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Prostate cancer; Psychological impact; Cancer diagnosis

Introduction

In the UK, prostate cancer is the most common cancer amongst men and the third most common cause of cancer death. The diagnosis of prostate cancer has a huge psychological impact to the patient and has been well described in the literature. However, the impact to the partners of these patients is less covered.[1,2] Couples often react to adversities as single emotional units, and therefore distressing news such as prostate cancer diagnosis can also negatively impact the emotional well-being of the partner.[3,4] Additionally, some studies have even shown that the partner may experience more distress than the patient.[5-7] Support in prostate cancer has predominantly been targeted to the patient’s psychological welfare and coping with symptoms of treatment. In contrast, partner support is severely lacking. The aim of this study is to assess the psychological impact of prostate cancer diagnosis to the partner/spouse and to gauge the demand for partner support services in North Wales.

Methods

Men with prostate cancer treated with laparoscopic radical prostatectomy were identified from our departmental cancer database between 1st June 2014 and 30th April 2021. Deceased patients were excluded as it was not possible to confirm marital status and locate corresponding addresses. Patients were posted an anonymous questionnaire to be completed by their partner or spouse. The mailing also contained a prepaid return envelope and a cover letter detailing the instructions for completion, including a one month timeframe for return. The covering letter also contained an email option to return competed questionnaires. Copies were sent in both English and Welsh. To our knowledge, no validated questionnaire exists for assessing the psychological distress of spouses of men with prostate cancer. Our questionnaire therefore consisted of two parts adapted from the Brief- COPE and selected questions from a Finnish national survey. [8-10] an additional question was included asking participants whether support for partners would be desired.

The original Brief-COPE questionnaire contains 28 items to measure effective and ineffective coping mechanisms to stressful events. Each coping style can be broadly categorised as avoidant coping (such as denial) or approach coping (such as taking direct action). [8,11] Higher avoidant coping has demonstrated increased longterm distress and negative outcomes. [5,11] For our questionnaire, we shortened the Brief-COPE to include 13 questions; this included 6 questions of avoidant coping, 5 on approach coping, 1 on religion, and 1 on humour. This action was taken to improve completion rate of the lengthier full version. [8] Free text space was also incorporated into 3 of the modified Brief-COPE questions to allow respondents to elaborate on their answer: for example, what activities they do to take their mind off things; who they were receiving emotional support from; and examples of actions they were doing to make the situation better.

Results

Response rate was 125 out of 218 (57.3%), with 8 (3.7%) questionnaires returned via email. 3 were excluded as they were completed by the patient rather than their partner, leaving 122 for analysis. One returned only the second page scanned by email. 92% of respondents were female, with a mean age of 67 (Table 1). 10 respondents did not complete demographic questions. Of the 122 respondents, 72 (61%) indicated they would be interested in psychological support for partners. The most common psychological reaction reported at time of diagnosis was concern about treatability of disease, with 82.8% of spouses answering yes. A significant proportion reported shock (55.7%), concern for the future (51.6%), and fear their partner would die (50%). Only 1 respondent reported feeling nothing (Table 2). Overall, approach coping methods were more common. The median approach coping score was 11 (±6 IQR) out of a maximum of 20, and 8 (±3 IQR) out of a maximum of 24 for avoidance coping. The most common coping strategy adapted was acceptance followed by self-distraction with work or activities, and emotional support from others. The least common coping methods were self-blame, humour use, and denial. Table 3 shows full breakdown of responses from the modified Brief-COPE questionnaire. 84 respondents provided free text answers in the modified Brief-COPE questionnaire. Some of the common activities mentioned for taking their mind off things were: house work, gardening, work, exercise, reading, sewing/knitting, art, reading, and volunteering. Sources of emotional support were mostly from friends and family with a few mentioning specialist nurses, such as Macmillan or uro-oncology cancer nurse specialists (CNS). Few provided free text responses to examples of action taken to improve the situation (21 respondents). The most common actions stated were providing support to the patient, open communication, and seeking information. Subgroup analysis was performed to compare responses between genders. Interest in psychological support was still significant across both genders. Among female respondents, 59/100 answered yes and for male participants, 6/9 (66.7%) answered yes. Median approach coping scores were 11 for both genders. Men (n=9) had a median avoidance score of 9, compared to 7 for the female cohort (n=103).

Table 1 Demographics

Table 2 Psychological reactions felt at time of diagnosis

Table 3 Responses to modified Brief-COPE

Discussion

Our main findings were that the diagnosis of prostate cancer affects the emotional wellbeing of the partner. Psychological support for them is scarce and there is a clear demand for such a service in North Wales across both genders.

As expected, receiving the diagnosis of prostate cancer has a high negative psychological impact on the partner. The diagnosis often comes as a shock, with initial concerns predominantly centred around treatment of the disease, which is concordant with findings in the wider literature [12]. Seeking out information from healthcare providers and other networks, was found to be an important coping strategy to help alleviate this distress, emphasized within the free text responses. Particular praise was given to the extra support provided by CNS teams, which highlights the need for support networks beyond clinical consultations with physicians.

Within our cohort, approach coping strategies were found to be more common with a high level of acceptance of disease status. However, a significant proportion of avoidant coping was still present. This has been demonstrated to be associated with higher levels of distress and worse quality of life, thus placing partners of men with prostate cancer at risk of ongoing emotional suffering [5,13].

From the responses to this questionnaire, it was also found that partners feel obliged to provide support as a coping method. This is also shown in other studies, where partners often assume a certain level of care giving roles to the patient [14]. However, the average age of these populations tends be higher, leading to an increased likelihood that partners may already be suffering with other health detriments themselves. Adding a care giver role to this can therefore negatively impact their own physical and psychological wellbeing.

The main limitation to this work is the retrospective nature of the data collection, which subjects the results to recall bias. Questionnaires were sent to patients who had received a diagnosis of prostate cancer across an approximate six year period. Such a time lapse could therefore affect recollection of levels of distress experienced at the time. Our cohort is also subject to selection bias as only patients who had undergone radical laparoscopic prostatectomy were contacted because they were included in our departmental database. As a result, all patients would have had organ confined disease suitable for surgery. It is possible that partners of these patients may have experienced less distress than those with advanced disease. Additionally, the health status of the partner was not assessed which may also impact levels of distress. The average age of respondents was 67 which also increases the likelihood that the partners may have personal health challenges themselves. Depending on their personal experience of this, levels of distress could be heightened or dampened. Despite these factors, however, there is still a clear psychological impact and a significant demand for support services to be offered. As it was not possible to confirm current marital status of patients, it is likely that this questionnaire may not have been applicable to a proportion of our population sample (for example due to being single or widowed). Therefore, we feel that the achieved response rate of 57% is an acceptable for this study.

Whilst it is clear that psychological support is needed, the format of this remains an area for further research. A variety of strategies have been described in the literature, including support groups for spouses with trained leaders. Providing information is a frequent focus, concordant with the demand demonstrated in our cohort, and has been suggested to reduce distress and improve coping.[15,16] Additionally, education on stress management, coping skills, and communication have also been shown to improve adaptive coping and outlook of spouses [16].

Conclusion

The diagnosis of prostate cancer has a clear negative psychological effect on the partners of these patients, with risk factors for long-term impact. There is a significant demand for psychological support for partners of men with prostate cancer in North Wales, which is currently unmet. Providing psychological support is important in order to help partners who are currently suffering in silence.

Contributorship

EC wrote the first draft of the manuscript. All authors reviewed and edited the manuscript and approved the final version

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