=a little stressful, 3=moderately stressful, and 4=very stressful). Men were also asked how confident (1=not at all confident, 2=a little confident, 3=moderately confident, 4=very confident) they were that they could deal with these issues (e.g., cope with their risk of developing prostate cancer, manage treatment-related side effects, communicate effectively with family members). Both scales had good internal consistency (Cronbach’s alpha=0.84 and 0.76 for perceptions of stress and confidence, respectively).
We used the religiosity, collectivism, and temporal orientation scales developed by Lukwago and colleagues  to evaluate the extent to which men endorsed religious values (e.g., when I am ill I pray for healing; I have a personal relationship with God) and present (e.g., as long as I feel good now, I do not worry about having health problems) and future temporal orientation (e.g., I have a plan for what I want to do in the next five years of my life). These scales had acceptable internal consistency in our sample (Cronbach’s alpha ranged from 0.66 to 0.78). Higher scores indicated greater levels of each cultural factor.
We used the modified 5-item version of the Social Constraints Scale  to assess the extent to which men perceived that their relationships with family members and/or friends were constrained in terms of talking about prostate cancer (1=never to 4=always). We also included two items from the original 15-item version of the constraints scale  to evaluate the extent to which men felt that family members and friends tried to change the subject when they talked about their prostate cancer and how often these individuals encouraged them not to worry about their health. This instrument had good internal consistency in our sample (Cronbach’s alpha=0.74).
We used the Impact of Event Scale (IES)  to evaluate cancer-specific distress. The IES is a 15-item Likert-style instrument that measures the frequency of intrusive thoughts about cancer and attempts to avoid cancer-related thoughts and feelings. The IES has been used in previous studies on the extent to which men have processed their experience with diagnosis [14,15]. The avoidance and intrusion scales had excellent internal consistency (Cronbach’s alpha=0.82 and 0.87, respectively) in this sample.
First, descriptive statistics were generated to characterize subjects in terms of sociodemographics, clinical characteristics, and reactions to being diagnosed with prostate cancer. Next, we conducted bivariate analyses using a combination of correlation analyses and non-parametric analysis of variance using the Kruskal-Wallis test to evaluate the relationship between intrusion and avoidance and sociodemographic, clinical, psychological, cultural, and social constraint variables and to identify factors for inclusion in the regression analysis. We used non-parametric analyses because scores for the IES were not normally distributed. Since adjusting for covariates in the model lead to more normally distributed residuals, we used regression analysis to identify factors having significant independent associations with intrusion and avoidance. Separate regression models were generated for intrusion and avoidance. Because of the potential for clustering within recruitment sites, we used a fixed effects model to identify factors having significant independent associations with men’s reactions to being diagnosed with prostate cancer. Recruitment site was treated as a fixed effect to control for clustering. Variables that had a bivariate association of p<0.10 with each distress variable were included in the model for that outcome.
The sample consisted of 70 non-Hispanic African American and 124 white men. Most men were married (79%), had some college education or were college graduates (63%), and had an annual household income greater than $50,000 (58%). About half of the sample (52%) was not employed (e.g., retired) and the mean (SD) age of participants was 63.6 (8.0). In terms of clinical factors, most men were diagnosed with stage T1 disease (68%) and had a Gleason score that was less than or equal to six (57%). The mean (SD) PSA was 6.4 (4.9) and 57% of men had initiated or completed treatment. Of these men, 71% had a radical prostatectomy, 14% had radiation, 8.2% had hormonal therapy, 5% had multiple types of treatment, and 1.8% had brachytherapy. As shown in Table 1, with the exception of age and employment status, there were significant racial differences in sociodemographic factors. African American and white men also differed with respect to PSA and treatment status; however, there were no racial differences in terms of stage or grade.
As shown in Table 2, men reported moderate levels of intrusive thoughts about cancer and attempts to avoid cancer-related thoughts and feelings. Further, 30% of men had distress scores that would warrant clinical intervention (e.g., total IES score ≥ 26) (data not shown). Table 3 shows the associations between cancer-related distress and sociodemographic factors and clinical characteristics. Of the sociodemographic factors, only age and marital status had significant associations with intrusion and avoidance, respectively. Men who were younger reported significantly more intrusive thoughts about their diagnosis, whereas men who were not married reported greater attempts to avoid cancer-related thoughts and feelings compared to those who were married. None of the clinical factors were associated significantly with intrusion or avoidance; however, cognitive appraisals had significant positive relationship with both outcomes (see Table 4). Men with greater perceptions of stress about their prostate cancer diagnosis reported more intrusive thoughts and attempts to avoid cancer-related thoughts and feelings whereas men with greater perceived confidence reported lower distress. With respect to cultural factors, only present temporal orientation was associated significantly with avoidance; men with greater present temporal orientation reported more attempts to avoid cancer-related thoughts and feelings. Men with greater social constraints also reported more intrusive thoughts and avoidance.
Table 5 shows the results of the multivariate models of intrusion and avoidance. Only perceptions of stress surrounding prostate cancer diagnosis had a significant main effect on intrusive thoughts about cancer. Men who perceived greater stress reported more intrusive thoughts about prostate cancer. Perceptions of stress had a similar effect on attempts to avoid cancer-related thoughts and feelings. Additionally, present temporal orientation and social constraints had significant main effects on avoidance. Increasing levels of present temporal orientation and more social constraints were associated with greater avoidance. There was also a non-significant trend for men who were not married to report greater attempts to avoid cancer-related thoughts and feelings compared to those who were married.
Since perceptions of stress and confidence and social constraints had significant associations with intrusion and avoidance in the bivariate analyses, we conducted additional analyses to determine if there were significant interactions between these variables. In these analyses, we re-coded constraints into low and high levels using the median split. These interactions were not significant in the model for avoidance (coefficient for constraints by perceptions of stress=0.19, SE=0.24, p=0.44 and coefficient for constraints by perceptions of confidence=−0.14, SE=0.15, p=0.36). The interaction between social constraints and perceived confidence was also not significant in the model for intrusion (coefficient=−0.20, SE=0.14p=0.16); however, the interaction between social constraints and perceived stress was significant (coefficient=0.58, SE=0.26, p=0.03) with higher levels of constraints exacerbating the negative effects of perceived stress on intrusion (coefficient=1.70, SE=0.20, p<0.0001) compared to the effects of perceived stress on intrusion at lower levels of constraints (coefficient=1.12, SE=0.19, p<0.0001).
The purpose of this study was to describe reactions to being diagnosed with prostate cancer and to identify predictors of these reactions among men who were newly diagnosed. Overall, men reported moderate levels of distress and a substantial minority of participants had distress levels that were clinically elevated. Intrusive thoughts are active efforts to make sense of one’s cancer diagnosis and indicate limited processing of one’s experience , whereas avoidance represents active efforts to not process being diagnosed with this disease. Previous research has shown that men with prostate cancer who have strong masculine gender scripts that include self-reliance and emotional control were most likely to report negative mental health functioning . Men’s needs for self-reliance and emotional control could possibly explain why avoidance was common among participants in this study. Other research has shown that cancer survivors are likely to progress through a series of stages as they move from diagnosis, treatment, and recovery; men are likely to be in the acute phase shortly after diagnosis and may be dealing with issues related to their own mortality, treatment decisions, and the impact of their diagnosis on family members [24, 25]. Our findings demonstrate that even though men are making active efforts to avoid their thoughts and feelings about cancer, they are also still trying to make sense of their diagnosis.
We found that men who had greater constraints in their relationships with family members and friends were most likely to avoid their thoughts and feelings about prostate cancer. This finding is similar to the results reported by Lepore and Helgeson  who found that prostate cancer patients who were socially constrained reported greater intrusion and avoidance. Although not statistically significant, avoidance was greater among men who were not married compared to those who were married in the present study. Spouses are an important source of support to men who are diagnosed with prostate cancer and they may play an important role during diagnosis by asking questions during consultations and obtaining other medical information . Our results underscore the importance of having family and friends who allow men to express their concerns freely.
In this study, increasing levels of present temporal orientation were associated with greater attempts to avoid cancer-related thoughts and feelings. Present temporal orientation reflects the extent to which individuals focus on the here and now rather than think about the past or things that may happen in the future . Men face a number of economic and physical stressors that require their immediate attention following diagnosis and treatment; it could be that men with higher levels of present temporal orientation are most likely to focus on these issues and other practical, everyday things as a way to avoid confronting their thoughts and feelings about being diagnosed with prostate cancer. This would explain why greater perceptions of stress about treatment side effects and other disease-specific issues also had a significant positive association with avoidance in the present study. However, other research has shown that some individuals who have a present temporal orientation may be unwilling to talk about stressors and they may also avoid coping with stressful situations because of a tendency to believe that these events cannot be modified . It is possible that these beliefs lead to avoidance of one’s thoughts and feelings about being diagnosed with prostate cancer.
In contrast to previous research , we did not find significant racial differences in reactions to being diagnosed with prostate cancer. In this study, we evaluated reactions to diagnosis in terms of attempts to avoid cancer-related thoughts and feelings and the frequency of intrusive thoughts, whereas other studies assessed the impact of diagnosis and treatment on men’s general emotional, physical, and social functioning . It could be that African American and white men differ in terms of the impact that prostate cancer diagnosis and treatment has on their overall functioning, but not in terms of their initial reactions. This may also explain why religiosity was not associated significantly with cancer-specific distress; religious activity and spirituality were associated with depressive symptoms and general health related quality of life in other studies with cancer survivors [10,11]. Another possible explanation may be that we evaluated men’s reactions shortly after they were diagnosed. We focused on this time frame because we were specifically interested in exploring this phase of the cancer survivorship trajectory. It may be that religious and spiritual factors, and concerns for one’s future well-being or future temporal orientation, become more salient as men face other types of stressors and progress through different phases of survivorship. For example, religion and spirituality may be a mechanism through which cancer survivors cope with and accept their diagnosis , which are processes that are in contrast with attempts to avoid cancer-related thoughts and feelings. Future studies are needed to determine if racial differences in reactions to being diagnosed with prostate cancer emerge as men progress through different phases. It will also be important to determine if values and preferences change as men become longer-term survivors and experience different types of stressors during these phases.
In considering the results of the present study, it is important to note some limitations that include the modest rates of study enrollment and racial differences in participation. However, our enrollment rates are similar to those reported in other samples of cancer patients  and racial differences in enrollment in survivorship research are common . It is noteworthy that African American men made up about 40% of our sample despite the challenges that are associated with recruiting this population to participate in prostate cancer research [30, 31]. While the observational nature of our study is an additional limitation that prevents us from determining causality with respect to reactions to being diagnosed with prostate cancer, sociodemographic and cultural beliefs and values are established before men are diagnosed with prostate cancer. For this reason, it is reasonable to conceptualize these factors antecedents to men’s reactions.
Despite these potential limitations, our results have several important implications for enhancing survivorship among men who are diagnosed with prostate cancer. Although the majority of men did not have scores for intrusion and avoidance that were suggestive of the need for intensive clinical intervention, support services may still be beneficial and needed  since not completely processing one’s diagnosis may lead to poor mental health functioning . Previous efforts to address these needs have focused on improving communication with spouses, enhancing strategies for coping with stress and dealing with uncertainty, and managing treatment-related symptoms among patients and their spouses [33, 34]. Psychoeducational approaches that provide information about prostate cancer along with discussions about side effects, nutrition, and stress and coping in group settings have also been developed and evaluated with mixed results [35, 36]. Our findings suggest that some men may be especially reluctant to discuss their reactions to being diagnosed with prostate cancer in group settings; thus, individualized approaches may be needed in addition to group programs and those that provide support to patient and spouse dyads. For example, helping men to identify aspects of their prostate cancer diagnosis and treatment that are particularly stressful and pinpoint specific stressors that are changeable and unchangeable during individuals sessions may help them to process their experiences and identify coping strategies that are likely to be effective at managing disease-related stressors. As part of these approaches, it may be particularly useful to address cultural beliefs and values that are likely to influence how men prioritize coping with cancer-specific stressors as well as incorporate strategies that help men to be more effective at obtaining social support. For example, training in how to communicate effectively with relatives and friends and to identify the most effective resources for emotional, informational, and tangible support may address the needs of men with constrained relationships. Similar strategies have been used to address psychological concerns among breast cancer survivors ; future studies should evaluate these approaches in prostate cancer survivors.
This research was supported by National Cancer Institute grants #P50CA105641-010004 and R01CA100254. We would like to acknowledge Aliya Collier for assistance with data management and George Moody for assistance with data collection. We would also like to thank Brandon Mahler, BA, S. Bruce Malkowicz, MD, David Vaughn, MD, and David Lee, MD for assistance with subject recruitment. We are very appreciative to all of the men who participated in this study.