Post-traumatic stress disorder symptoms in non-muscle-invasive bladder cancer survivors: A population-based study

Abstract

Objective:

This cross-sectional study examined the prevalence of post-traumatic stress disorder (PTSD) and identified the predictive factors associated with PTSD symptoms in a population of Non-Muscle-Invasive Bladder Cancer (NMIBC) survivors.

Methods:

A random sample of 2000 NMIBC survivors, identified through North Carolina Central Cancer Registry, were sent postal mail survey. PTSD symptoms were measured using the PTSD Checklist for DSM-5 (PCL-5). Descriptive statistics and hierarchical multiple linear regression were used to examine the prevalence of PTSD and to identify the factors associated with PTSD.

Results:

A total of 376 participants were included in the analysis. The average PCL-5 score was 7.1 (SD = 10.9, range: 0 - 66), where higher scores represent higher levels of PTSD symptoms. The prevalence of the provisional PTSD diagnosis was 5.3% or 6.9% (after adjusting for non-response). In addition, 28.7% of participants met criteria for at least one PTSD symptom cluster. After controlling for other variables, participants who were younger, had active disease or unsure of status, had more comorbidities, had lower social support, and had higher cognitive concerns reported significantly higher PTSD symptoms.

Conclusion:

More than one-fourth of NMIBC survivors had PTSD symptoms. Thus, healthcare providers should assess PTSD symptoms and provide supportive care for NMIBC survivors in the survivorship phase of care.

1. Introduction

Cancer diagnosis and treatments are stressful events that cause psychological distress including anxiety, depression, and symptoms of post-traumatic stress [1]. Patients with cancer experience trauma from initially receiving a diagnosis as well as ongoing care, including testing, undergoing treatment and side effects, and constant surveillance with fears of recurrence. These cancer experiences impact not only patients’ physical health but also their psychological health.

Post-traumatic stress disorder (PTSD) is a mental health problem that can develop after exposure to a traumatic event [2]. A substantial amount of research has been conducted regarding PTSD symptoms and PTSD in cancer populations. A meta-analysis reports that the prevalence of cancer-related PTSD in adult cancer survivors ranges from 7.3% to 13.8% using self-report screening [3]. Studies using structured clinical interview methods revealed a mean prevalence of 6.4% for current cancer-related PTSD and 12.6% for lifetime cancer-related PTSD in cancer survivors [3]. In contrast, the general US adult population is estimated to have a current PTSD prevalence of 3.5% and the lifetime PTSD prevalence of 6.8% [4]. In addition, 10-20% of patients with cancer had subsyndromal levels of PTSD symptoms (e.g., partial PTSD) [5]. Previous studies have shown that the observed higher levels of PTSD symptoms and PTSD are associated with poorer QOL in cancer populations [6–9].

Bladder cancer is the sixth most common cancer in the US, and non-muscle-invasive bladder cancer (NMIBC) represents approximately 75% of newly diagnosed patients with bladder cancer [10,11]. While NMIBC is considered an early stage of cancer, it has the highest recurrence rate (ranging from 50-90%) of any cancer site [12]. Against this backdrop, NMIBC survivors are required to have frequent surveillance cystoscopies (up to every three months) and often experience repeated intravesical treatments for the remainder of their life [13]. Given the high recurrence rate, repeated treatments and surveillance cystoscopies, NMIBC survivors may experience PTSD symptoms, potentially resulting in negative effects on quality of life. Additionally, PTSD symptoms can prevent NMIBC survivors from adhering to their surveillance/treatments, worsening their health outcomes. Many burdens experienced during NMIBC survivorship are risk factors for PTSD symptoms. However, PTSD symptoms have not been studied in NMIBC survivors. Thus, the aims of this study are to examine the prevalence of PTSD symptoms and to identify the predictive factors associated with PTSD symptoms in a population-based study of NMIBC survivors.

2. Methods

2.1. Participants and data collection procedures

Eligible survivors (N = 5979) were identified through the North Carolina Central Cancer Registry (CCR). Eligibility criteria for the study included: a) formal diagnosis of non-muscle-invasive bladder cancer (stage Ta, T1 or carcinoma in situ); b) 18 years or older; c) between 1- and 6-years post-diagnosis; and, d) completed initial NMIBC cancer treatment. Of the 5,979 eligible survivors, 2,000 were randomly selected and contacted by mail. Adapted from the Dillman’s method for mailed surveys [14], survivors were mailed a survey packet containing a letter of introduction, CCR brochure, consent form, future contact form, and self-administered questionnaire with a postage-paid return envelope. Survivors received a reminder postcard one week after the survey packet mailed-out. The study was approved by the Institutional Review Board (IRB) at the University of North Carolina at Chapel Hill (IRB number: 16-0696).

2.2. Measures

2.2.1. Demographics and clinical characteristics

Demographics and clinical information were collected from the North Carolina CCR and participants’ self-report. Other health-related problems were assessed by the 12-item Self-Administered Comorbidity Questionnaire (SCQ) [15].

2.2.2. Psychosocial characteristics

The perceived availability of social support was measured by the 19-item Medical Outcomes Study (MOS) Social Support Survey [16]. Each item has a five-point Likert scale that ranges from 1(‘none of the time’) to 5 (‘all of the time’). The total score can range from 19 to 95 with higher scores reflecting higher support. In this study, Cronbach’s alpha of the MOS was .98.

Cognition was assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Applied Cognition - Abilities Short Form v.1.0 and the PROMIS Applied Cognition - General Concerns Short Form v.1.0 [17], each of which has 8 items on a five-point Likert scale. The total score for each construct can range from 8 to 40 with higher scores indicating higher (better) cognitive abilities or greater (worse) cognitive general concerns. In this study, Cronbach’s alpha of the PROMIS Applied Cognition -Abilities and General Concerns were .98 and .97, respectively.

2.2.3. Post-traumatic stress symptoms

The PTSD Checklist for DSM-5 (PCL-5) [18,19] was used to assess PTSD symptoms. The PCL-5 has 20 items which correspond with the symptom criteria for PTSD in Diagnostic and Statistical Manual of Mental Disorders, Fifth edition (DSM-5) [2]. The PCL-5 instructions were modified for participants to reflect their diagnosis and treatment for bladder cancer. Each item has a five-point Likert scale from 0 (‘not at all’) to 4 (‘extremely’). The total symptom score, ranging from 0 to 80, was obtained by summing the scores for each of the 20 items; a higher score represents higher level of PTSD symptoms. Two approaches were used to identify a provisional PTSD diagnosis: 1) the total symptom score of 31 (cut-point) or higher; 2) treating each item rated as 2 (‘moderately’) or higher as a symptom endorsed, then following the DSM-5 diagnostic rule which requires one or more intrusion symptom (questions 1-5), one or more avoidance symptom (questions 6-7), two or more negative cognitions and mood symptoms (questions 8-14), and two or more arousal symptoms (questions 15-20) [2,18,20]. In this study, Cronbach’s alpha of the PCL-5 was .94.

2.3. Data analysis

Descriptive statistics were computed to examine demographics, clinical characteristics, and level of PTSD symptoms in NMIBC survivors. To adjust for sample non-response in the estimate of PTSD prevalence, multiple imputation with a logistic model was used to estimate PTSD status in non-respondents (n=1624) based on age at study enrollment, sex, race, years since diagnosis, cancer stage, and histology. One hundred data sets containing imputed values were generated. We used the SAS MIANALYZE procedure (SAS Institute, Cary, NC) to combine the results of imputations and obtain a single estimate for the PTSD prevalence. Multiple imputation was conducted only for calculating the PTSD prevalence. Data from respondents was used to examine the associations between covariates and PTSD symptoms; requiring the assumption that the associations observed in respondents also apply to non-respondents. Hierarchical multiple linear regression with backward selection was used to determine which covariates predict PTSD symptoms. The covariates were grouped into four categories (Table 1), with each category added sequentially to a multiple linear regression model. To maintain parsimony, after each category was added, backward selection was used to reduce the model, dropping the variable with the highest p-value until all remaining variables had p < .20. This cutoff was chosen to yield a parsimonious model without being overly restrictive. Sex, race/ethnicity, and age at study enrollment were always kept in the model regardless of p-value. Though predictors remained in the model when p < .20, statistical significance was set at p < .05. All statistical analyses were performed using SAS version 9.4.

Table 1.

Personal characteristics used as independent variables in hierarchical multiple linear regression

Category	Variable
Demographics	Sex, race/ethnicity, age at study enrollment, income, education, marital, employment, insurance
Disease Characteristics	Stage at diagnosis, treatment type (TURBT, cystectomy, intravesical chemotherapy, intravesical immunotherapy), current treatment status, current disease status, recurrence, frequency of surveillance cystoscopy, time since diagnosis
Health/Health-behavior status	Other cancer, comorbidities, general healthcare usage, tobacco use
Psychosocial	Social support, cognition-abilities, cognition-general concerns

Abbreviation: TURBT, transurethral resection of bladder tumor.

3. Results

3.1. Participants characteristics

The initial analysis included 376 participants who completed the PCL-5. Further details on the study flow and the demographics of the overall study population and sample of 2000 can be found elsewhere [21]. Demographics and clinical characteristics of participants and non-participants are provided in the supplementary information (Table S1). The characteristics of the participants are shown in Table 2. The majority were male (n=272, 72.3%), non-Hispanic white (n=351, 93.4%), married or living with partner (n=284, 75.5%), and had received college education or more (n=275, 73.2%). Mean age at study enrollment was 72.2 (SD = 9.2) and mean years since diagnosis was 3.4 years (SD = 1.5). Transurethral resection of a bladder tumor (TURBT) was reported as the primary treatment by 73.4% of participants, intravesical immunotherapy by 43.4%, intravesical chemotherapy by 36.2%, and cystectomy only by 5.6%. NIMBC had recurred in 40.7% of the participants. Most of the participants (71.3%) had a positive smoking history (at least 100 cigarettes or 5 packs in entire life), and 10.6% were current smokers. More than two-thirds participants (n=255, 67.8%) had three or more comorbidities, with the most common comorbidities being high blood pressure (n=248, 66.0%), back pain (n=194, 51.6%), and heart disease (n=157, 41.8%). Fifty-four participants (14.4%) had other cancers (e.g. prostate, n=16; skin cancer, n=9; GI cancer, n=8; lung cancer, n=6; etc.).

Table 2.

Participant characteristics

Characteristic	Participants (n=376)
Sex†
Male	272 (72.3%)
Female	104 (27.7%)
Race/Ethnicity†
Non-Hispanic white	351 (93.4%)
Other/ unknown	25 (6.6%)
Age at diagnosis, years†
Mean (SD), Range	68.3 (9.2), 34-89
Age at study enrollment, years†
Mean (SD), Range	72.2 (9.2), 39-94
Income level
< $50,000	132 (35.1%)
$50,000- $99,999	136 (36.2%)
≥$100,000	62 (16.5%)
No response given	46 (12.2%)
Education
High school graduate or less	89 (23.7%)
Some college or technical school/College graduate	210 (55.9%)
Post-graduate	65 (17.3%)
No response given	12 (3.2%)
Marital status
Married/ Living with partner	284 (75.5%)
Never married/ Divorced/ Widowed/ Separated	80 (21.3%)
No response given	12 (3.2%)
Employment
Employed	71 (18.9%)
Unemployed	20 (5.3%)
Retired	274 (72.9%)
No response given	11 (2.9%)
Current health care coverage
Don’t have	4 (1.1%)
Private insurance	65 (17.3%)
Government health care coverage (Medicare, Medicaid)	295 (78.5%)
No response given	12 (3.2%)
Stage at diagnosis†
Ta	250 (66.5%)
Tis	24 (6.4%)
T1	102 (27.1%)
Type of previous treatment
TURBT	276 (73.4%)
Intravesical immunotherapy	163 (43.4%)
Intravesical chemotherapy	136 (36.2%)
Removal of bladder	21 (5.6%)
Radiation therapy	3 (0.8%)
Other	14 (3.7%)
No treatment selected	11 (2.9%)
Years since diagnosis†
Mean (SD), Range	3.4 (1.5), 1-6
Current treatment status
Not in treatment	299 (79.5%)
Receiving treatment	71 (18.9%)
No response given	6 (1.6%)
Current NMIBC status
Cured	243 (64.6%)
Not cured	37 (9.8%)
Don’t know	88 (23.4%)
No response given	8 (2.1%)
Recurrence/progression of NMIBC history
Yes (recurrence)	153 (40.7%)
Yes (progression)	8 (2.1%)
No	207 (55.1%)
No response given	8 (2.1%)
Current cystoscopy frequency
Per 0-3 months	109 (29.0%)
Per 4-6 months	161 (42.8%)
Per 7-11 months	18 (4.8%)
Per 1 year	53 (14.1%)
Per 2 years	3 (0.8%)
Only had once	10 (2.7%)
No response given	22 (5.9%)
Number of comorbidities
Mean (SD), Range	3.7 (2.2), 0-12
0	15 (4.0%)
1-2	106 (28.2%)
3-4	136 (36.2%)
5-6	78 (20.7%)
≥7	41 (10.9%)
New other cancers
Yes	54 (14.4%)
No	316 (84.0%)
No response given	6 (1.6%)
Number of visits a primary care provider for general health needs within past year (General health care usage)
0	23 (6.1%)
1	91 (24.2%)
2	127 (33.8%)
3	71 (18.9%)
≥4	62 (16.5%)
No response given	2 (0.5%)
Smoking history (at least 100 cigarettes (5 packs) in entire life)
Yes	268 (71.3%)
No	103(27.4%)
No response given	5 (1.3%)
Current smoking
Yes	40 (10.6%)
No	329 (87.5%)
No response given	7 (1.9%)
Military veteran
Yes	144 (38.3%)
No	221(58.8%)
No response given	11 (2.9%)

Abbreviations: NMIBC, non-muscle-invasive bladder cancer; TURBT, transurethral resection of bladder tumor.

^†Data from North Carolina CCR.

3.2. Levels of PTSD symptoms

Table 3 shows the level of PTSD symptoms. The average PCL-5 score was 7.1 (SD = 10.9) with a range of 0 - 66, where higher scores indicate more PTSD symptoms. Defined by either a total symptom score of 31 (cut-point) or the DSM-5 diagnostic rule described earlier, 5.3% of participants met the provisional PTSD diagnosis. After using multiple imputation to adjust for non-response, the prevalence of PTSD was 6.9% (95% confidence interval: 3.9, 10.0). Overall, 28.7% met criteria for at least one PTSD symptom cluster.

Table 3.

Cognition, Social support, and PTSD scores

Measure	Characteristic	Possible Range	n	Mean (SD)	Range
PROMIS	Cognition - Abilities	8 – 40	372	31.9 (8.5)	8 - 40
	Cognition - General concerns†	8 – 40	371	14.4 (7.5)	8 - 40
MOS Social Support Survey	Social support	19– 95	369	77.5 (19.4)	19 - 95
PCL-5	PTSD symptoms total†	0 – 80	376	7.1 (10.9)	0 - 66
	Intrusions (Q1-5) †	0 – 20	376	1.6 (3.0)	0 - 15
	Avoidance (Q6-7) †	0 – 8	375	0.6 (2.3)	0 - 8
	Negative alterations in cognitions and mood (Q8-14) †	0 – 28	376	2.2 (4.2)	0 - 25
	Alterations in arousal and reactivity (Q15-20) †	0 – 24	376	2.6 (3.8)	0 - 23
	PTSD			Frequency
	PCL-5 total scorea	≥ 31		20 (5.3%)
		< 31		356 (94.7%)
	PTSD symptom clustersb	0		268 (71.3%)
		1		48 (12.8%)
		2		23 (6.1%)
		3		17 (4.5%)
		4		20 (5.3%)
	Provisional PTSD diagnosisc	Yes		20 (5.3%)
		No		356 (94.7%)

Abbreviations: MOS, Medical Outcomes Study; PCL-5, PTSD Checklist for DSM-5; PROMIS, Patient-Reported Outcomes Measurement Information System; PTSD, post-traumatic stress disorder.

^†High scores denote poorer quality of life in these domains.

^aPCL-5 total score ≥ 31 is a cut-point for indication of probable PTSD.

^bPTSD symptom clusters: Each item rated ≥ 2 (moderately) was endorsed as a symptom, then at least 1 intrusion item (questions 1-5), 1 avoidance item (questions 6-7), 2 negative alterations in cognitions and mood items (questions 8-14), and 2 alterations in arousal and reactivity items (questions 15-20) are required for each symptom cluster.

^cProvisional PTSD diagnosis: Each item rated ≥ 2 (moderately) was endorsed as a symptom, then PTSD diagnosis requires at least 1 intrusion item (questions 1-5), 1 avoidance item (questions 6-7), 2 negative alterations in cognitions and mood items (questions 8-14), and 2 alterations in arousal and reactivity items (questions 15-20) by the DSM-5 diagnostic rule.

3.3. Factors associated with PTSD symptoms

Table 4 displays the final results of hierarchical regressions showing the contribution of demographic, clinical, health/health-behavior status, and psychosocial variables explaining variance in PTSD symptoms (PCL-5) scores. PTSD symptoms had significant associations with age at study enrollment, current disease status, comorbidity number, social support, and cognition-general concerns (Table 6). After controlling for other variables, significantly higher PTSD symptoms were seen in participants who were younger, were not cured or did not know whether they were cured (vs. cured), had more comorbidities, had lower social support, and had higher cognition-general concerns. PTSD symptoms did not significantly vary by sex, race/ethnicity, receipt of TURBT, or cognition-ability. In addition, the mean PTSD symptom scores were not significantly different between veterans and non-veterans (191.6 and 177.4, respectively; Wilcoxon Rank Sum test, p=0.20).

Table 4.

Hierarchical multiple linear regression predicting PTSD symptoms

Variable		PTSD symptoms
		B (SE)	95% Confidence Interval
		Demographics
Sex	Female Male	−1.3 (1.0) Ref	−3.33 to 0.76
Race/ethnicity	Non-Hispanic white Other/Unknown	−0.6 (2.0) Ref	−4.53 to 3.31
Age at study enrollment		−0.2 (0.1)**	−0.27 to −0.07
Disease Characteristics
Received TURBT	No Yes	−1.4 (1.1) Ref	−3.60 to 0.75
Current disease status: Cure	Don’t know No Yes	4.4 (1.1)*** 6.6 (1.6)*** Ref	2.18 to 6.52 3.58 to 9.71
Health/Health-behavior status
Comorbidity number		1.0 (0.2)***	0.53 to 1.40
Psychosocial factors
Social support		−0.1 (0.03)*	−0.11 to −0.01
Cognition: Abilities		−0.1 (0.1)	−0.27 to 0.05
Cognition: General concerns		0.5 (0.1)***	0.34 to 0.69

Abbreviations: PTSD, post-traumatic stress disorder; TURBT, transurethral resection of bladder tumor. Ref = reference group.

^*p < .05;

^**p < .01;

^***p < .001

4. Discussion

This is the first study, to our knowledge, to measure PTSD symptoms in a population-based study of NMIBC survivors. In this study, the prevalence of PTSD symptoms was examined in NMIBC survivors and factors associated with PTSD symptoms were explored using hierarchical multiple linear regression. We found that 28.7% of the participants had PTSD symptoms, and higher PTSD symptoms were associated with younger age, lack of cure, more comorbidities, less social support, and higher cognition-general concerns.

The prevalence of provisional PTSD diagnosis in our NMIBC participants was 5.3% or 6.9% (after adjusting for non-response), which is somewhat lower than that found in some other adult cancer populations (from 7.3% to 13.8% by self-report PTSD symptom measures) [3], but higher than that of the general US adult (18 years and older) population (3.5%) [22]. In addition, more than 1 in 4 (28.7%) NMIBC participants in our study reported subsyndromal levels of PTSD symptoms (met PTSD diagnostic criteria for at least one PTSD symptom cluster), which is higher than that found in other adult cancer populations (10-20%) [5,23]. Prior studies also reported PTSD symptoms in different types of cancer patients. Some of the studies showed lower prevalence of PTSD symptoms than our study, while others had higher prevalence. For example, Nipp et al. [24] studied PTSD symptoms in 954 patients with all different types of cancer and found 13.3% of patients had PTSD symptoms, which is lower than the prevalence in our study. Another study of 1017 patients with different types of cancer, however, reported 31.7% of patients had PTSD symptoms [1], which is higher than those reported in our study. These differences of prevalence among studies may be because of the fact that each study used different study designs and instruments to measure PTSD symptoms in different types of cancer. Although the prevalence should be cautiously compared with findings of other studies as different instruments were used, this finding suggests that NMIBC survivors may be experiencing PTSD symptoms more than the general population. Our finding is also corroborated by a prior study in patients with muscle-invasive bladder cancer, which reported 50% of the patients were diagnosed with psychiatric disorders after treatment [25]. Thus, healthcare providers should be mindful of this possibility when planning and delivering care. Assessment and management of PTSD symptoms are needed for NMIBC survivors in the survivorship phase of care.

Our results of multiple regression analysis show that younger age, lack of cure, more comorbidities, less social support, and more cognitive general concerns were independently associated with higher PTSD symptoms. The association of PTSD symptoms with age, comorbidity, and social support in this research is consistent with literature on PTSD symptoms in other cancer survivors [5,26,27]. Previous studies also showed that older participants had significantly less PTSD symptoms [5,24,26,27]. This may be explained in that older survivors may have more experience in dealing with life threatening events than younger survivors, be more resilient, or have other protective psychological factors.

The association between lack of cure and higher PTSD symptoms in our study is not surprising. Given the high recurrence rate (>40%) of NMIBC, survivors are required to have frequent invasive surveillance cystoscopies and, if they have recurrence, repeated procedures and intravesical treatments, all of which can cause the patients to be reminded of and relive cancer-related experiences. Additionally, Cordova et al. [5] reported that invasive treatment is a risk factor for cancer-related PTSD, which corroborates the explanation of the association between lack of cure and higher PTSD symptoms. Invasive treatment being a risk factor for cancer-related PTSD [5] is also one possible explanation for our result that time since diagnosis was not associated with PTSD symptoms. Some studies reported time since diagnosis was a factor related with PTSD symptoms. For example, in a meta-analysis study [27], longer time since diagnosis was associated with lower proportion of sample with PTSD. However, we found that time since diagnosis was not associated with PTSD symptoms in NMIBC survivors. This may be because invasive cystoscopies are required for NMIBC survivors for the rest of their lives and it can remind of the cancer-related experience.

There are some limitations to consider. First, this was a cross-sectional study, therefore definitive inferences cannot be made about the impact of NMIBC and its treatment on PTSD symptoms over time. Replication of this study using a longitudinal design would be helpful to understand patterns of change in PTSD symptoms over time and the causal relationship between the associated factors and PTSD symptoms. Second, the sample was mostly non-Hispanic white (93.4%), which limited the generalizability of findings to other racial/ethnic groups. Further validation of the relationships between personal characteristics and PTSD symptoms in other racial/ethnic populations is needed. Third, the response rate of our survey was low (23.6%). This might have caused our study to be biased toward the inclusion of survivors without PTSD, affecting our unadjusted prevalence of PTSD symptoms. To address the bias, we used multiple imputation to estimate PTSD status in non-respondents. After adjusting for non-response, the prevalence of PTSD increased from 5.3% to 6.9%, suggesting survey respondents were potentially biased toward those without PTSD symptoms. Last, PTSD symptoms were assessed using self-report questionnaires only; although the questionnaire (PCL-5) is a validated instrument, it may not be as accurate as clinician-administered structured diagnostic interviews for PTSD. In addition, current disease status, treatment, and surveillance information were collected by self-report questionnaires only, which may not be as accurate as data from clinical record.

Findings from this study suggests that psychosocial assessment and management to improve PTSD symptoms are essential in NMIBC survivors. PTSD treatments have been studied in patients with cancer and have shown utility in cancer population. Evidence-based psychotherapeutic PTSD treatments that have been studied in patients with cancer include cognitive behavioral therapy (CBT) interventions [28,29], eye movement desensitization and reprocessing (EMDR) intervention [30], and mindfulness [31]. Healthcare providers are in critical positions to support NMIBC survivors. Thus, healthcare providers should regularly monitor survivors’ symptoms of PTSD. Healthcare providers should also be aware of the risk factors of PTSD symptoms and identify patients who are at higher risk for developing PTSD symptoms. In addition, providing appropriate support through referrals and cancer support services may help reduce symptoms of PTSD.

5. Conclusions

The current study demonstrated the prevalence of PTSD symptoms in NMIBC survivors. In addition, several covariates were identified that relate to symptoms of PTSD. The findings from this study will advance understanding about factors related to PTSD symptoms. Thus, these findings will lay the foundations for developing interventions to manage PTSD symptoms and ultimately improve QOL in NMIBC survivors.

Highlights.

• More than one-fourth of NMIBC survivors had PTSD symptoms.

• PTSD symptoms were associated with age, disease status, comorbidity, social support.

• Psychosocial assessment and management are essential in NMIBC survivors.