Positive and negative affect and prostate cancer-specific anxiety in Taiwanese patients and their partners

European Journal of Oncology Nursing 37 (2018) 1–11

Contents lists available at ScienceDirect

European Journal of Oncology Nursing journal homepage: www.elsevier.com/locate/ejon

Positive and negative affect and prostate cancer-specific anxiety in Taiwanese patients and their partners

T

Ching-Hui Chiena,∗, Cheng-Keng Chuangb, Kuan-Lin Liub, Chun-Te Wuc, See-Tong Pangb, Ying-Hsu Changb a

College of Nursing, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan Division of Urology, Department of Surgery, Chang Gung Memorial Hospital at Linkou, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan c Division of Urology, Department of Surgery, Chang Gung Memorial Hospital at Keelung, College of Medicine, Chang Gung University, Tao-Yuan, Taiwan b

ARTICLE INFO

ABSTRACT

Keywords: Prostate neoplasms Positive affect Negative affect Prostate cancer-specific anxiety

Purpose: Few studies have examined positive and negative affect and prostate cancer-specific anxiety in prostate cancer patients and their partners. Thus, this study explored positive and negative affect and prostate cancerspecific anxiety as well as their associated factors in prostate cancer patients and their partners. Method: A prospective repeated-measures design was used. Data were collected from 48 prostate cancer patients and their partners when treatment was determined (before treatment) and at 6, 10, 18, and 24 weeks thereafter. The questionnaire included the Expanded Prostate Cancer Index Composite, the Dyadic Adjustment Scale, the Positive and Negative Affect Schedule, and the Memorial Anxiety Scale for prostate cancer. Generalized estimating equations were used for statistical analysis. Results: Patients with lower relationship satisfaction experienced lower positive affect (β = 0.279) and higher negative affect (β = −0.323), and their partners experienced higher prostate specific antigen-related anxiety (β = −0.014). The presence of strong hormonal symptoms aggravated negative affect (β = −0.010) and prostate cancer-related anxiety (β = −0.009), but living with children and grandchildren improved prostate cancer-related anxiety (β = −0.445) and fear of cancer recurrence in patients (β = −0.232). Conclusions: There is an interaction between the prostate cancer-specific anxiety experienced by patients and that experienced by their partners. The emotional state of patients and their partners should be evaluated, and understandable information should be provided. Care strategies should include encouraging adult children to participate in the patients’ care plan, symptom management, and the teaching of coping skills.

1. Introduction In 2015, prostate cancer ranked first as the most common cancer in males, and fifth as a cause of cancer death worldwide (Fitzmaurice et al., 2017). Further, this type of cancer occurs in 90.2% of patients aged 55 years and above (Howlader et al., 2017). The median age of prostate cancer patients in Taiwan and the United States is 73 (Health Promotion Administration, Ministry of Health and Welfare, Taiwan, 2017) and 66 (Howlader et al., 2017) years, respectively. Further, research shows that the dependence of men on their partners gradually increases with age (Olsen et al., 1991; Segrin and Badger, 2010) and that the partner of a patient with prostate cancer is an important companion and caregiver (Segrin and Badger, 2010). The diagnosis and treatment of cancer may result in various types of emotional distress in

patients and their partners, including general anxiety (Chien et al., 2018; Kohler et al., 2014; Tavlarides et al., 2013; Watts et al., 2015), depression (Chien et al., 2018; Kohler et al., 2014; Watts et al., 2015), negative affect (Knoll et al., 2012; Lehto et al., 2017, 2018; Thorsteinsdottir et al., 2017; Voogt et al., 2005), and prostate cancerspecific anxiety (Mehnert et al., 2007; Pearce et al., 2015; Tavlarides et al., 2013), the latter two of which are associated with decreased quality of life (Segrin et al., 2012; Taoka et al., 2014; Tavlarides et al., 2013). In addition, there is an interaction between the emotional states of the patient and his partner (Segrin et al., 2012). Patients with prostate cancer experience poor quality of life due to depression and anxiety, and when their partners also experience depression and anxiety, the quality of their sexual lives suffers as well (Segrin et al., 2012). Higher prostate cancer-specific anxiety, in

Corresponding author. College of Nursing, National Taipei University of Nursing and Health Sciences, No.365, Ming-te Road, Peitou District, Taipei, Taiwan. E-mail addresses: [email protected] (C.-H. Chien), [email protected] (C.-K. Chuang), [email protected] (K.-L. Liu), [email protected] (C.-T. Wu), [email protected] (S.-T. Pang), [email protected] (Y.-H. Chang). ∗

https://doi.org/10.1016/j.ejon.2018.09.004 Received 3 October 2017; Received in revised form 11 August 2018; Accepted 24 September 2018 1462-3889/ © 2018 Elsevier Ltd. All rights reserved.

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

particular, leads to reduced sexual satisfaction and depression (Tavlarides et al., 2013). Positive affect, however, helps to relieve symptoms of physical discomfort (Pressman and Cohen, 2005) and improves the body's ability to repair itself (Sepah and Bower, 2009). Moreover, prostate cancer patients exhibit improved quality of life when they and their partners show significant positive affect (Segrin et al., 2012). The positive and negative affect and prostate cancerspecific anxiety of both the patient and his partner should therefore be considered during a patient's treatment period. Previous studies have focused mainly on the negative affect of prostate cancer patients and their partners (Chambers et al., 2013; Chien et al., 2018; Christie et al., 2009; Fagundes et al., 2012; Hyde et al., 2018; Keller et al., 2017; Knoll et al., 2012; Park et al., 2010; Punnen et al., 2013; Thorsteinsdottir et al., 2017), but few studies have focused on their positive emotions (Keller et al., 2017; Knoll et al., 2012; Segrin et al., 2012). In addition, the prostate cancer-specific anxiety experienced by patients’ partners has not yet been investigated. Thus, we aim to explore the effects of individual, partner, and common factors on positive and negative affect and prostate cancer-specific anxiety in prostate cancer patients and their partners. We hypothesized that negative affect and prostate cancer-specific anxiety of patients are higher than those of their partners, whereas positive affect of patients is lower than that of their partners. Individual, partner (including positive and negative affect), and common factors influence positive and negative affect in patients with prostate cancer and their partners. Similarly, individual, partner (including prostate cancer-specific anxiety), and common factors influence prostate cancer-specific anxiety in patients and their partners.

been widely investigated (Pearce et al., 2015; van den Bergh et al., 2010; Wilcox et al., 2014), and other research has focused on patients who receive different treatments for prostate cancer (Mehnert et al., 2007; Tavlarides et al., 2013, 2015; Thorsteinsdottir et al., 2017). Few studies, however, have focused on the prostate cancer-specific anxiety of both the patients and their partners simultaneously. A cross-sectional study on prostate cancer patients in Germany who received a radical prostatectomy showed that 53% of the patients experienced distress and/or prostate cancer-related anxiety. Finally, the factors that affect prostate cancer-related anxiety include sexual and sleep disorders, pain, fatigue, and nausea (Mehnert et al., 2007). Tavlarides et al. (2013) conducted a study of patients newly diagnosed with prostate cancer in USA and who received a radical prostatectomy revealed that younger patients and those of non-Caucasian race exhibit higher prostate cancer-specific anxiety. Other research has shown that patients with postoperative PSA > 0.1 ng/mL, tumor stage ≥ 2C, and Gleason score > 6 experience higher prostate cancer-specific anxiety (Tavlarides et al., 2015). Patients of younger age, with worse physical health and pain, and who live alone display higher negative intrusive thoughts about prostate cancer (Thorsteinsdottir et al., 2017). 2. Methods 2.1. Research design and sample The study was conducted in two stages. First, a prospective repeated-measures design with purposive sampling was used to recruit patients with prostate cancer and their partners who were receiving standard care. In this first stage, the data were used to examine the hypothesis and to assign a control group to compare the effectiveness of the intervention in the second stage. In the second stage, experimental design with random assignment were used to examine the effectiveness of the two types of psychosocial interventions, involving a comparison with the data of the first stage (control group). The research data served as the first-stage data and were collected from August 2015 to December 30, 2016. These data were not affected by the psychosocial interventions. This allows us to understand the relationship between the variables in a natural situation. Eligible prostate cancer patients and their partners were recruited (with their consent) from the outpatient urology departments of two medical centers in north and south Taiwan. The inclusion criteria for patients were as follows: (1) were first diagnosed with early prostate cancer with TNM staging from I to III who had not started the treatment; (2) decided to receive radical prostatectomy or radiation therapy; and (3) possessed conscious awareness and could communicate in Mandarin. The inclusion criteria for partners were as follows: (1) exhibited domestic partnership with patients involved in the study; and (2) possessed conscious awareness and could communicate in Mandarin. The exclusion criteria for patients or their partners were as follows: (1) a history of other cancers in addition to prostate cancer; (2) an Eastern Cooperative Oncology Group Performance Status level ≥ 2; (3) unaware of cancer diagnosis; (4) suffered from mental illness, such as schizophrenia, depression, anxiety disorder, or dementia; or (5) visually impaired and unable to read.

1.1. Positive and negative affect Positive affect refers to the degree to which a person enjoys life and feels enthusiastic, active, strong, and energetic (Watson and Tellegen, 1985). A person with a higher degree of positive affectivity possesses higher levels of energy and focus as well as participates enthusiastically in activities (Watson et al., 1988). Negative affect refers to the degree to which a person feels sad, distressed, fearful, hostile, anxious, nervous, and scornful (Watson and Tellegen, 1985). Studies show that negative affect influences the support acquired and quality of life in patients with prostate cancer and could be an indicator for intervention (Keller et al., 2017; Voogt et al., 2005). Newton et al. (2007) performed a retrospective cross-sectional study of patients with localized prostate cancer in Australia and found that their positive and negative affectivity was similar to that of the general healthy population. Similarly, Benedict et al. (2015) conducted a crosssectional study on patients with Stages III and IV prostate cancer who received hormone therapy in the United States and noted that their positive affect was greater than their negative affect, although the scores for both were lower than in patients with localized prostate cancer. Segrin and Badger (2010) found that the members of the social networks of breast cancer and prostate cancer patients (partners, children, friends, and parents) who had good levels of relationship satisfaction with the patient experienced higher positive and lower negative affect. Studies on other populations with different cancers have further indicated that positive affect is lower in older patients (Voogt et al., 2005) and patients with lower relationship satisfaction (Knoll et al., 2012) but also that negative affect is higher in younger patients (Voogt et al., 2005) and patients with lower relationship satisfaction (Knoll et al., 2012).

2.2. Data collection During the study period, potential cases were referred to the research assistant by the urologist when patients decided on their treatment. For patients and their partners who visited the hospital together, the research assistant assessed whether they satisfied the inclusion criteria through an interview and a review of their medical records. For patients and their partners who met the criteria, the research assistant explained the objective and content of the study and invited them to participate in the study. When a patient visited the hospital alone, the research assistant assessed whether the patient met the inclusion criteria through an interview and review of his medical records. For the

1.2. Prostate cancer-specific anxiety Prostate cancer-specific anxiety includes prostate cancer-related anxiety, prostate specific antigen-related anxiety (PSA-related anxiety), and fear of cancer recurrence (Roth et al., 2003). The prostate cancerspecific anxiety of patients who receive active surveillance (AS) has 2

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

Fig. 1. Flow diagram in the first stage of the study.

patients who satisfied the criteria, the research assistant explained the object and content of the study and invited them to participate in the study. If a patient was willing to participate in this study, then the research assistant, with the consent and referral of the patient, contacted the partner to conduct an assessment, in person or by telephone, of whether the partner met the criteria. If the partner met the criteria, the research assistant explained the object and content of the study and invited the partner to participate in the study. The first round of data collection commenced when the patients and their partners had agreed to participate and signed the consent form (T0). Data were collected, using questionnaires before treatment (T0), and at 6 (T1), 10 (T2), 18 (T3), and 24 weeks (T4) thereafter. The questionnaires were completed independently by the patients and their partners, with the research assistant's ensuring the absence of mutual interference. During data collection, 221 cases were referred from the Urology Department. A total of 48 patient-and-partner pairs were included in the study. All patients completed all five questionnaires, but two partners dropped out, one at T3 and the other at T4 due to their having too busy a schedule (Fig. 1).

2.3. Ethical considerations Cases were collected after obtaining the approval of the Institutional Review Board. Patients and their partners who met the inclusion criteria were provided with sufficient information and time to understand the purpose and content of the study. They were free to decide whether to participate in the study and to quit at any time during the study period. Refusal to participate or quitting the study did not affect the patient's right to treatment. 2.4. Instruments 2.4.1. Demographic and clinical variables The demographic data collected for the study participants included age, religion, employment status, and educational level. The clinical characteristics of disease for the patients included their self-perceived health status, initial PSA value, Gleason score, TNM cancer staging, and treatment method. The disease characteristics of their partners included their self-perceived health status and menopausal stage. Common 3

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

factors between patients and partners included relationship duration and habitation status. The self-perceived health status was self-reported and scored from 0 to 100, with higher scores’ indicating greater health.

2.5. Data analysis SPSS for Windows V. 20.0 was used for data processing and analysis. The positive and negative affect and prostate cancer-specific anxiety of the study participants were set as the primary outcome. Independent variables included patient, partner, and common factors. Paired samples t-tests were used to examine the differences of primary outcomes between prostate cancer patients and their partners. Univariate generalized estimating equations (GEEs) were used to identify factors that affected these variables during the study period. Variables that were found to be statistically significant in the univariate GEEs were used in the multivariate GEE model.

2.4.2. Physical symptoms The Chinese version of the Expanded Prostate Cancer Index Composite (EPIC) was used to score urinary, bowel, sexual, and hormonal symptoms in the patients (Chien et al., 2018; Wei et al., 2000). The questionnaire contains 50 items, and lower scores indicate the increased presence of symptoms. The English scale showed criterion validity and acceptable internal consistency (Wei et al., 2000). The Cronbach's α values of internal consistency for the Chinese version are as follows: urinary, 0.79–0.89; bowel, 0.82–0.92; sexual, 0.85–0.92; and hormonal, 0.70–0.80 (Chien et al., 2018). In this study, the Cronbach's α values of internal consistency were as follows: urinary, 0.78–0.87; bowel, 0.77–0.87; sexual, 0.84–0.89; and hormonal, 0.68–0.80.

3. Results A total of 48 patients and their partners, who all belong to heterosexual dyads, were enrolled in this study. The average age of the patients was 67.0 ± 6.8 years (standard deviation [SD]). Most patients possessed religious beliefs (77.1%), were either unemployed or retired (52.1%), and had been educated to at least junior high school level (79.2%). About two-thirds (62.5%) of the patients had been diagnosed with a TNM cancer stage of T2N0M0, and 77.1% were treated with a radical prostatectomy. The mean initial PSA value was 23.2 ng/ml. The average age of their partners was 62.0 ± 7.8 years (SD). Most of the partners also possessed religious beliefs (77.1%), were either unemployed or retired (64.6%), had received education up to junior or senior high school level (54.2%), and were not in menopause (77.1%). The average duration of the relationships between the patients and their partners was 37.5 years, and most patients lived with their partners and children (39.6%; Table 1). The mean values and standard deviation of positive affect, negative affect, and prostate cancer-specific anxiety are listed in Table 2.

2.4.3. Relationship satisfaction The marital satisfaction subscale of the Dyadic Adjustment Scale in Chinese was used to measure the study participants' relationship satisfaction (Hsieh, 1997). Fourteen items were included in the subscale. A 5-point Likert scale was used, with higher scores' indicating higher levels of relationship satisfaction. The scale showed good construct validity, and the Cronbach's α for internal consistency is 0.94 (Hsieh, 1997). In this study, the Cronbach's α values of internal consistency for the patients and their partners were 0.86–0.89 and 0.87–0.95, respectively. 2.4.4. Positive and negative affect The Chinese version of the Positive and Negative Affect Schedule (PANAS) (Hu, 2005; Watson et al., 1988) was used to measure the positive and negative affect of the study participants. Twenty items were used, and the answers were recorded using a 5-point Likert scale. Higher scores indicated higher levels of positive or negative affectivity. The English version of the scale exhibited good construct validity and very good internal consistency (Watson et al., 1988). In this study, the Cronbach's α values of internal consistency for the positive and negative affect subscales, respectively, were 0.76–0.87 and 0.89–0.90 in the patients, and 0.83–0.86 and 0.89–0.94 in their partners.

Table 1 Participant demographics and clinical characteristics at baseline. Variable

Age, mean (SD) Religion No Yes Employment status Unemployed/Retired Employed Educational level Below primary school Junior or senior high school College and above During menopausal stage No Yes TNM cancer stage T2N0M0 T3N0M0 Gleason score Low risk (5–6) Intermediate risk (7) High risk (8–10) Initial prostatic specific antigen, mean (SD) Treatment method Radical prostatectomy Radiotherapy Relationship duration (years), mean (SD) Habitation status Partner only Partner and children Partner, children, and grandchildren

2.4.5. Prostate cancer-specific anxiety The Memorial Anxiety Scale for prostate cancer (MAX-PC; Roth et al., 2003) was used to measure study participants' prostate cancerspecific anxiety experienced. This scale contains 18 items, including prostate cancer-related anxiety, PSA-related anxiety, and fear of cancer recurrence. A four-point Likert scale was used, with higher scores' indicating higher anxiety levels. The English version of the scale showed good construct, concurrent, and discriminant validity. The Cronbach's α value of overall internal consistency is 0.89 (Roth et al., 2003, 2006). With the developer's consent, a bilingual speaker translated the English version into Chinese. Another bilingual speaker then backtranslated the Chinese version into English, and a native English speaker who had not participated in the translation reviewed the semantic similarity between the original and back-translated versions. This translation process was repeated until the meaning of both versions was similar. The overall content validity index was 1. In this study, the Cronbach's α values for internal consistency for patients and partners, respectively, were 0.93–0.94 and 0.86–0.93 for the prostate cancer anxiety-related subscale, and 0.80–0.91 and 0.72–0.88 for the PSA-related anxiety subscale. All values for the fear of cancer recurrence subscale for patients were within 0.77–0.82, except for T1 (0.58); and, for partners, all values were within 0.73–0.76, except for T1 (0.65) and T4 (0.58). 4

Patient (n = 48)

Partner (n = 48)

n

n

%

%

67.0 (6.8)

62.0 (7.8)

11 37

22.9 77.1

11 37

22.9 77.1

25 23

52.1 47.9

31 17

64.6 35.4

10 19 19

20.8 39.6 39.6

17 26 5

35.4 54.2 10.4

37 11

77.1 22.9

30 18

62.5 37.5

28 58.3 16 33.3 4 8.4 23.2 (33.9) 37 77.1 11 22.9 37.5 (11.0) 18 19 11

37.5 39.6 22.9

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

Table 2 Differences of positive and negative affect and prostate cancer-specific anxiety between patients and partner. Variable (scale range)

Positive and negative affect Positive affect (10–50) Negative affect (10–50) Prostate cancer-specific anxiety Prostate cancer-related anxiety (0–33) PSA-related anxiety (0–9) Fear of cancer recurrence (0–12)

T0

T1

T2

T3

T4

Before treatment

6 weeks

10 weeks

18 weeks

24 weeks

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Mean (SD)

Patient Partner t-value Patient Partner t-value

28.44 (7.26) 27.46 (7.68) 0.689 17.71 (6.48) 18.54 (7.37) −0.620

28.46 (8.60) 26.42 (7.41) 1.421 15.92 (7.02) 18.35 (7.16) −1.832

26.79 (7.72) 26.75 (7.76) 0.033 15.33 (6.30) 18.06 (6.38) −2.953**

27.51 (8.39) 28.21 (7.89) −0.523 16.21 (6.43) 17.06 (5.59) −0.706

29.28 (7.90) 27.89 (7.69) 1.215 15.52 (5.05) 17.65 (6.44) −2.155*

Patient Partner t-value Patient Partner t-value Patient Partner t value

12.44 (9.23) 15.50 (7.94) −1.960 1.79 (2.41) 1.94 (2.12) −0.337 5.88 (2.37) 6.13 (2.20) −0.592

11.38 (8.26) 16.11 (7.71) −3.426** 1.38 (1.75) 1.92 (2.45) −1.476 5.69 (1.73) 6.27 (1.94) −1.611

10.33 (7.96) 14.19 (8.75) −2.989** 1.25 (1.92) 2.04 (2.19) −2.379* 5.17 (2.21) 5.63 (2.44) −0.918

12.66 (7.38) 14.21 (7.75) −1.254 1.45 (1.86) 1.53 (1.74) −0.277 5.04 (2.16) 5.47 (2.47) −0.961

11.37 (7.19) 14.02 (6.48) −1.963 1.24 (1.55) 1.80 (2.07) −1.778 4.89 (2.30) 5.22 (1.78) −0.715

*p < 0.05, **p < 0.01, ***p < 0.001.

partners and children: β = −0.358, p = 0.013; live with partners vs. live with partners, children, and grandchildren: β = −0.445, p = 0.014). Patients with an educational level of junior or senior high school showed higher PSA-related anxiety than did those with an educational level below primary school (β = 0.267, p = 0.027). Patients' PSA-related anxiety was higher when they experienced more bowel symptoms (β = −0.008, p = 0.030), when their partners' self-perceived health condition was satisfactory (β = 0.007, p = 0.029), and when their partners’ PSA-related anxiety was higher (β = 0.151, p = 0.006). The partners of patients with religious beliefs exhibited higher PSArelated anxiety than that of patients with no religious beliefs (β = 0.261, p = 0.007). Partners experienced higher PSA-related anxiety when the patients' relationship satisfaction was lower (β = −0.014, p = 0.027) and when the patients’ PSA-related anxiety was higher (β = 0.234, p = 0.013). Patients' fear of cancer recurrence was higher when their self-perceived health status was poor (β = −0.005, p = 0.020). Patients whose partners had religious beliefs exhibited less fear of cancer recurrence than did those whose partners had no religious beliefs (β = −0.211, p = 0.027). Patients who lived with their partners, children, and grandchildren showed less fear of cancer recurrence than did those who lived with only their partner (β = −0.232, p = 0.033). None of the factors tested affected the partners’ fear of cancer recurrence.

3.1. Factors that influence positive affect Tables 3 and 4 show the factors associated with positive affect, using the univariate GEE model. The results of multivariate GEE analysis (Table 5) showed that positive affect was lower when the relationship satisfaction of the patient was lower (β = 0.279, p = 0.013). In addition, when the self-perceived health status of the partners was poor, their positive affect was lower (β = 0.017, p < 0.001) (Table 5) (see Table 6). 3.2. Factors that influence negative affect Tables 3 and 4 contain the factors associated with negative affect, using the univariate GEE model. The results of the multivariate GEE model (Table 5) showed that the patients who receive radiation therapy exhibited lower negative affect than did those who received a radical prostatectomy (β = −0.244, p = 0.031). A stronger presence of hormonal symptoms in patients was associated with a higher negative affect (β = −0.010, p = 0.041). Further, patients' negative affect was higher when their relationship satisfaction was lower (β = −0.323, p < 0.001) and when their partners' negative affect was higher (β = 0.149, p = 0.032). Similarly, partners' negative affect was higher when their relationship satisfaction was lower (β = −0.246, p < 0.001) and when the patients’ negative affect was higher (β = 0.197, P = 0.012).

4. Discussion

3.3. Factors that influence prostate cancer-specific anxiety

A total of 48 heterosexual patient-and-partner dyads who were coping with prostate cancer were recruited in this study. Similar to previous studies (Christie et al., 2009; Fagundes et al., 2012; Keller et al., 2017), the current study found that both patients with prostate cancer and their partners experienced higher positive affect than negative affect during the study period. Based on the mean score for negative affect, as per our expectation, the patients (Christie et al., 2009) and their partners (Couper et al., 2006) experienced the highest negative affect before treatment, including distress and upset, which is similar to the findings of previous studies. The patients’ partners experienced more negative affect and prostate cancer-specific anxiety than did the patients, which was inconsistent with the study hypothesis. However, previous studies have shown that the partners of prostate cancer patients experience higher levels of general anxiety and depression than patients do themselves (Couper et al., 2006; Soloway

Tables 3 and 4 present the factors associated with prostate cancerrelated anxiety, PSA-related anxiety, and fear of cancer recurrence, using the univariate GEE model. The results of the multivariate GEE model (Table 5) showed that patients who experience higher levels of hormonal symptoms had higher levels of prostate cancer-related anxiety (β = −0.009, p = 0.021). Patients whose partners had religious beliefs exhibited lower prostate cancer-related anxiety than did those whose partners had no religious beliefs (β = −0.389, p = 0.010). There was a positive association between the patients' prostate cancer-related anxiety and that of their partners (i.e., if the patient's was higher, so was the partner's, and vice versa; β = 0.246, p < 0.001). Patients who live with their partners and children, or with partners, children, and grandchildren, showed lower prostate cancer-related anxiety than did those who live with their partners only (live with partners vs. live with 5

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

Table 3 Associated factors for positive and negative affect and prostate cancer-specific anxiety in patients. Variable

Patient factors Age Religion No Yes Employment status Unemployed/Retired Employed Educational level Below primary school Junior or senior high school College and above Self-perceived health status Treatment method Radical prostatectomy Radiotherapy TNM cancer stage T2N0M0 T3N0M0 Physical symptoms Urinary Bowel Sexual Hormonal Relationship satisfaction Partner factors Age Religion No Yes Employment status Unemployed/Retired Employed Educational level Below primary school Junior or senior high school College and above Self-perceived health status In menopause No Yes Relationship satisfaction Positive affects Negative affects Prostate cancer- specific anxiety Prostate cancer- related anxiety PSA-related anxiety Fear of cancer recurrence Common factors Habitation status Partner only Partner and children Partner, children, and grandchildren

Positive affect

Negative affect

Prostate cancer- related anxiety

PSA-related anxiety

Fear of cancer recurrence

β

SE

β

SE

β

SE

β

SE

β

SE

.012

.016

-.014

.006∗

-.030

< .001***

-.019

.009∗

-.009

.007

(reference) .309 .189

-.151

.154

-.225

.203

.079

.156

-.067

.100

(reference) .308 .168

-.053

.129

-.171

.170

-.139

.143

-.183

.095

(reference) .235 .206 .395 .200∗ .006 .005

.164 .093 -.005

.186 .176 .003

.452 .289 -.004

.240 .238 .004

.392 .260 -.004

.148** .124∗ .004

.042 .080 -.007

.138 .139 .003∗

(reference) -.381 .215

-.280

.121∗

-.309

.187

-.072

.144

-.175

.097

(reference) -.234 .172

.054

.141

.153

.173

.279

.149

.166

.092

.004 .005 -.003 .005 .277

.002 .004 .003 .004 .110∗

-.001 -.006 .004 -.014 -.361

.002 .003 .002 .005** .082***

-.001 -.008 -.001 -.012 -.242

.002 .003** .003 .004** .096∗

-.004 -.011 -.001 -.012 -.228

.002 .003*** .003 .004** .085**

-.004 -.002 < .001 -.013 -.163

.002∗ .005 .002 .005∗ .085

-.007

.012

-.005

.007

-.026

.009**

-.012

.009

-.005

.005

(reference) .064 .162

-.245

.163

-.471

.200∗

.068

.151

-.221

.110∗

(reference) .211 .171

.005

.126

-.036

.178

-.143

.141

-.056

.109

(reference) < .0001 .208 .341 .245 .001 .004

.029 .001 -.002

.140 .176 .003

.115 -.114 .002

.201 .225 .003

.053 -.207 .007

.164 .146 .003∗

.036 -.060 -.005

.117 .113 .003

.160 -.090

.147 .073

.249 -.101

.191 .092

.354 .019

.170∗ .087

.106 -.066

.124 .081

.175

.075∗ .248

.066***

.203

.051***

.025

.075

.036 -.285

.176 .157

-.131 -.323

.107 .125**

(reference) .036 .197 -.002 .121 .084 .106

(reference) -.259 .174 -.230 .255

-.147 -.336

.144 .185

-.309 -.570

.184 .223∗

∗

*p < 0.05,**p < 0.01,***p < 0.001.

et al., 2005), and a similar phenomenon has been observed for prostate cancer-related anxiety. The range for negative affect experienced by the partners was 17.06–18.54, which is similar to that of previous studies (19.46) (Fagundes et al., 2012). Christie et al. (2009) studied patients with early prostate cancer who were receiving various treatments in the United States and found that the negative and positive affect of the patients was in the range of 14.00–19.67 and 31.53–33.58, respectively, before treatment and up to six months after treatment. The negative affect of patients in the present study (15.33–17.71) was similar, whereas their positive affect (26.79–29.28) was lower than that reported by Christie et al. Hence, further study of prostate cancer-specific anxiety and positive affect experienced by prostate cancer patients and their partners is warranted, particularly in the Asian population.

In this study, the religious beliefs of patients and their partners were not associated with their own prostate cancer-related anxiety. In contrast, patients whose partners possessed religious beliefs experienced less prostate cancer-related anxiety and fear of cancer recurrence, whereas the partners of patients with religious beliefs experienced higher PSA-related anxiety. In time, and with changes in the side effects of treatment, different results will be obtained if patients and/or their partners change their religious behavior. Previous research has shown that religious beliefs are not associated with negative affect in cancer patients (Voogt et al., 2005). Some studies, however, have found that patients with prostate cancer are willing to adopt religious and spiritual coping behavior when they experience discomforting symptoms and increased anxiety (Hamrick and Diefenbach, 2006). The adoption of religious coping behavior is related to decreased emotional function 6

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

Table 4 Associated factors of positive and negative affect, and prostate cancer-specific anxiety in partners. Variable

Patient factors Age Religion No Yes Employment status Unemployed/Retired Employed Educational level Below primary school Junior or senior high school College and above Self-perceived health status Treatment method Radical prostatectomy Radiotherapy TNM cancer stage T2N0M0 T3N0M0 Physical symptoms Urinary symptoms Bowel symptoms Sexual symptoms Hormonal symptoms Relationship satisfaction Positive affect Negative affect Prostate cancer-specific anxiety Prostate cancer-related anxiety PSA-related anxiety Fear of cancer recurrence Partner factors Age Religion No Yes Employment status Unemployed/Retired Employed Educational level Below primary school Junior or senior high school College and above Self-perceived health status In Menopause No Yes Relationship satisfaction Common factors Habitation status Partner only Partner and children Partner, children, and grandchildren

Positive affect

Negative affect

Prostate cancer- related anxiety

PSA-related anxiety

Fear of cancer recurrence

β

SE

β

SE

β

SE

β

SE

β

SE

-.013

.013

-.003

.010

-.008

.012

-.002

.009

-.003

.009

(reference) .105 .182

.315

.159*

.230

.173

.385

.096***

.077

.081

(reference) .260 .166

-.189

.139

-.200

.146

-.166

.122

-.144

.087

(reference) .215 .206 .532 .195** .003 .003

-.234 -.152 < .001

.192 .199 .003

.190 .147 < .001

.193 .174 .004

.069 .077 -.001

.147 .133 .005

.092 -.028 -.001

.099 .084 .003

(reference) .046 .236

-.100

.168

-.153

.185

.003

.170

.017

.101

(reference) -.147 .172

-.287

.136*

-.228

.151

.071

.143

-.127

.078

-.001 -.001 -.001 -.007 -.035

.002 .003 .002 .004 .091

-.004 -.001 -.002 -.002 -.028

.002 .002 .003 .004 .083

-.005 -.005 -.004 -.010 -.022

.002 .003 .003 .004* .006***

-.002 < .001 -.002 .001

.002 .004 .002 .003 .006

.201

.080* .272

.079***

.296

.090**

.001 -.004 .002 -.004 .194 .113

.002 .004 .002 .006 .112 .094

.004

.029

.081

-.012

.011

-.010

.010

-.002

.012

-.006

.008

< .001

.005

.044

.169

.047

.195

.140

.194

.246

.116*

.073

.078

(reference) .265 .180

.053

.155

.030

.153

.057

.119

-.051

.088

(reference) .307 .173 .626 .165*** .018 .005***

-.044 -.281 .003

.153 .195 .004

-.052 -.130 .004

.171 .219 .004

.057 .116 < .001

.135 .284

-.055 -.127 .002

.099 .143 .003

(reference) .010 .228 .110 .093

.120 -.290

.163 -.015 .074***

.310 -.016

.122* .007*

-.073 -.005

.117 .005

-.039 -.166

.151 .161

.055 .178

.091 .138

(reference) -.378 .187* -.046 .194

-.105 .029

.166 .174

.001 .048

-.125

.173

.163 .218

.083

.004

*p < 0.05, **p < 0.01, ***p < 0.001.

(Gall, 2004). Further, partners who adopted religious coping behavior by themselves exhibited greater degrees of dysfunctional problem solving and impulsivity/carelessness than did those who adopted religious coping behavior simultaneously with the patients (Yoshimoto et al., 2006). This phenomenon needs to be clarified in future studies. Previous studies have shown that education is not significantly associated with PSA-related anxiety in the prostate cancer population (Nelson et al., 2016). However, in the present study, education level did affect PSA-related anxiety in the patients. This may indicate that, in the early phase of the disease, junior or senior high school-educated patients had more awareness regarding PSA than did patients who had not completed primary school. The former group's ability to understand and acquire relevant information was, nevertheless, poorer than that of the

college-educated patients. Therefore, disease-related information and teaching strategies should be tailored to patients' education level. In this study, patients with prostate cancer were less worried about cancer recurrence when their health status was self-perceived to be good, which is similar to previous studies (Thorsteinsdottir et al., 2017; van den Bergh et al., 2010). Partners also have a higher positive affect when their self-perceived health status is good. Interestingly, however, patients experience higher PSA-related anxiety when their partners have a good self-perceived health status. Prostate cancer patients with healthy partners probably expect the cancer to be controlled or cured and, thus, focus on monitoring medical reports and changes in PSA levels. In contrast to a study on patients with localized prostate cancer who 7

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

Table 5 Associated factors of positive and negative affect by multiple GEEs. Patient

Partner β

SE

p

β

Positive affect Patient factors Educational level Below primary school Junior or senior high school College and above Relationship satisfaction

.212 .362 .279

(reference) .195 .195 .113

Patient factors Educational level Below primary school Junior or senior high school College and above Partner factors Educational level Below primary school Junior or senior high school College and above Self-perceived health status Common factors Habitation status Partner only Partner and children Partner, children, and grandchildren

.277 .064 .013*

(reference)

.157 .342 .017

.801 .309

(reference) .045 .179 .190 .187 .005 < 0.001*** (reference) .173 .174

.126 .762

.211

(reference) .117

.070

-.228 .197

(reference) .116 .079

.050 .012*

-.246

.072

-.264 .053

Negative affect

-.006

.006

-.244 -.010 -.323

(reference) .113 .031* .005 .041* .078 < .001***

.149

p

Positive affect

Negative affect Patient factors Age Treatment method Radical prostatectomy Radiotherapy Hormonal symptoms Relationship satisfaction Partner factors Negative affect

SE

.070

Patient factors Religion No Yes Cancer stage T2N0M0 T3N0M0 Negative affect Partner factors Relationship satisfaction

.356

.032*

< .001***

*p < 0.05, **p < 0.01, ***p < 0.001.

had received treatment for 33–72 months in Australia (Newton et al., 2007), the present study found that the patients who had received a radical prostatectomy experienced higher negative affect within six months of the determination of treatment than did those who had received radiation therapy. Possible reasons could be that patients who received a radical prostatectomy had to face the cancer diagnosis, hospitalization, anesthesia, surgery, postoperative pain, limitation of activity, and other stressful conditions. Early prostate cancer patients with serious hormonal symptoms experienced more anxiety and a stronger depressive mood (Chien et al., 2018). The current study, however, demonstrates that patients’ negative affect, prostate cancerrelated anxiety, or PSA-related anxiety was related mainly to bowel and hormonal functions. When patients experienced worsened hormonal function, including hot flashes and breast tenderness, they experienced considerable negative affect and prostate cancer-related anxiety. Similarly, those who suffered worsened bowel function, including watery and bloody stools, experienced substantial PSA-related anxiety. The negative affect of the patients and their partners, and their prostate cancer-related anxiety and PSA-related anxiety, interact with each other. Therefore, proper management of the discomforting symptoms of prostate cancer may help to improve the negative affect, prostate cancer-related anxiety, and PSA-related anxiety experienced by both the patients and their partners. In this study, prostate cancer patients who lived with partners and their children and grandchildren experienced less prostate cancer-related anxiety and fear of cancer recurrence than did those who lived with only their partner; however, similar results were not found for negative affect. Previous studies on prostate cancer survivors indicated that married survivors with a higher degree of support experienced less general anxiety than did married survivors with a lower degree of support (Kamen et al., 2015); Patients who lived alone had more negative intrusive thoughts than did those who lived with a partner

(Thorsteinsdottir et al., 2017). In traditional Taiwanese culture, the elderly are cared for by their family, as many live with their descendants, and adult children are expected to care for their elderly parents as part of their filial duty. In addition, elderly people are generally grandparents, who enjoy the company of their grandchildren, contributing to their happiness (Lee, 2015). Prostate cancer patients who live with their children and grandchildren can benefit from their support and substantial resources, including company and conversation, assistance in daily living, obtaining disease-related resources, and mental support, all of which are directly applicable in disease care. Prostate cancer patients, however, also may receive support from other family members and friends (Boehmer and Babayan, 2005; Segrin and Badger, 2010). Data regarding the level of support that patients perceived from partners, children, other family members, and friends, however, were not collected in this study. The results of this study can be understood as implying that the relationship between available sources, support systems, self-perceived support from others, and prostate cancer-specific anxiety are important in Asian prostate cancer patients without partners. Further studies are needed to clarify these issues in prostate cancer patients who have partners versus those who do not. Previous studies in the United States revealed a significant correlation between general anxiety, cancer-specific depression, and positive affect experienced by prostate cancer patients and their partners (Segrin et al., 2012). This phenomenon, however, was not observed in this study. Instead, negative affect, prostate cancer-related anxiety, and PSA-related anxiety were important predictors of each other in both the patients and their partners. Similar to the findings for prostate cancer patients in Germany (Knoll et al., 2012), the patients in the present study experienced greater negative affect and reduced positive affect when their relationship satisfaction was lower. Furthermore, relationship satisfaction was a key predictor of negative affect in the patients' 8

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

Table 6 Associated factors of prostate cancer-specific anxiety by multiple GEEs. Patient

Partner β

SE

p

β

Prostate cancer-related anxiety Patient factors Age Bowel symptoms Hormonal symptoms Relationship satisfaction Partner factors Age Religion No Yes Prostate cancer-related anxiety Common factors Living status Partner only Partner and children Partner, children, and grandchildren

-.020 -.004 -.009 -.168

.014 .003 .004 .091

.151 .130 .021* .065

-.003

.013

.818

-.389 .246

(reference) .151 .010** .057 < .001***

-.358 -.445

.144 .181

Patient factors Prostate cancer-related anxiety

.272

.079

.001***

.261 < .001 -.014 .234

(reference) .097 < .001 .007 .094

.007** .318 .027* .013*

.124

(reference) .088

.160

.192 -.011

(reference) .108 .006

.075 .077

.013* .014* PSA-related anxiety

-.009

.008

.267 .138 -.002 -.008 -.005 -.141

(reference) .121 .113 .002 .004 .004 .079

.027* .223 .348 .030* .217 .076

.007

.003

.029*

.264 .151

(reference) .153 .054

Patient factors Religion No Yes Hormonal symptoms Relationship satisfaction PSA-related anxiety Partner factors Religion No Yes In menopause No Yes Relationship satisfaction

.218

.086 .006**

Fear of cancer recurrence Patient factors Self-perceived health status Urinary symptoms Hormonal symptoms Partner factors Religion No Yes Common factors Habitation status Partner only Partner and children Partner, children, and grandchildren

p

Prostate cancer-related anxiety

PSA-related anxiety Patient factors Age Educational level Below primary school Junior or senior high school College and above Urinary symptoms Bowel symptoms Hormonal symptoms Relationship satisfaction Partner factors Self-perceived health status In menopause No Yes PSA-related anxiety

SE

Fear of cancer recurrence

-.005 -.003 -.009

.002 .002 .005

.020* .078 .059

-.211

(reference) .095

.027*

-.108 -.232

(reference) .095 .109

.256 .033*

*p < 0.05, **p < 0.01, ***p < 0.001.

partners, which was similar to the findings of previous studies (Hyde et al., 2018). The relationship satisfaction of the partners, however, was not associated with prostate cancer-related anxiety, PSA-related anxiety, or fear of cancer recurrence in either the patients or their partners. Instead, the factors that predict the partners' PSA-related anxiety included the patients' relationship satisfaction and PSA-related anxiety. The patients' prostate cancer-related anxiety, however, was the only predictor of their partners' prostate cancer-related anxiety. This could be because partners tend to give heightened attention to patients when prostate cancer is diagnosed. Therefore, the factors that affect the partners’ prostate cancer-related and PSA-related anxiety stem mainly from the response of the patients, rather than from their individual factors such as relationship satisfaction. Hence, further studies are needed to improve our understanding of this relationship. Disease-

related information, stress-coping strategies, and psychological intervention should be provided to prostate cancer patients and their partners. 5. Strengths and limitations In this study, data were collected from prostate cancer patients and their partners simultaneously, five times over six months. To the best of the authors’ knowledge, this study is the first to explore the positive and negative affect and prostate cancer-specific anxiety of patients and their partners in an Asian country. Study material was obtained from the control group in the first phase of an intervention project; nevertheless, the intervention was performed after data collection from the control group was complete. Hence, the data collected in this study reflects the 9

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al.

actual situation. Nevertheless, this study has several limitations. First, the sample size was relatively small. Consequently, inferences based on this study should be treated with caution. Second, only prostate cancer patients and their partners in cohabitation were included. The support from partners could help to ease the emotional distress of patients; therefore, the present results cannot be extrapolated to prostate cancer patients who are widowed, single, or separated. Third, this study did not investigate the self-perceived support provided by partners, family, and other family members of the patients and their partners. As a result, it provides no insight into the effect of social support on positive and negative affect and prostate cancer-specific anxiety. Fourth, this study collected data on the religious belief of patients and their partners but not on their religious attitudes, participation frequency, or content of religious activities. Therefore, in-depth analysis of these aspects of religious belief was not performed. Fifth, the 48 pairs of patients and partners belonged to heterosexual dyads, as this study limited the sexual orientation of the patients and their partners. Therefore, the results of the study cannot be applied to homosexual dyads.

Couper, J.W., Bloch, S., Love, A., Duchesne, G., Macvean, M., Kissane, D.W., 2006. The psychosocial impact of prostate cancer on patients and their partners. Med. J. 185, 428–432. Fagundes, C.P., Berg, C.A., Wiebe, D.J., 2012. Intrusion, avoidance, and daily negative affect among couples coping with prostate cancer: a dyadic investigation. J. Fam. Psychol. 26, 246–253. Fitzmaurice, C., Allen, C., Barber, R.M., Barregard, L., Bhutta, Z.A., Brenner, H., Naghavi, M., 2017. Global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 32 cancer groups, 1990 to 2015: a systematic analysis for the global burden of disease study. JAMA Oncol. 3 (4), 524–548. Gall, T.L., 2004. The role of religious coping in adjustment to prostate cancer. Canc. Nurs. 27, 454–461. Hamrick, N., Diefenbach, M.A., 2006. Religion and spirituality among patients with localized prostate cancer. Palliat. Support Care 4, 345–355. Health Promotion Administration, Ministry of Health and Welfare, Taiwan, 2017. Cancer Registry Annual Report, 2014 Taiwan. . https://www.hpa.gov.tw/Pages/List.aspx? nodeid=119, Accessed date: 20 September 2017. Howlader, N., Noone, A.M., Krapcho, M., Miller, D., Bishop, K., Kosary, C.L., Yu, M., Ruhl, J., Tatalovich, Z., Mariotto, A., Lewis, D.R., Chen, H.S., Feuer, E.J., Cronin, K.A. (Eds.), April 2017. SEER Cancer Statistics Review, 1975–2014. National Cancer Institute, Bethesda, MD based on November 2016 SEER data submission, posted to the SEER website. https://seer.cancer.gov/csr/1975_2014/, Accessed date: 6 March 2018. Hsieh, Y.S., 1997. A study of the relationships among personal characteristics, marital communication and marital adjustment of married women. In: Home Economics Education 13. pp. 27–34. Hu, S.E., 2005. The Relationship of Cognitive Features, Coping, and Adaptation in Rheumatoid Arthritis Patients. Chung Yuan Christian University Tao-Yuan, Taiwan, ROC. Hyde, M.K., Legg, M., Occhipinti, S., Lepore, S.J., Ugalde, A., Zajdlewicz, L., Laurie, K., Dunn, J., Chambers, S.K., 2018. Predictors of long-term distress in female partners of men diagnosed with prostate cancer. Psycho Oncol. 27, 946–954. Kamen, C., Mustian, K.M., Heckler, C., Janelsins, M.C., Peppone, L.J., Mohile, S., McMahon, J.M., Lord, R., Flynn, P.J., Weiss, M., Spiegel, D., Morrow, G.R., 2015. The association between partner support and psychological distress among prostate cancer survivors in a nationwide study. J. Cancer Surviv. 9, 492–499. Keller, J., Wiedemann, A.U., Hohl, D.H., Scholz, U., Burkert, S., Schrader, M., Knoll, N., 2017. Predictors of dyadic planning: perspectives of prostate cancer survivors and their partners. Br. J. Health Psychol. 22, 42–59. Knoll, N., Burkert, S., Scholz, U., Roigas, J., Gralla, O., 2012. The dual-effects model of social control revisited: relationship satisfaction as a moderator. Hist. Philos. Logic 25, 291–307. Kohler, N., Friedrich, M., Gansera, L., Holze, S., Thiel, R., Roth, S., Rebmann, U., Stolzenburg, J.U., Truss, M.C., Fahlenkamp, D., Scholz, H.J., Brahler, E., 2014. Psychological distress and adjustment to disease in patients before and after radical prostatectomy. Results of a prospective multi-centre study. Eur. J. Canc. Care 23, 795–802. Lee, S.C., 2015. Intimacy and family consent: a Confucian ideal. J. Med. Philos. 40, 418–436. Lehto, U.S., Aromaa, A., Tammela, T.L., 2018. Experiences and psychological distress of spouses of prostate cancer patients at time of diagnosis and primary treatment. Eur. J. Canc. Care 27, e12729. Lehto, U.S., Tenhola, H., Taari, K., Aromaa, A., 2017. Patients' perceptions of the negative effects following different prostate cancer treatments and the impact on psychological well-being: a nationwide survey. Br. J. Canc. 116, 864–873. Mehnert, A., Lehmann, C., Schulte, T., Koch, U., 2007. Presence of symptom distress and prostate cancer-related anxiety in patients at the beginning of cancer rehabilitation. Onkologie 30, 551–556. Nelson, C.J., Starr, T.D., Macchia, R.J., Hyacinthe, L., Friedman, S., Roth, A.J., 2016. Assessing anxiety in black men with prostate cancer: further data on the reliability and validity of the memorial anxiety scale for prostate cancer (MAX-PC). Support. Care Canc. 24, 2905–2911. Newton, F., Burney, S., Frydenberg, M., Millar, J., Ng, K., 2007. Assessing mood and general health-related quality of life among men treated in Australia for localized prostate cancer. Int. J. Urol. 14, 311–316. Olsen, O., Iversen, L., Sabroe, S., 1991. Age and the operationalization of social support. Soc. Sci. Med. 32, 767–771. Park, C.L., Chmielewski, J., Blank, T.O., 2010. Post-traumatic growth: finding positive meaning in cancer survivorship moderates the impact of intrusive thoughts on adjustment in younger adults. Psycho Oncol. 19, 1139–1147. Pearce, S.M., Wang, C.H.E., Victorson, D.E., Helfand, B.T., Novakovic, K.R., Brendler, C.B., Albaugh, J.A., 2015. A longitudinal study of predictors of sexual dysfunction in men on active surveillance for prostate cancer. Sex. Med. 3, 156–164. Pressman, S.D., Cohen, S., 2005. Does positive affect influence health? Psychol. Bull. 131, 925–971. Punnen, S., Cowan, J.E., Dunn, L.B., Shumay, D.M., Carroll, P.R., Cooperberg, M.R., 2013. A longitudinal study of anxiety, depression and distress as predictors of sexual and urinary quality of life in men with prostate cancer. BJU Int. 112, E67–E75. Roth, A., Nelson, C.J., Rosenfeld, B., Warshowski, A., O'Shea, N., Scher, H., Holland, J.C., Slovin, S., Curley-Smart, T., Reynolds, T., Breitbart, W., 2006. Assessing anxiety in men with prostate cancer: further data on the reliability and validity of the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Psychosomatics 47, 340–347. Roth, A.J., Rosenfeld, B., Kornblith, A.B., Gibson, C., Scher, H.I., Curley-Smart, T., Holland, J.C., Breitbart, W., 2003. The Memorial Anxiety Scale for Prostate Cancer: validation of a new scale to measure anxiety in men with prostate cancer. Cancer 97,

6. Research implications for the advancement of clinical practice It is recommended that the clinical health provider assess and follow up on the positive and negative affect and prostate cancer-specific anxiety, particularly for newly diagnosed patients with prostate cancer and their female partners. The health care provider can provide interventions to patients with prostate cancer and their partners, which may be more effective than providing interventions to patients alone. With the consent of the patients and their partners, the adult children who live with them can be invited to join in the patients' care plan and be provided with related information. The health care provider should provide and explain the information in accordance with the individual's educational level. Utilizing multiple methods that the individual can comprehend can promote the effectiveness of the intervention. The information content should cover the possible causes of the changes in PSA value, prognosis of prostate cancer, coping strategies for treatment side effects/complications, ways to promote and maintain physical health (e.g., healthy diet and exercise), stress management, and strategies to mitigate negative affect and improve positive affect and ways of effective communication. Funding The project was funded by the Ministry of Science and Technology, Taiwan, R.O.C. [MOST104-2314-B-227-004] Acknowledgments The authors would like to thank the following for his support: Dr. Wei-Yu Lin, MD, at Chang Gung Memorial Hospital at Chiayi, Taiwan. References Benedict, C., Dahn, J.R., Antoni, M.H., Traeger, L., Kava, B., Bustillo, N., Zhou, E.S., Penedo, F.J., 2015. Positive and negative mood in men with advanced prostate cancer undergoing androgen deprivation therapy: considering the role of social support and stress. Psycho Oncol. 24, 932–939. Boehmer, U., Babayan, R.K., 2005. A pilot study to determine support during the pretreatment phase of early prostate cancer. Psycho Oncol. 14, 442–449. Chambers, S.K., Schover, L., Nielsen, L., Halford, K., Clutton, S., Gardiner, R.A., Dunn, J., Occhipinti, S., 2013. Couple distress after localised prostate cancer. Support. Care Canc. 21, 2967–2976. Chien, C.H., Chuang, C.K., Liu, K.L., Wu, C.T., Pang, S.T., Tsay, P.K., Chang, Y.H., Huang, X.Y., Liu, H.E., 2018. Effects of individual and partner factors on anxiety and depression in Taiwanese prostate cancer patients: a longitudinal study. Eur. J. Canc. Care 27, e12753. Christie, K.M., Meyerowitz, B.E., Giedzinska-Simons, A., Gross, M., Agus, D.B., 2009. Predictors of affect following treatment decision-making for prostate cancer: conversations, cognitive processing, and coping. Psycho Oncol. 18, 508–514.

10

European Journal of Oncology Nursing 37 (2018) 1–11

C.-H. Chien et al. 2910–2918. Segrin, C., Badger, T.A., 2010. Psychological distress in different social network members of breast and prostate cancer survivors. Res. Nurs. Health 33, 450–464. Segrin, C., Badger, T.A., Harrington, J., 2012. Interdependent psychological quality of life in dyads adjusting to prostate cancer. Health Psychol. 31, 70–79. Sepah, S.C., Bower, J.E., 2009. Positive affect and inflammation during radiation treatment for breast and prostate cancer. Brain Behav. Immun. 23, 1068–1072. Soloway, C.T., Soloway, M.S., Kim, S.S., Kava, B.R., 2005. Sexual, psychological and dyadic qualities of the prostate cancer ‘couple’. BJU Int. 95, 780–785. Taoka, R., Matsunaga, H., Kubo, T., Suzuki, T., Yamamoto, S., 2014. Impact of trait anxiety on psychological well-being in men with prostate cancer. Int. Braz J. Urol. 40, 620–626. Tavlarides, A.M., Ames, S.C., Diehl, N.N., Joseph, R.W., Castle, E.P., Thiel, D.D., Broderick, G.A., Parker, A.S., 2013. Evaluation of the association of prostate cancerspecific anxiety with sexual function, depression and cancer aggressiveness in men 1 year following surgical treatment for localized prostate cancer. Psycho Oncol. 22, 1328–1335. Tavlarides, A.M., Ames, S.C., Thiel, D.D., Diehl, N.N., Parker, A.S., 2015. Baseline and follow-up association of the MAX-PC in men with newly diagnosed prostate cancer. Psycho Oncol. 24, 451–457. Thorsteinsdottir, T., Valdimarsdottir, H., Hauksdottir, A., Stranne, J., Wilderang, U., Haglind, E., Steineck, G., 2017. Care-related predictors for negative intrusive thoughts after prostate cancer diagnosis-data from the prospective LAPPRO trial. Psycho Oncol. 26, 1749–1757. van den Bergh, R.C.N., Essink-Bot, M.L., Roobol, M.J., Schroder, F.H., Bangma, C.H.,

Steyerberg, E.W., 2010. Do anxiety and distress increase during active surveillance for low risk prostate cancer? J. Urol. 183, 1786–1791. Voogt, E., van der Heide, A., van Leeuwen, A.F., Visser, A.P., Cleiren, M.P., Passchier, J., van der Maas, P.J., Cleiren, M.P.H.D., 2005. Positive and negative affect after diagnosis of advanced cancer. Psycho Oncol. 14, 262–273. Watson, D., Clark, L.A., Tellegen, A., 1988. Development and validation of brief measures of positive and negative affect: the PANAS scales. J. Pers. Soc. Psychol. 54, 1063–1070. Watson, D., Tellegen, A., 1985. Toward a consensual structure of mood. Psychol. Bull. 98, 219–235. Watts, S., Leydon, G., Eyles, C., Moore, C.M., Richardson, A., Birch, B., Prescott, P., Powell, C., Lewith, G., 2015. A quantitative analysis of the prevalence of clinical depression and anxiety in patients with prostate cancer undergoing active surveillance. BMJ Open 5, e006674. Wei, J.T., Dunn, R.L., Litwin, M.S., Sandler, H.M., Sanda, M.G., 2000. Development and validation of the expanded Prostate Cancer Index Composite (EPIC) for comprehensive assessment of health-related quality of life in men with prostate cancer. Urology 56, 899–905. Wilcox, C.B., Gilbourd, D., Louie-Johnsun, M., 2014. Anxiety and health-related quality of life (HRQL) in patients undergoing active surveillance of prostate cancer in an Australian centre. BJU Int. 113 (Suppl. 2), 64–68. Yoshimoto, S.M., Ghorbani, S., Baer, J.M., Cheng, K.W., Banthia, R., Malcarne, V.L., Sadler, G.R., Ko, C.M., Greenberg, H.L., Varni, J.W., 2006. Religious coping and problem-solving by couples faced with prostate cancer. Eur. J. Canc. Care 15, 481–488.

11