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The Impact of Partnership Status and Social Support on Health Related Quality of Life Outcomes in Men with Prostate Cancer
Author's Accepted Manuscript The Impact of Partnership Status and Social Support on Health Related Quality of Life Outcomes in Men with Prostate Cancer Avi Baskin, MPhil, Lorna Kwan, MPH, Mary Zavala, MA, MSW, Karim Chamie, MD, MSHS
PII: DOI: Reference:
S2352-0779(16)30182-0 10.1016/j.urpr.2016.05.004 URPR 206
To appear in: Urology Practice Accepted Date: 23 May 2016 Please cite this article as: Baskin A, Kwan L, Zavala M, Chamie K, The Impact of Partnership Status and Social Support on Health Related Quality of Life Outcomes in Men with Prostate Cancer, Urology Practice (2016), doi: 10.1016/j.urpr.2016.05.004. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
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THE IMPACT OF PARTNERSHIP STATUS AND SOCIAL SUPPORT ON HEALTH RELATED QUALITY OF LIFE OUTCOMES IN MEN WITH PROSTATE CANCER
Department of Urology, David Geffen School of Medicine, UCLA, Los Angeles, CA Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA
Corresponding Author: Avi Baskin 300 Stein Plaza, Suite 348 Los Angeles, California 90095 Office: 310-794-2858 Fax: 310-794-3513 Email: [email protected]
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Avi Baskin, MPhil1 Lorna Kwan, MPH1 Mary Zavala, MA, MSW1 Karim Chamie, MD, MSHS1,2
of life
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Abstract Word Count: 242 Manuscript Word Count: 2442 References: 28 Keywords (MeSH Terms): prostatic neoplasms, social support, marital status, health-related quality Running Title: Social support and HRQOL
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FUNDING SOURCE: This work was supported by the National Institutes of Health Loan Repayment Program (L30 CA154326 (Principal Investigator: KC)); and the STOP Cancer Foundation (Principal Investigator: KC).
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ABSTRACT Introduction: We aim to examine the relationship between partnership status and social
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support on longitudinal health-related quality-of-life outcomes in underserved lowincome men with prostate cancer.
Methods: We prospectively analyzed quality of life outcomes across both partnership
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status and the social support of each patient enrolled in a state-funded program for free prostate cancer treatment. The UCLA Prostate Cancer Index Short Form was used to
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quantify urinary, sexual and bowel habits in two domains: bother and function. Physical and mental health were measured with RAND Medical Outcomes Study Short form. We compared four levels of partnership and social support dyads with a repeated measures analysis while controlling for patient characteristics.
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Results: 223 men were eligible for inclusion in our study. Of the 70 patients with a partner, 54 (77%) listed their partner as the only support member, the remaining 16 listed their partner and one or two children as their support group. There were few differences
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in the major quality of life domains of urinary, bowel and bladder function and bother. The physical and mental health scores did not differ by partnership status or social
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support.
Conclusions: While we hypothesized that being partnered and having increased social support would have a positive effect on quality of life, we did not find this association in our longitudinal analysis. We propose that patterns of confiding in others and integration of a nurse case manager are highly gender-based and may provide possible explanations for our findings
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INTRODUCTION Increased social support has been associated with survival, quality of life and better management for patients with cancer. (1-5) Pinquart et al. offered a number of
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explanations for these relationships: biologically mediated through neuroendocrine
pathways; as well as a social support system that prompts individuals to maintain a
healthier diet and lifestyle and utilize healthcare services more consistently. (4) It has also
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been hypothesized that healthy individuals may have a higher probability of building and maintaining broader social support.
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Current consensus suggests that married patients have significantly lower risk of mortality from prostate cancer than those who were divorced, single, separated or widowed. (4, 6, 7) Examining a cohort of uninsured men receiving free prostate cancer treatment, Gore et al. described the positive effect of partnership status on quality of life
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in low-income men with prostate cancer. (8)
However, the issue of collinearity between partnership status and social support with improved outcomes has not been fully explored, and may be attributed to either
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selection bias or cause and effect. In selection bias, those with greater baseline physical and psychological health remain in a committed relationship and have a wider social
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support base. Meanwhile in cause and effect, partnership status enhances social support, which improves survival and health-related quality of life (HRQOL). There is a dearth of literature exploring the impact of partnership status and social support as predictors of longitudinal HRQOL in prostate cancer. These measures are particularly important to patients with prostate cancer, given the variant treatment-related adverse effects such as urinary incontinence, erectile dysfunction, and bowel dysfunction. (9) Our study aims to
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explore the possibility that fostering social connections, via a partnership or wider support group, may predict better HRQOL. We hypothesize that patients with more social
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support and a partner will report better HRQOL outcomes.
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MATERIALS AND METHODS Study Population: We prospectively analyzed data from men enrolled in the UCLA Men’s Health
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Study (MHS). Men enrolled in this study are drawn from a state-funded prostate cancer
treatment program—Improving Access, Counseling, and Treatment for Californians with Prostate Cancer (IMPACT)—that provides free medical care and case management
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services to low-income, uninsured and underinsured California residents. All IMPACT Program participants receive telephonic case management services, including care
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coordination, health education, support and referrals from the program’s clinical team, comprised of nurse case managers and specialized paraprofessionals. (10) To be included in this study, IMPACT patients must have undergone treatment with curative intent in the form of radical prostatectomy, radiation therapy or brachytherapy. Exclusion criteria
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included patients with metastatic disease at enrollment, patients who speak a primary language other than English or Spanish, diagnosis outside the US, and those participants without pre-treatment data or without one-year post-treatment data. UCLA Men’s Health
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Study questionnaire was administered every 6 months for up to 5 years. Study variables:
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Upon enrollment in IMPACT, each patient identified individuals with whom the
clinical team could communicate with to assist in the care of his prostate cancer, referred to as his ‘social support’ for this study. Only individuals who were directly involved with the patient’s care on two or more occasions were included. These individuals could participate in clinic and laboratory visits, nursing education, and other sessions. We categorized the social support into those with <2 or ≥2 named individuals. Partnership
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status was defined as either partnered (living with a spouse or partner or being in a significant relationship but not living together) versus not partnered (not in a significant relationship). We combined these two variables to create a four-level category for
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analysis: <2 in the support group with and without a partner, and ≥2 in the support group with and without a partner. We stratified the cohort into <2 vs ≥2 for multiple reasons.
First, we wanted to look at the effect of both partnership status and saturation of social
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support group on our population. By definition, if a patient has a partner they have a
support member. Moreover, stratifying the cohort at 0 vs >0 social support would result
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in cell sizes with 0 (partnered patients without any further social support). Therefore, given the complexities of dealing with language barriers and contacting patients in the IMPACT program, we decided to combine social support group and partnership status in
Covariates:
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the analysis.
We abstracted records for both demographic and clinical variables, including
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patient age at program enrollment, race (white vs non-white), BMI (<25, 25–29, 30–35, >35), language (English vs Spanish), education level (≥high school vs
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annual household income (>$1500 vs ≤$1500), treatment type (radical prostatectomy vs radiation therapy) and provider type (public vs private). Median household income of $1500 was used based on prior investigations in the IMPACT population. We also quantified coexisting medical problems using the Charlson Comorbidity Index (0 vs >0). (11) We used the validated D’Amico criteria, which includes PSA at the time of biopsy, clinical Gleason score, and clinical stage at diagnosis. (12) Tumors were classified as low
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(PSA <10 ng/mL, Gleason score <7 and clinical stage ≤T2a), intermediate (PSA 10–19.9 ng/mL, Gleason score 7 or clinical stage T2b) or high D’Amico risk (PSA ≥20 ng/mL,
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Gleason score ≥8 or clinical stage ≥T2c). (13)
Outcome Measures:
The UCLA Prostate Cancer Index Short Form (PCI-SF) is a questionnaire used to
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measure urinary, sexual and bowel habits in two domains: bother and function. (14) Scores range from 0–100, with higher scores denoting better outcomes. This
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questionnaire has been validated in men with prostate cancer for both Spanish and English speakers. (14, 15) We used the RAND Medical Outcomes Study Short Form-12 version 2 (SF-12), a shorter version of the Short-Form Health Survey (SF-36), to measure both physical and mental health in eight domains. (16-18) The scores range from 0–100,
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where a greater score indicates a better level of health. The physical and mental health composite scores are calculated from a combination of weighted scores of the eight domains and then standardized to the national norm with a mean of 50.0 and standard
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deviation of 10.0. Physical and mental health scores of the SF-12 correlate well with the SF-36 (R2 = 0.905 and 0.938, respectively). (18) These HRQOL measures have been
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validated in Spanish speaking populations. (15, 19) For this analysis, we analyzed the two composite scores.
Statistical Analysis:
Patient characteristics were compared across the four groups with Chi-square test for categorical variables and ANOVA for continuous variables. We then conducted
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separate multivariable, repeated-measures analyses for each of the 8 HRQOL outcomes to compare the four groups over time. We used the unpartnered men with <2 people in their support group as the referent group due to it being the largest group (n=141).
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Variables that had a p-value of 0.20 or less in the univariate analyses were considered for multivariable analyses. However, race, provider type, and treatment type were included
irrespective of statistical significance. We used a backwards selection process to achieve
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with a quadratic time variable (i.e. time x time).
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the most parsimonious model. For each outcome, we also tested non-linear time trends
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RESULTS 223 men were eligible for inclusion under the study criteria. The mean (SD), median and range of income for the whole group was $7728.33 ($8333.82), $4800, $0–
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40,800. The number of follow-ups interviews by participants ranged from 1 to 10. The
majority of men had 2 or more follow-up visits (81%), with 19% having 9 or more follow up visits. Patients with ≥2 people in their social support group were more likely to speak
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Spanish and had less formal education than those with <2 people in their social support group, regardless of partnership status (Table 1). Of the 70 patients with a partner, 54
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(77%) listed their partner as the only support member, the remaining 16 listed their partner and one or two children as their support group. Participants who were partnered and had ≥2 in their social support group were more likely to have a higher income. There was no difference in the pre-treatment HRQOL for both PCI-SF and SF-12
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measures between the groups. (Table 2) This includes urinary, sexual and bowel function and bother as well as mental and physical composite scores. In the multivariable, repeated measures analyses, several variables were
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statistically significant as main effects. Patients treated with radiation therapy had
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improved urinary function (β=21.05, p<0.0001), sexual function (β=10.15, p=0.0019), and sexual bother (β=9.05, p=0.0192), but worse physical health than patients who underwent radical prostatectomy (β=-2.77, p=0.0118). Men with D’Amico high-risk prostate cancer had worse sexual function (β=-12.51, p=0.0017), sexual bother (β=-14.26, p=0.0025), and bowel bother than those with low-risk disease (β=-7.73, p=0.0433). Nonwhite patients had worse sexual function than white patients (β=-12.18, p=0.0062), but had better mental health (β=4.00, p=0.0034). Finally, men with comorbidities had
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worse bowel function (β=-5.78, p=0.0317) and physical health (β=-4.27, p=0.0003) than men with no comorbid conditions. There were few differences between physical health scores and partnership and
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social support strata over time. (Table 3) Compared with the referent group (no partners and less than two social support members), a partnered patient with ≥2 people in his
support group had worsening urinary function (β=-0.38, p=0.03), and partnered men with
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<2 people in their social support had worsening urinary bother over time (β=-0.91,
p=0.01). Conversely, unpartnered patients with ≥2 people in their social support group
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had an improved bowel bother trend over time (β=0.88, p=0.02). The physical and mental
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health scores from the SF-12 did not differ across groups.
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DISCUSSION We initially hypothesized that increased social support would be positively associated with HRQOL outcomes. While we found a few domains that were congruent
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with existing literature, overall HRQOL, physical and mental health scores were not
different between the levels of social support and partnership. Additionally, the amount of social support was not associated with better outcomes.
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The role of support in prostate cancer, a disease of men, can be most readily compared with breast cancer, predominantly a disease of women. Socially isolated
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women were found to have a higher risk of mortality after a diagnosis of breast cancer than socially un-isolated women. (3) Pre-diagnosis social support appears to be a better predictor of HRQOL among breast cancer survivors than even treatment or tumor characteristics. (20)
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However, in our population of underserved men with prostate cancer, neither social support nor partnership status was found to be associated with improved HRQOL. Some authors suggested that cancer patients’ social relationships may actually provide an
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additional avenue of stress. (21, 22) Why would patients in our population not respond to support the same way as, say, a breast cancer patient? Many have suggested that the lack
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of association may be attributed to gender differences in patterns of confiding in others during a crisis. (23) We offer two possible explanations for the findings based on differences between men and women: 1) with an excess of social support, men are prone to a loss of autonomy and embarrassment due to the multiple symptoms and treatmentrelated side effects, and 2) the unique role of the nurse case manager in the IMPACT
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program may confound the relationship between support and partnership status and HRQOL outcomes. First, for men with prostate cancer, more social support may lead to not only a
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loss of autonomy, but increased embarrassment to the symptoms and treatment-related
complications. During interactions with the IMPACT clinical team, patients often have
their support members on the telephone with them. Of the 223 patients in the study, 207
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identified someone in their support system, with most of these being female. Previous
research in this population has elicited the effect of partnership status and social support
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on treatment choice, each with distinct side effect profiles. (24) For example, married men with fewer than two members in their social cohort were more likely to undergo surgery. (25) The decision to pursue one treatment (and thus side effects) over another, may be difficult to discuss with close female relatives. Moreover, the number of people
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involved in the patient’s care may create a loss of autonomy. As one man with prostate cancer said, “I consider these things [urinary and erectile dysfunction] to be very personal, and I would be uncomfortable talking about them in a group, even if it were just a group
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of men.” (26)
Secondly, the role of the nurse case managers in the program may ameliorate
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some of the challenges facing IMPACT patients who lack the social support of a partner or others. Nurse case managers work individually with patients to tailor interventions specifically for each patient. (10) For those without identified social support, this part of the IMPACT program can help provide many of the perceived benefits. Because each patient had a nurse case manager assigned to them and received individually tailored
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interventions for the duration of their enrollment in IMPACT, it is possible that additional support members (e.g. partners or friends) may not have had an added positive effect. Our study is not without limitations. First, in assessing the social support
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members for each individual enrolled in IMPACT, we used individuals who the patient identified to assist with his care as a proxy measure. We did not query men on social
support directly and thus are limited in assessing the quality of the support. To help stem
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this bias, we only counted social support members who were involved with the patient’s care on two or more occasions. Second, we had no information on the quality of the
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partnership. In patients with poor martial adjustment, the stress of a cancer diagnosis can exacerbate anxiety and depressive symptoms. (27) Third, omitted variable bias that may not be accounted for may explain the lack of association between social support, partnership status and HRQOL. Fourth, our sample was a cohort of severely
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impoverished men. Despite the many services of the IMPACT program, they still face many barriers to care those patients of lower socioeconomic status face. Thus, the results may not be generalizable to men with prostate cancer as a whole. (28) Fourth, missing
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data may have confounded our findings. Finally, in this population, many men present with advanced or metastatic disease. While we controlled for Gleason score and clinical
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stage at diagnosis, it is thus possible that some may never return to baseline sexual, urinary and bowel function irrespective of social support or partnership status.
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CONCLUSIONS Partnership status and social support were not associated with HRQOL in our
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longitudinal analysis of low-income, uninsured and underinsured California residents. We propose that patterns of confiding in others and integration of a nurse case manager
are highly gender-based and may provide possible explanations for our findings. Future
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investigations should be undertaken to further parse out the complex relationship between
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social support and quality of life in prostate cancer patients.
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1. Funch DP, Marshall J. The role of stress, social support and age in survival from breast cancer. Journal of Psychosomatic Research. 1983;27(1):77-83. 2. Ell K, Nishimoto R, Mediansky L, Mantell J, Hamovitch M. Social relations, social support and survival among patients with cancer. Journal of Psychosomatic Research. 1992;36(6):531-41. 3. Kroenke CH, Kubzansky LD, Schernhammer ES, Holmes MD, Kawachi I. Social networks, social support, and survival after breast cancer diagnosis. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2006;24(7):1105-11. 4. Pinquart M, Duberstein PR. Associations of social networks with cancer mortality: a meta-analysis. Critical reviews in oncology/hematology. 2010;75(2):122-37. 5. House JS, Landis KR, Umberson D. Social relationships and health. Science (New York, NY). 1988;241(4865):540-5. 6. Krongrad A, Lai H, Burke MA, Goodkin K, Lai S. Marriage and mortality in prostate cancer. J Urol. 1996;156(5):1696-70. 7. Harvei S, Kravdal Ø. The Importance of Marital and Socioeconomic Status in Incidence and Survival of Prostate Cancer. Preventive Medicine. 1997;26(5):623-32. 8. Gore JL, Krupski T, Kwan L, Maliski S, Litwin MS. Partnership status influences quality of life in low-income, uninsured men with prostate cancer. Cancer. 2005;104(1):191-8. 9. Kaplan AL, Crespi CM, Saucedo JD, Connor SE, Litwin MS, Saigal CS. Decisional conflict in economically disadvantaged men with newly diagnosed prostate cancer: Baseline results from a shared decision-making trial. Cancer. 2014;120(17):27217. 10. Maliski SL, Clerkin B, Litwin MS. Describing a nurse case manager intervention to empower low-income men with prostate cancer. Oncology nursing forum. 2004;31(1):57-64. 11. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of chronic diseases. 1987;40(5):373-83. 12. Boorjian SA, Karnes RJ, Rangel LJ, Bergstralh EJ, Blute ML. Mayo Clinic validation of the D'amico risk group classification for predicting survival following radical prostatectomy. J Urol. 2008;179(4):1354-60; discussion 60-1. 13. D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick GA, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. Jama. 1998;280(11):969-74. 14. Litwin MS, Ron DH, Fink A, Ganz PA, Leake B, Brook RH. The UCLA Prostate Cancer Index: Development, Reliability, and Validity of a Health-Related Quality of Life Measure. Medical Care. 1998;36(7):1002-12. 15. Krongrad A, Perczek RE, Burke MA, Granville LJ, Lai H, Lai S. Reliability of Spanish translations of select urological quality of life instruments. J Urol. 1997;158(2):493-6.
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16. Ware J, Kosinski M, Turner-Bowker D, Gandek B. How to score version 2 of the SF-12 health survey (with a supplement documenting version 1). Quality Metric. Lincoln, RI. 2002. 17. Ware Jr JE, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. Journal of Clinical Epidemiology. 1998;51(11):903-12. 18. Ware Jr JE, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical care. 1996;34(3):220-33. 19. Alonso J, Prieto L, Anto JM. [The Spanish version of the SF-36 Health Survey (the SF-36 health questionnaire): an instrument for measuring clinical results]. Medicina clinica. 1995;104(20):771-6. 20. Michael YL, Berkman LF, Colditz GA, Holmes MD, Kawachi I. Social networks and health-related quality of life in breast cancer survivors: a prospective study. J Psychosom Res. 2002;52(5):285-93. 21. Krishnasamy M. Social support and the patient with cancer: a consideration of the literature. J Adv Nurs. 1996;23(4):757-62. 22. Novotny PJ, Smith DJ, Guse L, Rummans TA, Hartmann L, Alberts S, et al. A pilot study assessing social support among cancer patients enrolled on clinical trials: a comparison of younger versus older adults. Cancer Manag Res. 2010;2:133-42. 23. Harrison J, Maguire P, Pitceathly C. Confiding in crisis: gender differences in pattern of confiding among cancer patients. Soc Sci Med. 1995;41(9):1255-60. 24. Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358(12):1250-61. 25. Chamie K, Kwan L, Connor SE, Zavala M, Labo J, Litwin MS. The impact of social networks and partnership status on treatment choice in men with localized prostate cancer. BJU Int. 2012;109(7):1006-12. 26. Weber BA, Roberts BL, McDougall Jr GJ. Exploring the Efficacy of Support Groups for Men with Prostate Cancer. Geriatric Nursing. 2000;21(5):250-3. 27. Nijboer C, Triemstra M, Tempelaar R, Sanderman R, van den Bos GA. Determinants of caregiving experiences and mental health of partners of cancer patients. Cancer. 1999;86(4):577-88. 28. Miller DC, Litwin MS, Bergman J, Stepanian S, Connor SE, Kwan L, et al. Prostate cancer severity among low income, uninsured men. J Urol. 2009;181(2):579-83; discussion 83-4.
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9 (16.7) 33 (61.1) 10 (18.5) 2 (3.7)
0 (0) 12 (100) 0 (0) 0 (0)
109 114
3 (18.8) 13 (81.2)
116 96
4 (25.0) 12 (75.0) 15 (93.7) 1 (6.3)
140 83
15 (93.7) 1 (6.3)
127 96
9 (56.2) 7 (43.8)
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73 83 66 42 89 46 12
25 (47.2) 28 (52.8) 28 (70.4) 16 (29.6)
6 (37.5) 4 (25.0) 6 (37.5) 3 (23.1) 7 (53.8) 3 (23.1) 0 (0)
1 (8.3) 11 (91.7) 3 (25.0) 9 (75.0)
0.07 0.02
33 (23.4) 67 (47.5) 29 (20.6) 12 (8.5)
<0.01
82 (58.2) 59 (41.8) <0.01 84 (64.1) 47 (35.9) 0.21
8 (66.7) 4 (33.3)
99 (70.2) 42 (29.8)
30 (55.6) 24 (44.4)
8 (66.7) 4 (33.3)
87 (61.7) 54 (38.3)
39 (72.2) 15 (27.8)
6 (50.0) 6 (50.0)
73 (51.8) 68 (48.2)
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150 63
23 (42.6) 31 (57.4)
Social Support 141 60.1 ± 6.1
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1 (6.3) 14 (87.4) 1 (6.3) 0 (0)
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43 126 40 14
Social Support 12 64.7 ± 5.4
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Social Support 54 59.8 ± 5.5
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Number of patients Mean age ± SD Ethnicity (%) White Hispanic Black Other Language (%) English Spanish Education level (%) ≥High School $1500 ≤ $1500 Treatment (%) Radical Retropubic Prostatectomy Radiation therapy D’Amico tumor risk (%) Low Intermediate High BMI (%) <25 25-29 30-35 >35
Social Support 16 60.5 ± 5.1
p-value
0.05
0.07
0.66 17 (31.5) 22 (40.7) 15 (27.8)
2 (16.7) 4 (33.3) 6 (50.0)
48 (34.3) 53 (37.8) 39 (27.9) 0.72
12 (24.5) 17 (34.7) 15 (30.6) 5 (10.2)
2 (22.2) 6 (66.7) 1 (11.1) 0 (0)
25 (21.2) 59 (50.0) 27 (22.9) 7 (5.9)
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Table 2: Health-related Quality of Life Measures at Baseline Stratified by Partnership Status and Social Support Partnered No partner <2 Social Support
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54
Urinary Function
77.7 ± 22.7
64.0 ± 35.1
Urinary Bother
76.7 ± 28.5
68.5 ± 34.2
Sexual Function
23.7 ± 22.5
36.7 ± 33.7
Sexual Bother
36.5 ± 39.0
40.1 ± 39.2
Bowel Function
68.1 ± 33.9
Bowel Bother
66.1 ± 33.4
Number of patients
12
Mental Composite
44.4 ± 9.3
141
0.35
54.2 ± 31.7
61.6 ± 35.8
0.23
31.3 ± 24.8
36.5 ± 31.6
0.51
27.3 ± 32.5
33.6 ± 36.4
0.66
75.6 ± 26.5
58.1 ± 40.5
73.9 ± 28.3
0.26
77.0 ± 31.5
60.4 ± 39.1
71.0 ± 32.8
0.37
40.7 ± 12.3
46.3 ± 10.0
0.23
45.5 ± 6.9
44.1 ± 9.0
0.15
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65.8 ± 31.7
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43.6 ± 11.7
<2 Social Support
55.6 ± 29.2
44.2 ± 11.7
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Physical Composite
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PCI-Short Form
SF-12
≥2 Social Support
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≥2 Social Support
p-value
47.6 ± 10.1
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Table 3: Results From 8 Separate Multivariate Repeated Measures Analysis of Health Related Quality of Life Metrics (β (Standard Error))
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Bowel Bother 0.15 0.01
SF-12 Physical composite 0.09 -0.01
Mental Composite 0.20 0.01
Referent
Referent
Referent
Referent
Referent
-0.36 (0.48)
0.36 (0.29)
0.88 (0.36)*
0.14 (0.13)
-0.15 (0.26)
-0.14 (0.14)
0.06 (0.08)
-0.01 (0.10)
0.05 (0.04)
-0.12 (0.09)
0.31 (0.17)
0.31 (0.21)
0.02 (0.07)
0.27 (0.17)
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time time x time <2 social support, no partner Referent Referent Referent ≥2 social support, -0.16 (0.31) -0.26 (0.91) 0.31 (0.45) no partner <2 social support, -0.01 (0.08) -0.91 (0.35)* -0.02 (0.16) partnered ≥2 social support, 0.38 (0.18)* -0.85 (0.68) -0.09 (0.29) partnered * p <0.05 time, time x time variables are all significant to p <0.05
Bowel Function 0.72 -0.01
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Urinary Bother 1.42 -0.01
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Urinary Function 0.77 -0.01
PCI Short Form Sexual Sexual Function Bother -0.39 -0.81 0.01 0.02
0.07 (0.28)
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Abbreviations HRQOL: Health Related Quality of Life
PII: DOI: Reference:
S2352-0779(16)30182-0 10.1016/j.urpr.2016.05.004 URPR 206
To appear in: Urology Practice Accepted Date: 23 May 2016 Please cite this article as: Baskin A, Kwan L, Zavala M, Chamie K, The Impact of Partnership Status and Social Support on Health Related Quality of Life Outcomes in Men with Prostate Cancer, Urology Practice (2016), doi: 10.1016/j.urpr.2016.05.004. DISCLAIMER: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our subscribers we are providing this early version of the article. The paper will be copy edited and typeset, and proof will be reviewed before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to The Journal pertain. All press releases and the articles they feature are under strict embargo until uncorrected proof of the article becomes available online. We will provide journalists and editors with full-text copies of the articles in question prior to the embargo date so that stories can be adequately researched and written. The standard embargo time is 12:01 AM ET on that date.
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THE IMPACT OF PARTNERSHIP STATUS AND SOCIAL SUPPORT ON HEALTH RELATED QUALITY OF LIFE OUTCOMES IN MEN WITH PROSTATE CANCER
Department of Urology, David Geffen School of Medicine, UCLA, Los Angeles, CA Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA
Corresponding Author: Avi Baskin 300 Stein Plaza, Suite 348 Los Angeles, California 90095 Office: 310-794-2858 Fax: 310-794-3513 Email: [email protected]
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Avi Baskin, MPhil1 Lorna Kwan, MPH1 Mary Zavala, MA, MSW1 Karim Chamie, MD, MSHS1,2
of life
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Abstract Word Count: 242 Manuscript Word Count: 2442 References: 28 Keywords (MeSH Terms): prostatic neoplasms, social support, marital status, health-related quality Running Title: Social support and HRQOL
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FUNDING SOURCE: This work was supported by the National Institutes of Health Loan Repayment Program (L30 CA154326 (Principal Investigator: KC)); and the STOP Cancer Foundation (Principal Investigator: KC).
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ABSTRACT Introduction: We aim to examine the relationship between partnership status and social
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support on longitudinal health-related quality-of-life outcomes in underserved lowincome men with prostate cancer.
Methods: We prospectively analyzed quality of life outcomes across both partnership
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status and the social support of each patient enrolled in a state-funded program for free prostate cancer treatment. The UCLA Prostate Cancer Index Short Form was used to
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quantify urinary, sexual and bowel habits in two domains: bother and function. Physical and mental health were measured with RAND Medical Outcomes Study Short form. We compared four levels of partnership and social support dyads with a repeated measures analysis while controlling for patient characteristics.
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Results: 223 men were eligible for inclusion in our study. Of the 70 patients with a partner, 54 (77%) listed their partner as the only support member, the remaining 16 listed their partner and one or two children as their support group. There were few differences
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in the major quality of life domains of urinary, bowel and bladder function and bother. The physical and mental health scores did not differ by partnership status or social
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support.
Conclusions: While we hypothesized that being partnered and having increased social support would have a positive effect on quality of life, we did not find this association in our longitudinal analysis. We propose that patterns of confiding in others and integration of a nurse case manager are highly gender-based and may provide possible explanations for our findings
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INTRODUCTION Increased social support has been associated with survival, quality of life and better management for patients with cancer. (1-5) Pinquart et al. offered a number of
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explanations for these relationships: biologically mediated through neuroendocrine
pathways; as well as a social support system that prompts individuals to maintain a
healthier diet and lifestyle and utilize healthcare services more consistently. (4) It has also
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been hypothesized that healthy individuals may have a higher probability of building and maintaining broader social support.
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Current consensus suggests that married patients have significantly lower risk of mortality from prostate cancer than those who were divorced, single, separated or widowed. (4, 6, 7) Examining a cohort of uninsured men receiving free prostate cancer treatment, Gore et al. described the positive effect of partnership status on quality of life
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in low-income men with prostate cancer. (8)
However, the issue of collinearity between partnership status and social support with improved outcomes has not been fully explored, and may be attributed to either
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selection bias or cause and effect. In selection bias, those with greater baseline physical and psychological health remain in a committed relationship and have a wider social
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support base. Meanwhile in cause and effect, partnership status enhances social support, which improves survival and health-related quality of life (HRQOL). There is a dearth of literature exploring the impact of partnership status and social support as predictors of longitudinal HRQOL in prostate cancer. These measures are particularly important to patients with prostate cancer, given the variant treatment-related adverse effects such as urinary incontinence, erectile dysfunction, and bowel dysfunction. (9) Our study aims to
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explore the possibility that fostering social connections, via a partnership or wider support group, may predict better HRQOL. We hypothesize that patients with more social
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support and a partner will report better HRQOL outcomes.
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MATERIALS AND METHODS Study Population: We prospectively analyzed data from men enrolled in the UCLA Men’s Health
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Study (MHS). Men enrolled in this study are drawn from a state-funded prostate cancer
treatment program—Improving Access, Counseling, and Treatment for Californians with Prostate Cancer (IMPACT)—that provides free medical care and case management
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services to low-income, uninsured and underinsured California residents. All IMPACT Program participants receive telephonic case management services, including care
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coordination, health education, support and referrals from the program’s clinical team, comprised of nurse case managers and specialized paraprofessionals. (10) To be included in this study, IMPACT patients must have undergone treatment with curative intent in the form of radical prostatectomy, radiation therapy or brachytherapy. Exclusion criteria
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included patients with metastatic disease at enrollment, patients who speak a primary language other than English or Spanish, diagnosis outside the US, and those participants without pre-treatment data or without one-year post-treatment data. UCLA Men’s Health
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Study questionnaire was administered every 6 months for up to 5 years. Study variables:
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Upon enrollment in IMPACT, each patient identified individuals with whom the
clinical team could communicate with to assist in the care of his prostate cancer, referred to as his ‘social support’ for this study. Only individuals who were directly involved with the patient’s care on two or more occasions were included. These individuals could participate in clinic and laboratory visits, nursing education, and other sessions. We categorized the social support into those with <2 or ≥2 named individuals. Partnership
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status was defined as either partnered (living with a spouse or partner or being in a significant relationship but not living together) versus not partnered (not in a significant relationship). We combined these two variables to create a four-level category for
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analysis: <2 in the support group with and without a partner, and ≥2 in the support group with and without a partner. We stratified the cohort into <2 vs ≥2 for multiple reasons.
First, we wanted to look at the effect of both partnership status and saturation of social
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support group on our population. By definition, if a patient has a partner they have a
support member. Moreover, stratifying the cohort at 0 vs >0 social support would result
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in cell sizes with 0 (partnered patients without any further social support). Therefore, given the complexities of dealing with language barriers and contacting patients in the IMPACT program, we decided to combine social support group and partnership status in
Covariates:
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the analysis.
We abstracted records for both demographic and clinical variables, including
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patient age at program enrollment, race (white vs non-white), BMI (<25, 25–29, 30–35, >35), language (English vs Spanish), education level (≥high school vs
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annual household income (>$1500 vs ≤$1500), treatment type (radical prostatectomy vs radiation therapy) and provider type (public vs private). Median household income of $1500 was used based on prior investigations in the IMPACT population. We also quantified coexisting medical problems using the Charlson Comorbidity Index (0 vs >0). (11) We used the validated D’Amico criteria, which includes PSA at the time of biopsy, clinical Gleason score, and clinical stage at diagnosis. (12) Tumors were classified as low
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(PSA <10 ng/mL, Gleason score <7 and clinical stage ≤T2a), intermediate (PSA 10–19.9 ng/mL, Gleason score 7 or clinical stage T2b) or high D’Amico risk (PSA ≥20 ng/mL,
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Gleason score ≥8 or clinical stage ≥T2c). (13)
Outcome Measures:
The UCLA Prostate Cancer Index Short Form (PCI-SF) is a questionnaire used to
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measure urinary, sexual and bowel habits in two domains: bother and function. (14) Scores range from 0–100, with higher scores denoting better outcomes. This
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questionnaire has been validated in men with prostate cancer for both Spanish and English speakers. (14, 15) We used the RAND Medical Outcomes Study Short Form-12 version 2 (SF-12), a shorter version of the Short-Form Health Survey (SF-36), to measure both physical and mental health in eight domains. (16-18) The scores range from 0–100,
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where a greater score indicates a better level of health. The physical and mental health composite scores are calculated from a combination of weighted scores of the eight domains and then standardized to the national norm with a mean of 50.0 and standard
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deviation of 10.0. Physical and mental health scores of the SF-12 correlate well with the SF-36 (R2 = 0.905 and 0.938, respectively). (18) These HRQOL measures have been
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validated in Spanish speaking populations. (15, 19) For this analysis, we analyzed the two composite scores.
Statistical Analysis:
Patient characteristics were compared across the four groups with Chi-square test for categorical variables and ANOVA for continuous variables. We then conducted
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separate multivariable, repeated-measures analyses for each of the 8 HRQOL outcomes to compare the four groups over time. We used the unpartnered men with <2 people in their support group as the referent group due to it being the largest group (n=141).
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Variables that had a p-value of 0.20 or less in the univariate analyses were considered for multivariable analyses. However, race, provider type, and treatment type were included
irrespective of statistical significance. We used a backwards selection process to achieve
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with a quadratic time variable (i.e. time x time).
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the most parsimonious model. For each outcome, we also tested non-linear time trends
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RESULTS 223 men were eligible for inclusion under the study criteria. The mean (SD), median and range of income for the whole group was $7728.33 ($8333.82), $4800, $0–
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40,800. The number of follow-ups interviews by participants ranged from 1 to 10. The
majority of men had 2 or more follow-up visits (81%), with 19% having 9 or more follow up visits. Patients with ≥2 people in their social support group were more likely to speak
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Spanish and had less formal education than those with <2 people in their social support group, regardless of partnership status (Table 1). Of the 70 patients with a partner, 54
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(77%) listed their partner as the only support member, the remaining 16 listed their partner and one or two children as their support group. Participants who were partnered and had ≥2 in their social support group were more likely to have a higher income. There was no difference in the pre-treatment HRQOL for both PCI-SF and SF-12
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measures between the groups. (Table 2) This includes urinary, sexual and bowel function and bother as well as mental and physical composite scores. In the multivariable, repeated measures analyses, several variables were
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statistically significant as main effects. Patients treated with radiation therapy had
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improved urinary function (β=21.05, p<0.0001), sexual function (β=10.15, p=0.0019), and sexual bother (β=9.05, p=0.0192), but worse physical health than patients who underwent radical prostatectomy (β=-2.77, p=0.0118). Men with D’Amico high-risk prostate cancer had worse sexual function (β=-12.51, p=0.0017), sexual bother (β=-14.26, p=0.0025), and bowel bother than those with low-risk disease (β=-7.73, p=0.0433). Nonwhite patients had worse sexual function than white patients (β=-12.18, p=0.0062), but had better mental health (β=4.00, p=0.0034). Finally, men with comorbidities had
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worse bowel function (β=-5.78, p=0.0317) and physical health (β=-4.27, p=0.0003) than men with no comorbid conditions. There were few differences between physical health scores and partnership and
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social support strata over time. (Table 3) Compared with the referent group (no partners and less than two social support members), a partnered patient with ≥2 people in his
support group had worsening urinary function (β=-0.38, p=0.03), and partnered men with
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<2 people in their social support had worsening urinary bother over time (β=-0.91,
p=0.01). Conversely, unpartnered patients with ≥2 people in their social support group
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had an improved bowel bother trend over time (β=0.88, p=0.02). The physical and mental
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health scores from the SF-12 did not differ across groups.
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DISCUSSION We initially hypothesized that increased social support would be positively associated with HRQOL outcomes. While we found a few domains that were congruent
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with existing literature, overall HRQOL, physical and mental health scores were not
different between the levels of social support and partnership. Additionally, the amount of social support was not associated with better outcomes.
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The role of support in prostate cancer, a disease of men, can be most readily compared with breast cancer, predominantly a disease of women. Socially isolated
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women were found to have a higher risk of mortality after a diagnosis of breast cancer than socially un-isolated women. (3) Pre-diagnosis social support appears to be a better predictor of HRQOL among breast cancer survivors than even treatment or tumor characteristics. (20)
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However, in our population of underserved men with prostate cancer, neither social support nor partnership status was found to be associated with improved HRQOL. Some authors suggested that cancer patients’ social relationships may actually provide an
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additional avenue of stress. (21, 22) Why would patients in our population not respond to support the same way as, say, a breast cancer patient? Many have suggested that the lack
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of association may be attributed to gender differences in patterns of confiding in others during a crisis. (23) We offer two possible explanations for the findings based on differences between men and women: 1) with an excess of social support, men are prone to a loss of autonomy and embarrassment due to the multiple symptoms and treatmentrelated side effects, and 2) the unique role of the nurse case manager in the IMPACT
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program may confound the relationship between support and partnership status and HRQOL outcomes. First, for men with prostate cancer, more social support may lead to not only a
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loss of autonomy, but increased embarrassment to the symptoms and treatment-related
complications. During interactions with the IMPACT clinical team, patients often have
their support members on the telephone with them. Of the 223 patients in the study, 207
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identified someone in their support system, with most of these being female. Previous
research in this population has elicited the effect of partnership status and social support
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on treatment choice, each with distinct side effect profiles. (24) For example, married men with fewer than two members in their social cohort were more likely to undergo surgery. (25) The decision to pursue one treatment (and thus side effects) over another, may be difficult to discuss with close female relatives. Moreover, the number of people
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involved in the patient’s care may create a loss of autonomy. As one man with prostate cancer said, “I consider these things [urinary and erectile dysfunction] to be very personal, and I would be uncomfortable talking about them in a group, even if it were just a group
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of men.” (26)
Secondly, the role of the nurse case managers in the program may ameliorate
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some of the challenges facing IMPACT patients who lack the social support of a partner or others. Nurse case managers work individually with patients to tailor interventions specifically for each patient. (10) For those without identified social support, this part of the IMPACT program can help provide many of the perceived benefits. Because each patient had a nurse case manager assigned to them and received individually tailored
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interventions for the duration of their enrollment in IMPACT, it is possible that additional support members (e.g. partners or friends) may not have had an added positive effect. Our study is not without limitations. First, in assessing the social support
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members for each individual enrolled in IMPACT, we used individuals who the patient identified to assist with his care as a proxy measure. We did not query men on social
support directly and thus are limited in assessing the quality of the support. To help stem
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this bias, we only counted social support members who were involved with the patient’s care on two or more occasions. Second, we had no information on the quality of the
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partnership. In patients with poor martial adjustment, the stress of a cancer diagnosis can exacerbate anxiety and depressive symptoms. (27) Third, omitted variable bias that may not be accounted for may explain the lack of association between social support, partnership status and HRQOL. Fourth, our sample was a cohort of severely
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impoverished men. Despite the many services of the IMPACT program, they still face many barriers to care those patients of lower socioeconomic status face. Thus, the results may not be generalizable to men with prostate cancer as a whole. (28) Fourth, missing
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data may have confounded our findings. Finally, in this population, many men present with advanced or metastatic disease. While we controlled for Gleason score and clinical
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stage at diagnosis, it is thus possible that some may never return to baseline sexual, urinary and bowel function irrespective of social support or partnership status.
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CONCLUSIONS Partnership status and social support were not associated with HRQOL in our
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longitudinal analysis of low-income, uninsured and underinsured California residents. We propose that patterns of confiding in others and integration of a nurse case manager
are highly gender-based and may provide possible explanations for our findings. Future
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investigations should be undertaken to further parse out the complex relationship between
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social support and quality of life in prostate cancer patients.
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1. Funch DP, Marshall J. The role of stress, social support and age in survival from breast cancer. Journal of Psychosomatic Research. 1983;27(1):77-83. 2. Ell K, Nishimoto R, Mediansky L, Mantell J, Hamovitch M. Social relations, social support and survival among patients with cancer. Journal of Psychosomatic Research. 1992;36(6):531-41. 3. Kroenke CH, Kubzansky LD, Schernhammer ES, Holmes MD, Kawachi I. Social networks, social support, and survival after breast cancer diagnosis. Journal of clinical oncology : official journal of the American Society of Clinical Oncology. 2006;24(7):1105-11. 4. Pinquart M, Duberstein PR. Associations of social networks with cancer mortality: a meta-analysis. Critical reviews in oncology/hematology. 2010;75(2):122-37. 5. House JS, Landis KR, Umberson D. Social relationships and health. Science (New York, NY). 1988;241(4865):540-5. 6. Krongrad A, Lai H, Burke MA, Goodkin K, Lai S. Marriage and mortality in prostate cancer. J Urol. 1996;156(5):1696-70. 7. Harvei S, Kravdal Ø. The Importance of Marital and Socioeconomic Status in Incidence and Survival of Prostate Cancer. Preventive Medicine. 1997;26(5):623-32. 8. Gore JL, Krupski T, Kwan L, Maliski S, Litwin MS. Partnership status influences quality of life in low-income, uninsured men with prostate cancer. Cancer. 2005;104(1):191-8. 9. Kaplan AL, Crespi CM, Saucedo JD, Connor SE, Litwin MS, Saigal CS. Decisional conflict in economically disadvantaged men with newly diagnosed prostate cancer: Baseline results from a shared decision-making trial. Cancer. 2014;120(17):27217. 10. Maliski SL, Clerkin B, Litwin MS. Describing a nurse case manager intervention to empower low-income men with prostate cancer. Oncology nursing forum. 2004;31(1):57-64. 11. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. Journal of chronic diseases. 1987;40(5):373-83. 12. Boorjian SA, Karnes RJ, Rangel LJ, Bergstralh EJ, Blute ML. Mayo Clinic validation of the D'amico risk group classification for predicting survival following radical prostatectomy. J Urol. 2008;179(4):1354-60; discussion 60-1. 13. D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Blank K, Broderick GA, et al. Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. Jama. 1998;280(11):969-74. 14. Litwin MS, Ron DH, Fink A, Ganz PA, Leake B, Brook RH. The UCLA Prostate Cancer Index: Development, Reliability, and Validity of a Health-Related Quality of Life Measure. Medical Care. 1998;36(7):1002-12. 15. Krongrad A, Perczek RE, Burke MA, Granville LJ, Lai H, Lai S. Reliability of Spanish translations of select urological quality of life instruments. J Urol. 1997;158(2):493-6.
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16. Ware J, Kosinski M, Turner-Bowker D, Gandek B. How to score version 2 of the SF-12 health survey (with a supplement documenting version 1). Quality Metric. Lincoln, RI. 2002. 17. Ware Jr JE, Gandek B. Overview of the SF-36 Health Survey and the International Quality of Life Assessment (IQOLA) Project. Journal of Clinical Epidemiology. 1998;51(11):903-12. 18. Ware Jr JE, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Medical care. 1996;34(3):220-33. 19. Alonso J, Prieto L, Anto JM. [The Spanish version of the SF-36 Health Survey (the SF-36 health questionnaire): an instrument for measuring clinical results]. Medicina clinica. 1995;104(20):771-6. 20. Michael YL, Berkman LF, Colditz GA, Holmes MD, Kawachi I. Social networks and health-related quality of life in breast cancer survivors: a prospective study. J Psychosom Res. 2002;52(5):285-93. 21. Krishnasamy M. Social support and the patient with cancer: a consideration of the literature. J Adv Nurs. 1996;23(4):757-62. 22. Novotny PJ, Smith DJ, Guse L, Rummans TA, Hartmann L, Alberts S, et al. A pilot study assessing social support among cancer patients enrolled on clinical trials: a comparison of younger versus older adults. Cancer Manag Res. 2010;2:133-42. 23. Harrison J, Maguire P, Pitceathly C. Confiding in crisis: gender differences in pattern of confiding among cancer patients. Soc Sci Med. 1995;41(9):1255-60. 24. Sanda MG, Dunn RL, Michalski J, Sandler HM, Northouse L, Hembroff L, et al. Quality of life and satisfaction with outcome among prostate-cancer survivors. N Engl J Med. 2008;358(12):1250-61. 25. Chamie K, Kwan L, Connor SE, Zavala M, Labo J, Litwin MS. The impact of social networks and partnership status on treatment choice in men with localized prostate cancer. BJU Int. 2012;109(7):1006-12. 26. Weber BA, Roberts BL, McDougall Jr GJ. Exploring the Efficacy of Support Groups for Men with Prostate Cancer. Geriatric Nursing. 2000;21(5):250-3. 27. Nijboer C, Triemstra M, Tempelaar R, Sanderman R, van den Bos GA. Determinants of caregiving experiences and mental health of partners of cancer patients. Cancer. 1999;86(4):577-88. 28. Miller DC, Litwin MS, Bergman J, Stepanian S, Connor SE, Kwan L, et al. Prostate cancer severity among low income, uninsured men. J Urol. 2009;181(2):579-83; discussion 83-4.
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9 (16.7) 33 (61.1) 10 (18.5) 2 (3.7)
0 (0) 12 (100) 0 (0) 0 (0)
109 114
3 (18.8) 13 (81.2)
116 96
4 (25.0) 12 (75.0) 15 (93.7) 1 (6.3)
140 83
15 (93.7) 1 (6.3)
127 96
9 (56.2) 7 (43.8)
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73 83 66 42 89 46 12
25 (47.2) 28 (52.8) 28 (70.4) 16 (29.6)
6 (37.5) 4 (25.0) 6 (37.5) 3 (23.1) 7 (53.8) 3 (23.1) 0 (0)
1 (8.3) 11 (91.7) 3 (25.0) 9 (75.0)
0.07 0.02
33 (23.4) 67 (47.5) 29 (20.6) 12 (8.5)
<0.01
82 (58.2) 59 (41.8) <0.01 84 (64.1) 47 (35.9) 0.21
8 (66.7) 4 (33.3)
99 (70.2) 42 (29.8)
30 (55.6) 24 (44.4)
8 (66.7) 4 (33.3)
87 (61.7) 54 (38.3)
39 (72.2) 15 (27.8)
6 (50.0) 6 (50.0)
73 (51.8) 68 (48.2)
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150 63
23 (42.6) 31 (57.4)
Social Support 141 60.1 ± 6.1
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1 (6.3) 14 (87.4) 1 (6.3) 0 (0)
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43 126 40 14
Social Support 12 64.7 ± 5.4
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Social Support 54 59.8 ± 5.5
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Number of patients Mean age ± SD Ethnicity (%) White Hispanic Black Other Language (%) English Spanish Education level (%) ≥High School
Social Support 16 60.5 ± 5.1
p-value
0.05
0.07
0.66 17 (31.5) 22 (40.7) 15 (27.8)
2 (16.7) 4 (33.3) 6 (50.0)
48 (34.3) 53 (37.8) 39 (27.9) 0.72
12 (24.5) 17 (34.7) 15 (30.6) 5 (10.2)
2 (22.2) 6 (66.7) 1 (11.1) 0 (0)
25 (21.2) 59 (50.0) 27 (22.9) 7 (5.9)
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Table 2: Health-related Quality of Life Measures at Baseline Stratified by Partnership Status and Social Support Partnered No partner <2 Social Support
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54
Urinary Function
77.7 ± 22.7
64.0 ± 35.1
Urinary Bother
76.7 ± 28.5
68.5 ± 34.2
Sexual Function
23.7 ± 22.5
36.7 ± 33.7
Sexual Bother
36.5 ± 39.0
40.1 ± 39.2
Bowel Function
68.1 ± 33.9
Bowel Bother
66.1 ± 33.4
Number of patients
12
Mental Composite
44.4 ± 9.3
141
0.35
54.2 ± 31.7
61.6 ± 35.8
0.23
31.3 ± 24.8
36.5 ± 31.6
0.51
27.3 ± 32.5
33.6 ± 36.4
0.66
75.6 ± 26.5
58.1 ± 40.5
73.9 ± 28.3
0.26
77.0 ± 31.5
60.4 ± 39.1
71.0 ± 32.8
0.37
40.7 ± 12.3
46.3 ± 10.0
0.23
45.5 ± 6.9
44.1 ± 9.0
0.15
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65.8 ± 31.7
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43.6 ± 11.7
<2 Social Support
55.6 ± 29.2
44.2 ± 11.7
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Physical Composite
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PCI-Short Form
SF-12
≥2 Social Support
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≥2 Social Support
p-value
47.6 ± 10.1
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Table 3: Results From 8 Separate Multivariate Repeated Measures Analysis of Health Related Quality of Life Metrics (β (Standard Error))
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Bowel Bother 0.15 0.01
SF-12 Physical composite 0.09 -0.01
Mental Composite 0.20 0.01
Referent
Referent
Referent
Referent
Referent
-0.36 (0.48)
0.36 (0.29)
0.88 (0.36)*
0.14 (0.13)
-0.15 (0.26)
-0.14 (0.14)
0.06 (0.08)
-0.01 (0.10)
0.05 (0.04)
-0.12 (0.09)
0.31 (0.17)
0.31 (0.21)
0.02 (0.07)
0.27 (0.17)
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time time x time <2 social support, no partner Referent Referent Referent ≥2 social support, -0.16 (0.31) -0.26 (0.91) 0.31 (0.45) no partner <2 social support, -0.01 (0.08) -0.91 (0.35)* -0.02 (0.16) partnered ≥2 social support, 0.38 (0.18)* -0.85 (0.68) -0.09 (0.29) partnered * p <0.05 time, time x time variables are all significant to p <0.05
Bowel Function 0.72 -0.01
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Urinary Bother 1.42 -0.01
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Urinary Function 0.77 -0.01
PCI Short Form Sexual Sexual Function Bother -0.39 -0.81 0.01 0.02
0.07 (0.28)
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M AN U
SC
RI PT
Abbreviations HRQOL: Health Related Quality of Life