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. Author manuscript; available in PMC: 2018 Jul 11.
Published in final edited form as: J Behav Med. 2014 Sep 19;38(2):214–223. doi: 10.1007/s10865-014-9594-1

The Importance of Perceived Stress Management Skills for Patients with Prostate Cancer in Active Surveillance

Betina Yanez 1, Natalie Bustillo 2, Michael Antoni 2, Suzanne Lechner 2, Jason Dahn 3, Bruce Kava 4, Frank Penedo 1
PMCID: PMC6040892  NIHMSID: NIHMS629665  PMID: 25234859

Abstract

Little is known about whether and how stress management skills may improve adjustment for men diagnosed with prostate cancer who opt for active surveillance. This study examined whether two types of perceived stress management skills (PSMS), specifically the ability to relax and confidence in coping, moderated the relationship between prostate cancer (PC) concerns and psychological distress. Participants were 71 ethnically diverse men in active surveillance. Coping confidence moderated the relationship between PC concerns and intrusive thoughts (p< .01). At low levels of coping confidence, PC concerns was positively related to intrusive thoughts, β= .95, p< .001, but not when coping confidence was high, β= .19, p>.05. Coping confidence also moderated the relationship between PC treatment concerns (a subscale of PC concerns) and intrusive thoughts. At low levels of coping confidence, PC treatment concerns was positively associated with intrusive thoughts, β=.73, p<.001, but not when coping confidence was high, β= .20, p> .05. Findings underscore the importance of interventions aimed at improving coping in men undergoing active surveillance.

Keywords: oncology, distress, stress management, active surveillance, prostate cancer

Introduction

Prostate cancer (PC) is the second most common non-skin cancer in men worldwide ("Global Cancer Facts & Figures - 2nd Edition," 2011). Despite being the second leading cause of cancer-related death among American men and the third leading cause of cancer-related death among men in developed countries ("Global Cancer Facts & Figures - 2nd Edition," 2011), the majority of men diagnosed with PC have low-risk disease where immediate active treatment is unnecessary and could result in substantial decrements in quality of life ("Prostate cancer: Guideline for the management of clinically localized prostate cancer,"; 2007). Active surveillance is a type of clinical management recommended for men with low-risk PC that involves monitoring disease status via routine prostate specific antigen (PSA) testing and digital rectal exams (DREs) while delaying curative treatment (e.g., surgery, radiation) and treatment-related side effects such as urinary incontinence and erectile dysfunction ("Prostate cancer: Guideline for the management of clinically localized prostate cancer," 2007; Schroder et al., 2009; Soloway et al., 2008; “Treatment choices for men with early-stage prostate cancer (Publication No. 05-4659),”).

Not all men diagnosed with low-risk PC elect to undergo active surveillance. Results from the CaPSURE study revealed that over 90% of men that met criteria for low-risk PC elected treatment rather than active surveillance (Barocas, Cowan, Smith, & Carroll, 2008; Lubeck et al., 1996). Additionally, research findings indicate that men who have elected active treatment report greater treatment satisfaction compared to those who chose active surveillance (Hoffman, Hunt, Gilliland, Stephenson, & Potosky, 2003). One of the reasons that men might not elect active surveillance is due to psychological barriers such as anxiety, uncertainty, distress associated with living with an active cancer, and fear of possible disease progression (Pickles, Ruether, Weir, Carlson, & Jakulj, 2007; Roos, 2003).

Psychological Distress

Individuals diagnosed and treated for cancer experience varying levels of psychological distress. Among the most commonly diagnosed cancers, the prevalence of clinically significant distress is approximately 35% (Zabora, BrintzenhofeSzoc, Curbow, Hooker, & Piantadosi, 2001). Elevated anxiety during PC screening and PSA monitoring is well documented in the literature (Dale, Bilir, Han, & Meltzer, 2005; Roth, Weinberger, & Nelson, 2008) suggesting that men undergoing active surveillance may not experience continuous elevated levels of anxiety; instead, anxiety may rise during PSA testing and upon notification of rising PSA levels (Kunkel, Bakker, Myers, Oyesanmi, & Gomella, 2000). Anxiety may play a central role in the extent to which men choose active treatment. Some work has documented that at low levels of anxiety and depression, the number of men who received unnecessary treatment was minimal (2%) (van den Bergh et al., 2010). Therefore, there is a need to examine the factors that contribute to distress and anxiety when undergoing active surveillance (Latini et al., 2007; Patel et al., 2004). A study consisting of in-depth interviews among men diagnosed with localized cancer revealed that 19 out of the 21 men did not want active surveillance. Anxiety and fear of the cancer spreading, family persuasion to seek treatment, lack of knowledge about active surveillance, and feeling young were reasons men provided for preferring treatment to active surveillance (Xu, Neale, Dailey, Eggly, & Schwartz, 2012). Another study of participants diagnosed with localized prostate cancer interviewed men following their first consultation with a urologist and revealed that fear and uncertainty were major themes reported by men who decided to seek treatment instead of undergo active surveillance (Denberg, Melhado, & Steiner, 2006).

PC Psychosocial Concerns

The diagnosis of a chronic illness, such as cancer, can lead to illness perceptions that may impact emotional well-being (Leventhal, Meyer, & Nerenz, 1980). Among men treated for PC who reported high levels of stress, lower perceived negative consequences of PC were associated with greater emotional well-being (Traeger et al., 2013). Moreover, negative illness perceptions about the severity and consequences of disease are associated with poorer recovery, independent of the initial medical prognosis in other chronic disease populations (Leventhal et al., 1980; Petrie & Weinman, 2006). However, to date no study has examined the relationship between PC-specific concerns and psychological distress in men undergoing active surveillance for PC.

Perceived Stress Management Skills (PSMS)

The ability to manage stress may be a valuable skill for men undergoing active surveillance as those with less anxiety may be able to make more balanced decisions about extending the active surveillance period until active treatment is medically indicated, if ever medically indicated. The positive effects of stress management interventions on quality of life are well documented in men with localized PC (Penedo et al., 2006) and in other cancer patients, greater PSMS may buffer the effects of stress by lowering levels of anxiety and depression and improving the quality of life prior to initiating treatment (Faul, Jim, Williams, Loftus, & Jacobsen, 2010). Perceived stress management skills consist of the ability to relax at will, recognize stress-inducing situations and physical tension, being assertive about needs, and coping confidence. Specific to cancer-related distress, some types of PSMS may be more relevant to reductions in distress than others. Previous research has indicated that the ability to relax, one type of PSMS, facilitated a reduction in intrusive thoughts among women treated for breast cancer (Antoni et al., 2006). Another type of PSMS that might be especially relevant in the context of distress is coping confidence, as individuals with a high sense of coping confidence may be more likely effectively manage cancer-related distress relative to individuals low in coping confidence.

Present Study

The current study examined associations between PC concerns, two types of PSMS and distress in men on active surveillance for PC. Specifically we tested whether confidence in coping and the ability to relax moderated the relationship between PC concerns (e.g., feeling less masculine, becoming more distant from one’s family, feeling physically damaged from the disease, inability to do things one would like to do) and cancer-specific psychological distress (i.e., hyperarousal, intrusive thoughts, and avoidance) among men who had been diagnosed with PC within the past two years and were undergoing active surveillance. We hypothesized that for men with less PSMS, high PC concerns would be associated with greater distress.

Method

Participants

All procedures were approved by the Institutional Review Board (IRB) and were in full accordance with the Health Information Portability and Accountability Act (HIPAA) guidelines. Participants were recruited as part of a larger study, funded by the National Institute of Health (NIH), examining the role of ethnicity on disease-specific and general quality of life in men newly diagnosed with PC. Inclusion criteria for the larger study were that participants: (1) have a PC diagnosis; (2) be ≥ 21 years of age; (3) not have received any type of active treatment for PC prior to the assessment visit; (4) have a ≥ sixth grade reading level; and (5) ability to speak and read in English or Spanish. Exclusion criteria were: (1) a history of cancer other than skin cancer; (2) active psychiatric disorders (e.g., dementia, psychotic disorder, panic disorder, and alcohol/substance dependence disorder), symptoms of psychosis, active suicidal ideation; (3) severe cognitive impairments as determined by the Mini Mental State Exam (MMSE [(Folstein, Folstein, & McHugh, 1975)]). Out of 897 men that were initially screened for the study and 445 were eligible. Out of the 452 who were eligible, 147 were eligible but refused to participate, leaving a sample of 305 men. Of the 305 eligible men, 32 withdrew or dropped from the study after consent leaving a total sample size of 273 men. Of the 273 men, 71 were confirmed to be eligible for the current study by medical chart review and were therefore included in the current sample. Eligibility criteria for undergoing active surveillance included: ≤ 80 years of age; PSA ≤ 15 nanograms per milliliter of blood (ng/mL) at diagnosis; Gleason score ≤ 6 with no pattern 4 or 5; no more than two positive cores out of total number of cores taken; no more than 50% tumor in each positive core; and clinical stage T1 to T2a (Soloway et al., 2008).

Procedure

Participants for this cross-sectional study were recruited from various urology clinics in South Florida: University of Miami Sylvester Comprehensive Cancer Center, Jackson Memorial Hospital, and Miami Veterans Affairs Medical Center between 2007 and 2011. Participants were directly referred by their urologist. During the full assessment visit, potential participants signed the IRB-approved informed consent form. Prior to the psychosocial interview, the Mini-Mental State Examination was administered to assess for cognitive impairment (Folstein et al., 1975). Participants that scored a 22 or below were only excluded if they were not oriented to person, place, and time and were unable to comprehend the study questionnaires. A score of 19 or below was a definite cut-off value for exclusion. A trained bilingual research assistant conducted the psychosocial assessments. Participants received $50.00 for the assessment. All assessments were provided in the language of the participant’s preference. All measures were translated by an IRB- approved translation company, which conducted forward and backward translations. Based on previous experience of bilingual staff working with the Hispanic population, translated measures were reviewed and final edits were made to address Hispanic word use variability.

Measures

Demographic and clinical characteristics

Variables assessed were age, ethnicity, marital/relationship status, educational level, annual household income, and health insurance coverage within the past 6 months. PSA level within 6 months of the assessment and time since diagnosis were obtained through review of patients’ medical records. Medical comorbidity was assessed using the Charlson Comorbidities Index, a self-report measure consisting of 13 medical conditions that yields a weighted index that takes into account the number and severity of medical conditions (Charlson, Pompei, Ales, & MacKenzie, 1987).

PC Knowledge Scale

PC knowledge was used as a control measure in all analyses and was assessed using the 27-item PC Knowledge Scale. The measure was comprised of the 12-item PC Knowledge Scale developed by Wilkinson et al. (Wilkinson, List, Sinner, Dai, & Chodak, 2003) and an additional 15 items based on information provided by the American Cancer Society (e.g., “PC is the most common cancer, excluding skin cancer, in men living in the U.S.” and “A Gleason score indicates how large a PC tumor is”). Response choices were “True” “False” or “Don’t Know.” Internal consistency of the English and Spanish versions combined was adequate (i.e., Cronbach’s alpha= .78) in contrast to the Spanish version alone (i.e., Cronbach’s alpha= .50). All correct responses received one point. “Don’t Know” and incorrect responses received a zero. Higher scores on this scale indicate more knowledge.

PSMS

The Measure of Current Status (MOCS) Scale A was used to measure participants’ PSMS (Carver). The MOCS-Scale A is a 13-item self-report scale that includes four subscales: 1) Relaxation, 2) Awareness of Tension, 3) Assertiveness, 4) Coping Confidence. For the purposes of the current study, only the ability to relax (2 items) and coping confidence (5 items) subscales were analyzed. Participants were asked to indicate the degree of confidence they had in doing each of the items on a 5-point scale ranging from “I cannot do this at all” to “I can do this extremely well”. Sample items in this measure included “I am able to use mental imagery to reduce any tension I experience,” “I am confident about being able to choose the best coping responses for hard situations” and “Whenever I get negative, I re-examine my thoughts to gain a new perspective.” The internal reliabilities for the MOCS-Scale A were good (Cronbach’s α = .80 and .81 in English and Spanish for relaxation and Cronbach’s α = .84 and .82 in English and Spanish for coping confidence). Higher scores on both subscales indicate greater perceived stress management skills.

PC Concerns

The Profile of Concerns about PC (PCPC), adapted from the Profile of Concerns about Breast Cancer (Spencer et al., 1999), was used to assess PC-related psychosocial concerns. The PCPC is a 25-item self-report measure designed to assess the concerns men may have when faced with a PC diagnosis. The domains tapped by this measure encompass sexual functioning, social well-being, and existential concerns. Participants were asked to use a 5-point scale ranging from “Not at all concerned” to “Very concerned” to describe how concerned they were about each listed issue. Higher scores on the scale indicate greater concerns. The internal reliability for the PCPC was adequate when testing English and Spanish versions combined (α= .92) as well the Spanish version alone (α= .92).

A dimension reduction analysis was used to determine whether there is a single dimension or multiple dimensions underlying the 25 PCPC items using baseline data from a larger sample of participants (N= 166) in the parent study. Principal Components Analysis (PCA) was used to determine the number of components underlying the measured variables (Green & Salkind, 2008). The components were extracted in order from greatest amount of variability to least amount of variability among the items. All components that had eigenvalues greater than “1” were retained. A total of five components were extracted, accounting for approximately 69% of the variance. An oblique rotation method was used in order to allow correlations among components.

To ensure maximum interpretability, the analysis procedures were repeated while excluding items with multiple loadings to produce a final model where each item loaded onto only one of the components. Only items with a loading exceeding .30 were retained. The final model resulted in the extraction of four components, accounting for approximately 70% of the variance, where each item loaded exclusively onto one of four components. The items within each component were examined to determine whether they made conceptual sense to load together. The final analyses omitted four items from the original PCPC scale.

Component 1 (Treatment Concerns) tapped into issues regarding potential urinary and sexual dysfunction, as well as a sense of compromised masculinity (e.g., “That the treatment makes you less responsive sexually” and “That the treatment will make you feel less masculine”). Component 2 (Social Rejection Concerns) was comprised of items related to possible isolation from family and friends (e.g., “That your friends will withdraw from you”). Component 3 (Life and Premature Closure Concerns) included items associated with fear of premature death, recurrence, and the inability to do the things one would like to do (“That you won’t be able to go to places you want to go or do things you want to do”). Component 4 (Financial Concerns) was made up of two items regarding job-related concerns (e.g., “That you won’t be given the raises you deserve because of your illness”). The total PCPC and its subscales identified via PCA were used in the present study. See supplementary online appendix for PCPC and component loadings.

Cancer-Related Psychological Distress

Level of cancer-related psychological distress was measured by using the Impact of Event Scale- Revised (IES-R), a 22-item self-report measure that assesses distress caused by traumatic events (Weiss & Marmar, 1997). Participants were asked to rate their level of distress for each item (with respect to their PC) during the past seven days using a 5-point scale ranging from “Not at all” to “Extremely”. The IES-R is comprised of three subscales: Intrusion, Avoidance, and Hyperarousal. The measure also yields a total score that ranges from 0 to 88, where a higher score indicates greater distress. Sample items included: “Any reminder brought feelings about it” (Intrusion), “I stayed away from reminders about it” (Avoidance), and “I was jumpy and easily startled” (Hyperarousal). The current study used the composite and subscale scores of the IES-R as measures of psychological distress. The IES-R total score demonstrated adequate internal consistency for the English and Spanish versions combined (α = .92). Reliability coefficients for the Spanish versions ranged from .69 for the Hyperarousal Scale to .88 for the Avoidance Scale.

Statistical Analyses

Dependent variables included in the study were tested for non-normality. Descriptive statistics for demographic, medical, and psychosocial variables were also evaluated. To adjust for possible confounds, several one-way analysis of variance (ANOVA) were conducted to determine whether demographic variables (e.g., income) should be included as covariates. Additionally, age, medical comorbidities, time since diagnosis, health insurance coverage, prostate cancer knowledge, and PSA level within six months of the assessment were variables that have been associated with distress were considered conceptually relevant to distress in previous studies (Henselmans et al., 2010; Hurria et al., 2009; Latini et al., 2007; van den Bergh et al., 2010; Zabora et al., 2001) and therefore included in all analyses.

Hierarchical multiple regression models were used to test whether the PSMS subscales were moderators of the association between PC concerns and cancer-related psychological distress. Mean substitution was used for missing values of all continuous variables, as the percentage of missing values in each measure ranged from only 1 – 7%. The following outcomes were included in the analyses: IES-R Total score, IES-R Avoidance, IES-R Hyperarousal, and IES-R Intrusion. An interaction term was created by multiplying the centered PSMS subscale variables (i.e., Relaxation or Coping Confidence) by the centered total PC concerns variable. Eight initial hierarchical regression models, one for each outcome (the three IES-R subscales and the total score on the IES-R) and one for each moderator (Coping Confidence and Relaxation), were evaluated. Within each model, variables were entered in the following order: covariates in the first block, centered PSMS subscale and centered total PC concerns score in the second block, and the interaction term in the third block. Significant interaction effects were followed up with additional analyses to test whether individual PC concerns component scores (i.e., Treatment Side Effect Concerns, Social Rejection Concerns, Life and Premature Closure Concerns, and Financial Concerns) interacted with the PSMS subscales on cancer-related psychological distress (IES-R total and subscale scores). The individual PC concerns component scores were each tested separately.

Results

Psychometric testing revealed normal distributions for all study dependent variables. Skewness ranged from 1.2 to 2.0 and kurtosis ranged from .71 to 4.3 or the IES Total score and its subscales. Variables were considered to have non-normal distributions if their absolute value of skew exceeded 3 and absolute value of kurtosis was greater than 10 (Kline, 2005). The sociodemographic characteristics of the sample are shown in Table 1. Descriptive statistics for the medical and psychosocial variables included in the current study are summarized in Table 2. Correlations among the coping confidence, relaxation, psychological distress, and PC concerns are presented in Table 3. Psychological distress as measured by the IES-R Total and IES-R subscales was correlated with PC concerns such that greater concerns was related to greater distress. Coping confidence was significantly correlated with lower hyperarousal and marginally associated with lower intrusive thoughts and lower total distress on the IES-R.

Table 1.

Descriptive Statistics for Sociodemographic Variables (N = 71)

Sociodemographic Variable Mean SD
Age (years) 65.40
N 		(7.85)
Percentage
Ethnicity/race
    Non-Hispanic White 37 52.10%
    Hispanic 22 31.00%
    African American/ Black 12 16.90%
Primary Language
    English 62 87.32%
    Spanish 9 12.68%
Partner status
    Single, never married 10 14.08%
    Married/equivalent relationship 42 59.15%
    Separated/Divorced 12 16.90%
    Widowed 6 8.45%
Education (highest degree earned)
    Less than high school 5 7.00%
    High school diploma or equivalent 27 38.00%
    Associate degree or 2-year technical degree 12 16.90%
    Bachelor’s degree 19 26.80%
    Graduate degree 8 11.30%
Total combined family income
    ≤ $24,999 19 26.76%
    $25,000 – $49,999 16 22.53%
    $50,000 – $99,999 16 22.53%
    ≥ $100,000 15 21.13%
Health Insurance Coverage
    Yes 50 70.42%
    No 14 19.72%
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Table 2.

Descriptive Statistics for Medical and Psychosocial Variables (N = 71)

Medical variable Mean SD Range
Time since diagnosis (months) 16.52 23.04 0–98
PSA level at baseline (ng/mL) 5.76 5.77 0–31
Charlson Medical co-morbidity 2.16 2.32 0–9
Psychosocial variable Mean SD Scale Range
PC Knowledge 14.24 4.81 0–27
MOCS-Scale A Coping Confidence 19.28 3.92 5–25
MOCS-Scale A Relaxation 4.75 2.55 2–10
PCPC 41.27 15.93 25–125
IES-R Total 9.46 11.03 0–88
IES-R Avoidance 0.67 0.79 0–4
IES-R Intrusion 0.51 0.61 0–4
IES-R Hyperarousal 0.27 0.47 0–4
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Note. PC is Prostate Cancer. MOCS is Measure of Current Status. PCPC is Profile of Concerns about Prostate Cancer. IES-R is Impact of Events Scale-Revised.

Table 3.

Correlations among Psychosocial Variables

IES-R
Total		 IES-R
Intrusions		 IES-R
Hyperarousal		 IES-R
Avoidance		 PCPC MOCS-
Scale A
Coping
Confidence		 MOCS-
Scale A
Relaxation
IES-R Total 1
IES-R .90** 1
Intrusions
IES-R .81** .86** 1
Hyperarousal
IES-R .81** .51** .38** 1
Avoidance
PCPC .65** .60** .56** .52** 1
MOCS-Scale −.231 −.231 −.25* −.12 −.02 1
A Coping
Confidence
MOCS-Scale −.07 −.06 .05 −.12 .14 .28* 1
A Relaxation
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Note. PC is Prostate Cancer. MOCS is Measure of Current Status. PCPC is Profile of Concerns about Prostate Cancer. IES-R is Impact of Events Scale-Revised.

*

Significant at the p<.05.

**

Significant at the p<.01.

1

Marginally significant at the p<.06 level.

Level of coping confidence and relaxation, PC concerns, and psychological distress did not vary as a function of ethnicity, marital/relationship status, education, or income (ps > .15). Therefore, these demographic variables were not included as control variables in subsequent analyses. Age, insurance coverage, and PC knowledge varied as a function of either coping confidence, relaxation, PC concerns, or psychological distress and therefore were included as covariates (all ps <.06). Medical co-morbidities, time since diagnosis, PSA level within six months of the assessment were also retained in the model as these medical variables have established relationships with distress in prostate cancer or breast cancer samples (Henselmans et al., 2010; Hurria et al., 2009; Latini et al., 2007; van den Bergh et al., 2010; Zabora et al., 2001).

Relaxation

The Relaxation Subscale was tested as a moderator of the relationship between the total PC concerns and psychological distress. The results of the hierarchical regression models indicated that the interaction terms of the Relaxation Subscale by the total PC concern were not significant for the IES-R Total, IES-R Avoidance, IES-R Intrusions, or IES-R Hyperarousal (all ps > .05).

Coping Confidence

The Coping Confidence Subscale was tested as a moderator of the relationship between the total PC concerns and psychological distress. The results of the hierarchical regression models did not indicate significant interaction terms for the IES-R Total, IES-R Avoidance, or IES-R Hyperarousal subscales (all ps > .05). However, the Coping Confidence Subscale did significantly moderate the relationship between the total PC concerns and IES-R Intrusions. Specifically, the covariates, main effects, and interaction accounted for approximately 48% of the variance in intrusive thoughts, R2= .475 (R2 change = .06, .34, .07 respectively for each block in the regression model). The main effects of coping confidence (β=−.36, p<.01) and the total PC concerns (β=.57, p<.01) were significant, indicating that lower coping confidence and greater total PC concerns were each associated with greater intrusive thoughts. The interaction effect of coping confidence and total PC concerns was significant when controlling for the main effects, R2 change= .07, F(1, 61)= 7.45, p< .01. Simple slope analyses revealed that at low levels of coping confidence (-1SD below the mean), total PC concerns was positively related to intrusive thoughts, β= .951, t(70)= 5.24 p< .001. In contrast, when coping confidence was high (+1SD above the mean), total PC concerns was not associated with intrusive thoughts, β= .19, t(70)= 1.16, p>.05 (see Figure 1).

Figure 1.

Figure 1

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Coping confidence moderated the effect of total PC (prostate cancer) concerns on intrusive thoughts.

The four distinct subscales yielded in the PCA of the PC concerns measure were used to test whether individual PC concerns components, in addition to the total PC concerns, interacted with coping confidence and intrusive thoughts. The follow-up analyses were conducted in order to understand whether a particular component of PC concerns was driving the interaction of the total PC concerns and coping confidence on intrusive thoughts. The only PC concerns component to significantly interact with coping confidence and intrusive thoughts was treatment concerns. The covariates, main effects and interaction accounted for approximately 24% of the variance in intrusive thoughts, R2= .243 (R2 change = .06, .23, .05 respectively for each block in the regression model). The main effects of coping confidence (β=−.35, p<.01) and treatment concerns (β=.47, p<.001) were significant, indicating that lower coping confidence and greater treatment concerns were each associated with greater intrusive thoughts. The interaction effect of coping concerns and treatment concerns was significant when controlling for the main effects, R2 change= .05, F(1, 61)= 4.47, p< .05. Post-hoc simple slope analyses revealed that at low levels of coping confidence (-1SD below the mean), PC treatment concerns was positively associated with intrusive thoughts, β=.73, t(70)= 3.93, p<.001. At high levels of coping confidence (+1SD above the mean), treatment concerns was not significantly related to intrusive thoughts, β= .20, t(70)= 1.39, p> .05 (see Figure 2). The interaction of coping confidence and social rejection concerns, life and premature closure concerns, and financial concerns were not significant (all ps > .05).

Figure 2.

Figure 2

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Coping confidence moderated the effect of PC (prostate cancer) treatment concerns on intrusive thoughts.

Discussion

The current study explored whether the relationship between PC concerns and psychological distress varied as a function of the level of PSMS, specifically relaxation and coping confidence, in a sample of men undergoing active surveillance for prostate cancer. Results of the current study indicated that at low levels of coping confidence, high levels of PC concerns (total PC concerns and treatment concerns) were significantly related to greater intrusive thoughts about cancer. At high levels of coping confidence, the relationship between PC concerns and intrusive thoughts was non-significant. Ability to relax did not moderate the relationship between PC concerns and distress. These findings suggest that it is coping confidence rather than ability to relax that is critical to moderating the relationship between PC concerns and distress.

Although the amount of variance gained in the interaction relative to the main effect was small (e.g., .34 and .07 for coping confidence as a moderator in the relationship between the total PC concerns and psychological distress), these novel findings contribute to the developing literature on the active surveillance experience by examining the role of two types of PSMS on psychological distress. All men undergoing active surveillance face the difficult circumstance of living with an active cancer, and may be torn between living with cancer or undergoing active treatment that is associated with side effects that are highly concerning. The findings imply that among men reporting greater PC-related concerns, coping confidence may reduce intrusive thoughts about PC. More specifically, PC patients who have confidence in their ability to cope well may manage this experience with less persistent thought intrusions. Having skills to deal with concerns may protect men from becoming overly worried about any physical changes, especially treatment-related changes in urinary or sexual functioning, they may experience.

The finding that intrusive thoughts was the only significant outcome in the moderation analyses may be explained by the strong cognitive component of the items in the Coping Confidence Subscale. Therefore, participants who reported a greater ability to reframe negative thinking may have been more capable of directly managing intrusive thoughts. Taken together, these findings suggest that there may be a role for coping as it relates to distress in the active surveillance experience and underscore the importance of interventions aimed at improving coping rather than enhancing relaxation skills when targeting distress in this population.

It is important to compare findings on our study outcome, distress, to other studies. The mean score on the IES-R Total and mean level of IES-R Intrusion in the current study were greater than a sample of post-treatment rectal cancer survivors (1.22 and .37 respectively for the total score and intrusive thoughts) (Ristvedt & Trinkaus, 2009) a sample of breast cancer survivors (.29 and .31 respectively) (Oh et al., 2004). The mean score of the IES-R Total in a sample of veterans seeking treatment for post-traumatic stress disorder was 2.64, which is lower than that reported in the current sample. However, the mean score on the IES-R Intrusion for veterans was 2.72, which is higher than the mean score reported in the current study (Creamer, Bell, & Failla, 2003). Taken together, these findings suggest that the scores on the IES-R Total and IES-R Intrusions are slightly greater compared to other samples of individuals diagnosed with cancer but intrusive thoughts in this study were lower than veterans.

There were some similarities and differences that resulted from the PC concerns component analysis compared to a prior study of breast cancer concerns (Spencer et al., 1999). The factor analysis of the Primary Concerns about Breast Cancer revealed that women’s greatest concerns were related to premature death and loss of independence. In contrast, PC patients in the current sample reported most concern over their sense of masculinity and sexual functioning. Both breast cancer and PC patients indicated social rejection concerns as moderately important. Interestingly, concerns such as social rejection, life and premature closure concerns, and financial concerns did not interact with PSMS on intrusive thoughts. This finding suggests that when men are able to manage (i.e., cognitively reframe) concerns related to treatment side effects, they experience fewer intrusive thoughts about their illness. While other concerns may be present, threats to their sense of masculinity may drive intrusive thoughts more than other PC concerns.

Limitations

As with all cross-sectional studies, caution should be taken when interpreting results as causal relationships cannot be determined and longitudinal designs are needed to verify the directionality and durability of the relationships among these variables. It is important to note that findings are based on a sample size of 71 participants, which is a relatively small sample size given that there were up to 9 predictors in the regression models. It is also important to note that the amount of variance gained in interaction effects relative to the main effect was small. Although the sample is diverse in terms of racial/ethnic composition, our findings are not generalizable to Spanish monolingual Hispanics or other ethnic groups. Another limitation in the current study was that no information was collected regarding the treatment decision process. Specifically, it would have been useful to know whether the doctor, the patient or both made the decision for active surveillance. Also it is unclear which specific treatment options were offered to the patients in this sample. Gaining a broader perspective of the treatment decision process is helpful as it may provide insight into individual factors that may lead some PC survivors to undergo active surveillance, while others choose to undergo immediate active treatment.

Additionally, no information was collected regarding the time since the participants’ last PSA test, time to upcoming PSA test, and number of PSA tests prior to entering the study. Future studies should examine treatment compliance in men undergoing active surveillance in the context of psychological distress to determine whether men who report greatest levels of anxiety are the same men that do not adhere to treatment recommendations. It may be possible that a greater or lesser number of PSA tests related to individual differences in anxiety. The current study did account for time since diagnosis, as men undergoing active surveillance and other cancer survivors have reported higher levels of anxiety with greater time since diagnosis (Burnet, Parker, Dearnaley, Brewin, & Watson, 2007). However, time since diagnosis was not significantly related to psychological distress. A possible explanation for the null finding is that on average participants in the current study were diagnosed within 17 months of the study assessment whereas prior studies that have examined elevated anxiety levels in cancer survivors have assessed patients greater than one year post-diagnosis (Burnet et al., 2007).

Future Work

Future research should use the findings of the current study as a foundation to continue to explore the psychosocial experience of men undergoing active surveillance. An area that remains to be explored in this population is treatment adherence. Treatment adherence is an important measure to consider as anxiety may prevent proper care (i.e., attending appointments regularly). Active surveillance is only effective when men adhere to the recommended screening schedule to monitor disease progression so that active treatment may be initiated at an appropriate time (if necessary).

With the increase in screening procedures, it is beneficial for men to remain on active surveillance for as long as clinically indicated. Follow-up studies should use a longitudinal design to determine whether greater coping confidence at diagnosis results in lower psychological distress and a significant reduction in unnecessary treatment at follow-up. Such a study would provide support for an intervention aimed at improving stress management skills in men who choose to undergo active surveillance and promote optimal well-being.

Supplementary Material

10865_2014_9594_MOESM1_ESM

Footnotes

Dr. Betina Yanez, Natalie Bustillo, Dr. Michael Antoni, Dr. Suzanne Lechner, Dr. Jason Dahn, Dr. Bruce Kava and Dr. Frank Penedo declare that they have no conflict of interest.

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000 (Schroder et al., 2009). Informed consent was obtained from all patients for being included in the study.

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Supplementary Materials

10865_2014_9594_MOESM1_ESM
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