In this sample of prostate cancer patients within 18 months of diagnosis, and their partners, both patients and partners generally reported that patients had significant PC-related urinary, bowel, and sexual problems, at levels consistent with prior reports (Bremner, et al., 2007
; Eton & Lepore, 2002
). Patient-partner appraisals were strongly and positively correlated, similar to previous findings (Hagedoorn et al., 2008
). While there is a great range of levels of (dis)agreement among couples facing PC, most couples, in most appraisal domains, were concordant. The exception to this was sexual bother. (Dis)agreement scores for SB had the largest range and standard deviation of any appraisal domain. The mean patient-partner (dis)agreement was 13 points, with partners perceiving that patients experienced lower levels of sexual bother than the patients experienced in actuality. Such discrepancies are common; patients regularly report greater worry regarding their sexual dysfunction than partners report regarding patient sexual dysfunction (Couper et al., 1999).
The nature of (dis)agreement was assessed for patterns of minimization, concordance and maximization. Overall, patient-partner (dis)agreement was not significantly associated with many outcomes. Several significant curvilinear relationships emerged, suggesting that physical and mental HRQOL outcomes are related to (dis)agreement patterns in the domains of urinary and bowel function. Minimization and maximization were generally associated with negative outcomes; however, the effects were modest and dependent on the appraisal domain.
(Dis)agreements on urinary and bowel, versus sexual, problems were most strongly related to negative outcomes, as has been previously reported (Baider et al., 2003; Kornblith et al. 1994
). While both function and bother (dis)agreement scores were predictive of outcomes, (dis)agreement about bother appraisals appeared to be most predictive, at least for patients. Thus, outcomes were most negative when patients and partners differently perceived the degree of bother patients experienced, rather than when they differently perceived the actual levels of function.
When partners minimize urinary bother or disagree in either direction on bowel bother (i.e., minimization or maximization) patients experienced poorer physical HRQOL, findings similar to those of Riemsa, Taal, and Rasker (2000)
. This suggests that disagreement, regardless of the direction, may be maladaptive for the patient. Minimization may distress patients if they feel their partner does not accurately perceive their PC-related bother and thus is underappreciative of the negative aspects of their experience, while maximization may unnecessarily increase patient dependence on the partner due to the partners’ inflated perception of patient bother. Thus, either disagreement pattern may negatively influence HRQOL (Weinman, Heijmans & Figueiras, 2003
Partners who maximized patient problems in urinary function/bother and bowel function reported poorer physical or mental HRQOL. Maximization, or partner exaggeration of the disease appraisal, was the most maladaptive (dis)agreement pattern for partners. When a partner overstates the patient’s level of dysfunction and/or bother, the partner may become excessively worried, overprotective, and stressed, which could compromise their own HRQOL. Because it has been well established that partners experience psychological consequences from PC (Couper et al., 2006
), it is surprising that the majority of studies examining (dis)agreement have focused exclusively on patient outcomes. Because PC is a “relationship disease” (Gray et al., 1999
), it is equally important to assess factors that may negatively influence partner HRQOL.
Interestingly, the relatively large level of disagreement between patients and partners on sexual function and bother, which represent the most interactive of the three domains examined here, did not predict maladaptive adjustment in either member of the dyad. While this seems surprising, given that sexual problems are greatly distressing to patients, partner minimization in this case may reflect an acceptance that sexual problems are an unavoidable result of life-saving PC treatments (Korfage, deKoning, Habbema, Schröder & Essink-Bot, 2007
). In general, partners tend to placate patients who experience sexual dysfunction (Couper et al., 2006
). Thus the pattern of (dis)agreement on sexual problems found here, in which the partner views the problems as less serious than the patient, may not be maladaptive.
Overall, these findings suggest that (dis)agreement on urinary and bowel disease appraisals may predict maladaptive adjustment outcomes for both patients and partners and thus may be a clinically important point of intervention. Interestingly, in most cases (dis)agreement was associated with negative individual patient or partner outcomes, and not with dyadic adjustment. In this sample, most couples reported high-functioning relationships, perhaps reflecting a self-selection bias in which more well-adjusted couples were receptive to enrolling in the problem-solving clinical trial. Thus, limited variance may have restricted our ability to detect relationships between (dis)agreement and marital strength. The only significant finding was that minimization of bowel bother was associated with better marital strength. Bowel problems are of particular concern to patients with prostate cancer, and thus it is interesting that it is for this side effect that partner minimization of patient experience was associated with happier marriages. That patients may have experienced their partners’ minimization as reassuring is one possibility; however, this was an isolated finding, and overall there was little evidence of (dis)agreement being associated with marital strength in these relatively happy couples.
The present findings suggest that one way to identify patients and partners who are at risk for maladaptive HRQOL outcomes may be to determine the dyad’s level of agreement on PC-related function and bother. Psychoeducation and the use of well-established strategies for improving couples’ communication patterns may be helpful in resolving points of disagreement, or helping to promote better understanding of different perspectives on aspects of prostate cancer.
Limitations and Future Directions
Although this study contributes to the growing literature on couples’ adjustment to prostate cancer, it has several limitations. Recruitment of a larger and more diverse sample is needed. Despite our best efforts at recruitment, the sample was predominantly Caucasian and all couples were heterosexual, limiting generalizability. Also, although HRQOL levels reported by patients and partners were consistent with those reported in the existing literature on adjustment in PC, patients with poor HRQOL are likely underrepresented in the sample, thus limiting our ability to identify risk factors for maladaptive outcomes. As already noted, the preponderance of couples with strong marriages limits variance as well. Although a contribution of the study was to examine (dis)agreement on two types of appraisals (function and bother) across several important prostate cancer problem areas, this necessarily inflated family-wise error rate, and thus patterns of findings should be given greater emphasis than any individual result. Finally, all data were cross-sectional, precluding any conclusions about cause-effect relationships. Couples’ adjustment to prostate cancer must be followed over time in order to understand the relationship between concordance of appraisals and individual/couples outcomes.