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ONLINE EXCLUSIVE
Quality of Life After Radical Prostatectomy
LouAnn M. Rondorf-Klym, PhD, RN, and Joyce Colling, PhD, RN, FAAN
Key Points . . .
Purpose/Objectives: To examine physical and psychosocial factors
that affect the quality of life (QOL) for men 1224 months after radical
prostatectomy treatment for prostate cancer.
Sexual and urinary function and their appraisal are shown to
Design: Cross-sectional survey.
have negative effects on psychosocial variables and, subse-
Setting: An entire population from one tumor registry.
quently, on quality of life (QOL) after radical prostatectomy.
Sample: Of the 132 men meeting inclusion criteria, 97 men re-
sponded, with 91 meeting analysis requirements. Analysis was com-
Rather than focusing on the disease symptoms alone, clini-
pleted on the Caucasian sample (n = 88) with a mean age of 66 years.
cians must make an assessment of patients' values that may
Most men were married, lived with a spouse or partner, and had a high
affect their QOL before intervention begins.
level of education.
After presenting evidence-based information regarding the risks
Methods: A survey was developed to assess men 1224 months
and benefits of interventions, patients may consider selecting a
prostatectomy. The tumor registry mailed the survey, which was com-
treatment option that balances a long life with a quality life.
pleted at home, and participants returned it in a prestamped, addressed
envelope.
Men may choose a treatment option that will minimize the
Main Research Variables: Major hypotheses in the causal model
probability of loss of sexual function or normal urinary func-
were that age, sexual function, urinary function, and sexual appraisal
tion if the options are equally efficacious.
would only have indirect effects on QOL, whereas urinary function ap-
praisal, self-esteem, anger suppression, perceived social support, de-
pression, and health locus of control would directly affect QOL.
Findings: As analyzed by path analytic techniques, the hypoth-
esized causal model explained 72% variance in the QOL variable. Per-
Caucasian or Asian men. An estimated 30,200 men in the
ceived social support, self-esteem, and health locus of control were
United States die of the disease every year (American Cancer
significant predictors of QOL. Urinary function appraisal contributed
Society, 2002). Beyond these stark statistics lie a number of
indirectly through health locus of control. Contrary to the hypotheses,
profound quality-of-life (QOL) issues for the millions of men
anger suppression and depression were not significant predictors of
who are living with this disease and the sequelae of treatment.
QOL.
Considerable descriptive research has been conducted re-
Conclusions: After radical prostatectomy for prostate cancer, per-
garding prostate cancer survivors in the area of health-related
ceived social support, self-esteem, and health locus of control may in-
QOL; however, findings have been inconsistent. Litwin et al.
fluence men's QOL. Future research is needed to increase understand-
(1995) found no differences in health-related QOL among three
ing about the adaptation trajectory of men's response to the impact of
prostate cancer treatment groups and a comparison group. Two
prostate cancer.
Implications for Nursing: Nurses can help patients by providing a
other studies found that health-related QOL was similar in two
thorough assessment of each patient's values that may affect QOL be-
post-treatment groups. One group received only prostatectomy,
fore any intervention begins, using research-based evidence regarding
and another group was treated with only radiotherapy (Lim et
potential side effects of interventions, clear and concise information
al., 1995; Shrader-Bogen, Kjellberg, McPherson, & Murray,
from a variety of sources that addresses the possible concerns of men
1997). Disparate results were found by Rieker et al. (1993),
and their spouses, and focused counseling that addresses patient-spe-
with a prostatectomy group having better physical functioning
cific problems.
LouAnn M. Rondorf-Klym, PhD, RN, is the department director and
ancer touches the lives of many people every year.
C
Joyce Colling, PhD, RN, FAAN, is professor emeritus, both in the
One man in six will be diagnosed with prostate cancer
School of Medicine at Oregon Health Sciences University in Port-
land. This research is supported by the National Institute of Nurs-
in his lifetime. Prostate cancer is the second leading
ing Research Institutional National Research Scholarship Award,
cause of cancer death in men in the United States. About
Sigma Theta Tau, Beta Psi Chapter. (Submitted January 2002. Ac-
189,000 new cases of prostate cancer are diagnosed in the
cepted for publication August 23, 2002.)
United States every year. African American men are more
likely to have prostate cancer and die from the disease than are
Digital Object Identifier: 10.1188/03.ONF.E24-E32
ONF VOL 30, NO 2, 2003
E24
Samet, 1991). The current study's researchers posited that age
and general health perception scores on health-related QOL
affects QOL indirectly through its relationship with perceived
than the radiotherapy group. Four studies have examined
social support and depression.
postprostatectomy health-related QOL. Prostatectomy inconti-
Sexual and urinary appraisals are each patient's judgment
nence was found to have adverse effects on General Health
of whether sexual or urinary function has been problematic or
Index and Mental Health Index scores (Fowler et al., 1995).
bothersome, and patients' previous sexual function influences
Braslis, Santa-Cruz, Brickman, and Solloway (1994) reported
their appraisal of problems after treatment (Fowler et al.,
that although tension did diminish after surgery, participants
1995). Increased sexual symptom severity also has been asso-
experienced worsened sexual and continence dysfunction,
ciated with an increase in sexual problems (Braslis et al.,
hardship, and symptom severity in feelings about sex and
1994; Pedersen et al., 1993). Many men have reported dete-
sexual problems. Other studies have reported that men have
rioration of sexual function postprostatectomy (Braslis et al.;
suffered from severe overall distress and activity limitations
Fowler et al.; Heyman & Rosner, 1996; Kornblith et al., 1994;
after prostatectomy (Herr, 1994; Pedersen, Carlsson, Rahm-
Pedersen et al.). Two studies found that prostatectomy patients
quist, & Varenhorst, 1993).
exhibited poorer sexual function than radiotherapy patients
Studies completed in the 1990s have revealed that treat-
(Lim et al., 1995; Rieker et al., 1993), whereas two other stud-
ments have affected health-related QOL for those with pros-
ies found no differences (Gburek, Harmon, & Chodak, 1992;
tate cancer and disease-specific conditions such as sexual and
Litwin et al., 1995). Both the prostatectomy and radiotherapy
urinary dysfunction (Bacon, Giovannucci, Testa, & Kawachi,
patients displayed worse sexual function than comparison pa-
2001; Davis, Kuban, Lynch, & Schellhammer, 2001; Fowler
tients without prostate cancer. About 25% of the men in the
et al., 1995; Heyman & Rosner, 1996; Kornblith, Herr, Of-
radiation and prostatectomy treatment groups with poor or
man, Scher, & Holland, 1994; Krongrad et al., 1997; Krupski,
very poor sexual function expressed that they were moder-
Petroni, Bissonette, & Theodorescu, 2000; Lim et al., 1995;
ately bothered by this diminished function (Litwin et al.).
Litwin et al., 1995; Rossetti & Terrone, 1996; Shrader-Bogen
Several studies have found that urinary function diminishes
et al., 1997; Steineck et al., 2002; Wei et al., 2002). Unlike the
in prostatectomy patients (Braslis et al., 1994; Herr, 1994;
broader concept of QOL, these health-related QOL studies
Heyman & Rosner, 1996; Pedersen et al., 1993). However,
have focused on only one domain of life quality, such as
Fowler et al. (1995) determined that dripping urine had a more
health.
negative effect on men than did diminished sexual function.
The broad concept of QOL may include descriptors such
Prostatectomy patients displayed poorer urinary function than
as well-being, life satisfaction, and happiness. For most
three other groups (i.e., radiotherapy, only observations, and
people, QOL represents life priorities. These priorities gen-
patients without prostate cancer) (Litwin et al., 1995). Com-
erate thoughts of value and cross many domains within the
pared with radiotherapy patients, prostatectomy patients have
broader definition of life quality, such as physical and mate-
demonstrated poorer urinary function (Gburek et al., 1992;
rial well-being; relations with others; social, community, and
Lim et al., 1995; Rieker et al., 1993). In Litwin et al.'s study,
c i v i c activities; personal development and fulfillment;
a difference existed in the level of function between prostatec-
and recreation (Flanagan, 1978; Patrick & Erickson, 1993).
tomy and radiotherapy patients, but incontinence equally
The present study included a number of QOL domains. Spe-
bothered these two groups. Herr found similar results between
cifically, this study examined the relative contribution of age,
incontinence and distress. The current study's researchers
several disease-specific factors (e.g., sexual and urinary func-
posited that the sexual and urinary functional changes would
tion, sexual and urinary appraisal), and several psychosocial
result in alterations in sexual and urinary appraisal.
factors (e.g., self-esteem, anger, perceived social support,
Self-esteem was a predictor of life satisfaction in an Ameri-
depression, health locus of control) to QOL in a group of
can national sample, in college students, and in adult Austra-
postprostatectomy patients 1224 months after treatment.
lians (Campbell, Converse, & Rodgers, 1976; Diener, 1984;
Causal modeling was used to clarify and explain these com-
Diener & Diener, 1995; Hong & Giannakopoulos, 1994).
plex relationships by testing the hypothesized causal path-
Self-esteem also has been linked to life satisfaction and QOL
ways. Model variables were selected from one of two sources:
in a number of disabled and chronically ill populations
Empirical findings from qualitative and quantitative findings
(Anderson, 1995; Burckhardt, 1985; Kinney & Coyle, 1992;
were used, or theoretical views were chosen when no empiri-
Lewis, 1982; Wingate, 1995). Only qualitative research,
cal findings were available.
which indicates that the side effects of impotence and inconti-
Although a radical prostatectomy may provide effective
nence may cause a loss of self-worth (Heyman & Rosner,
control of cancer (Walsh & Partin, 1994), other factors may
1996), is available regarding post-treatment of localized pros-
impede sexual function and continence recovery after surgery.
tate cancer. The current study's researchers posited that self-
Some studies indicate that age is associated with potency or
esteem would be a positive mediating factor in predicting QOL.
sexual function (Braslis et al., 1994; Catalona & Bigg, 1990;
Health-related QOL studies of prostate cancer indicate that
Walsh & Donker, 1982). Other studies have found no rela-
anger suppression is a pertinent variable in this population.
tionship between age and recovery of continence or urinary
Studies in other populations indicate that more symptoms
function (Walsh, Partin, & Epstein, 1994). Although men
were predictive of patients experiencing more anger (Lane,
younger than 60 years of age may recover potency or conti-
1991). Likewise, treatment side effects, specifically inconti-
nence faster, studies have found at one-year postprostatec-
nence, have been associated with anger in patients with pros-
tomy that no difference existed across age groups (Leandri,
tate cancer (Braslis et al., 1994; Lim et al., 1995). Qualitative
Rossignol, Gautier, & Ramon, 1992; Rossignol et al., 1991;
interviews with patients after prostate cancer treatment indi-
Steiner, Morton, & Walsh, 1991). Psychosocial factors, such
cated early-phase issues included feelings of anger and early-
as social support and depression, may change during the ag-
phase coping strategies involved feelings of anger when
ing process (Conn, Taylor, & Abele, 1991; Goodwin, Hunt, &
RONDORF-KLYM VOL 30, NO 2, 2003
E25
An entire population of men 1224 months after radical
expectations were not met (Heyman & Rosner, 1996). In the
present study, anger suppression was posited as a negative
prostatectomy for localized prostate cancer from one tumor
registry was given the opportunity to participate. The tumor
mediating factor in predicting QOL.
registry searched its records to select possible participants ac-
Social support is a predictor of well-being in the commu-
nity-dwelling elderly and in those with chronic illnesses
cording to the inclusion criteria: (a) primary cancer site was the
prostate, (b) the SEER Summary Staging Guide included either
(Anderson, 1995; Burckhardt, 1985; Levitt, Clark, Rotton, &
in situ classification (i.e., neoplasm that fulfilled all microscopic
Finley, 1987), as well as an influence on QOL for those encoun-
criteria for malignance except invasion) or localized classifica-
tering life-threatening illness (Guillory, 1996; Wingate, 1995).
tion (i.e., neoplasm that appears entirely confined to the or-
In their research, Kornblith et al. (1994) studied men with
gan), (c) the TNM Classification System included either stage
prostate cancer and their partners and found that the social
I or stage II groups, and (d) the treatment type was the cancer-
support system may be altered by prostate cancer treatment as
directed surgical code of C61.9, indicating prostate cancer sur-
evidenced by the perception that sexual problems differed
gery. Patients were excluded if (a) they had surgery less than 12
among couples and by partners having had more psychological
or greater than 24 months before, (b) they currently were insti-
distress and intrusion from the disease. Heyman and Rosner
tutionalized in a long-term care facility, or (c) their tumor reg-
(1996) determined that the intimacy relationship changed, yet
istry information revealed that other prostate cancer treatments,
couples learned new ways to express intimacy. The current
such as radiation therapy, had been administered.
study's researchers posited that perceived social support
The recursive causal model was unidirectional and without
would be a positive mediating factor in predicting QOL.
feedback loops. Temporal relationships were presented in the
In a large sample of Australian adults, Hong and Gianna-
model, which contained three types of variables: exogenous
kopoulos (1994) concluded that depression affects life satis-
variables that are determined by factors outside the model,
faction. Research also has identified that depression may af-
endogenous variables that are determined by variables in the
fect QOL after diagnosis and treatment of chronic illnesses
model, and mediating variables that link two variables in the
(Anderson, 1995; Godding, McAnulty, Wittrock, Britt, &
model together. Negative and positive relationships are indi-
Khansur, 1995; Strauss et al., 1992). In the prostatectomy
cated by minus () and plus (+) symbols. Path analysis tech-
population, depression has been associated with incontinence
niques were applied to test the model using multiple regres-
and decreased sexual function (Braslis et al., 1994; Lim et al.,
sion to isolate the effects on the dependent variable made by
1995). Therefore, in the present study, depression was posited
the set of independent variables (Polit, 1996).
as a negative mediating factor in predicting QOL.
Based on the literature review, the current study's research-
The concept of locus of control focuses on an individual's
ers hypothesized that the principle bodily functions affected
perception of relationships between behavior and events that
by radical prostatectomy treatment were sexual and urinary
follow a behavior. Those with internal locus of control believe
function. Further, these functional changes were posited to
that their actions control their lives, whereas those with exter-
lead to alterations in sexual and urinary appraisal; subse-
nal control believe that exterior forces, such as fate, control
quently, this appraisal was expected to influence psychosocial
their lives (Hong & Giannakopoulos, 1994; Rotter, 1966;
responses. In the path analytic model, the researchers hypoth-
Seligman, 1973). Several studies have shown that locus of
esized that urinary appraisal, self-esteem, anger suppression,
control is associated with life satisfaction (Hickson, Housley,
perceived social support, depression, and health locus of con-
& Boyle, 1988; Hong & Giannakopoulos; Levitt et al., 1987)
trol would have direct effects on QOL.
and that internal control over health is related to life satisfac-
Path analysis was used to examine the patterns of causation
tion in those with chronic illnesses (Burckhardt, 1985; La-
among the variables in a nonexperimental context to test
borde & Powers, 1985), whereas other studies have found no
whether the hypothesized pathway from the causes to the effect
relationship (Lewis, 1982; Wingate, 1995). The qualitative
was consistent with the data (Pedhazur, 1982; Polit & Hungler,
work conducted by Heyman and Rosner (1996) indicated that
1995). Hierarchical multiple regression with 10 independent
a reaction to treatment side effects was loss related to a sense
variables was used to test the hypotheses. The total covariance,
of control. In the current study, the researchers posited that
direct, indirect, total, and noncausal effects between indepen-
health locus of control would be a positive mediating factor in
predicting QOL.
dent and dependent variables were used to construct the model.
Instruments
Methods
Standardized instruments were combined to form a single
The current study used a correlational design to examine
questionnaire containing 90 items that took participants ap-
the individual study hypotheses. This study assumed a mod-
proximately one hour to complete. A summary of the items
erate effect size, cumulative power from 0.630.92, and an
related to the scale characteristics of number of items, previ-
alpha of 0.05. An a priori power analysis indicated that the
ous psychometric evaluations, and Cronbach's alpha coeffi-
study needed about 80 responses. Because response rates for
cients were constructed (see Table 1).
mailed questionnaires tend to be low, the population was
Four variables (i.e., sexual function, urinary function,
oversampled to secure the 80 questionnaires for analysis. The
sexual appraisal, and urinary appraisal) represented the endog-
study was reviewed and approved by an institutional review
enous variables. Sexual and urinary function and appraisal were
board. Eligible participants received an introductory letter
assessed with subscales of the University of California, Los
about the study and a participant information sheet, which
Angeles, Prostate Cancer Index (Litwin et al., 1995). Sexual
complied with informed consent requirements. Informed con-
function was assessed with eight items, and sexual appraisal
sent was inferred from the participant's return of the com-
was assessed with one item. Urinary function was assessed
pleted questionnaire.
with five items, and urinary appraisal was assessed with one
ONF VOL 30, NO 2, 2003
E26
Table 1. Summary of Scales
Number
of Items
Reliability
Cronbach's Alpha
Validity
Scale
15
Face validity, factor analysis
Sexual function alpha coefficients = 0.93, test-
Prostate Cancer Index
Sexual function = 0.9
retest = 0.92; urinary function alpha coeffi-
Urinary function = 0.87
cients = 0.87, test-retest = 0.93; sexual ap-
praisal test-retest = 0.70; urinary appraisal
test-retest = 0.66
10
Alpha coefficients = 0.740.87; test-retest = 0.85
0.88
Multitrait, multimethod study;
Rosenberg Self-Esteem Scale
convergent validity
18
Alpha coefficients = 0.84
0.81
Discriminant validity
Anger Expression-In Subscale
Alpha coefficients = 0.790.88; test-retest = 0.72
25
0.94
Content, construct, and predic-
Personal Resource Question-
tive validity
naire 85 Part 2
10
Alpha coefficients = 0.85; test-retest = 0.71
0.81
Convergent, discriminant, and
Center for Epidemiologic Stud-
predictive validity
ies Depression 10 Scale
16
Convergent and discriminant va-
Equivalent forms = 0.710.86
Internal Health Locus of Con-
0.83
lidity
trol Subscale
Alpha coefficients = 0.820.92; test-retest = 0.76
16
0.93
Content, convergent, and dis-
Quality-of-Life Scale
criminant validity
0.84
is "the degree of satisfaction with the perceived present life
item. Each scale had a possible score range of 0100. Higher
circumstances" (p. 220). One instrument, the Quality-of-Life
scores represent a high level of function and indicate that the
Scale (Burckhardt, Woods, Schultz, & Ziebarth, 1989), was
function is not a problem.
used to measure the outcome variable (i.e., overall QOL).
Five variables (i.e., self-esteem, anger suppression, perceived
Flanagan (1978) conceptualized QOL as having five domains:
social support, depression, and health locus of control) repre-
(a) physical and material well-being, (b) relations with others,
sented the mediating variables. Self-esteem was measured with
(c) social, community, and civic activities, (d) personal de-
the Rosenberg Self-Esteem Scale (Rosenberg, 1965). The
velopment and fulfillment, and (e) recreation. Burckhardt et
scale consists of a 10-item, four-point, Likert-like scale rang-
al. modified the Quality-of-Life Scale by adding indepen-
ing from "strongly agree" to "strongly disagree." Scale scores
dence as a domain and including a seven-point Delighted-
range from 1040, with a lower scale score indicating lower
Terrible Scale. The rating method was viewed as more sensi-
self-esteem. Anger suppression was assessed by the Anger Ex-
tive and less negatively skewed; the seven available responses
pression-In Subscale of the 24-item Anger Expression Scale
were delighted (7), pleased, mostly satisfied, mixed, mostly
(Spielberger, 1996). The Anger Expression-In generally mea-
dissatisfied, unhappy, and terrible (1), allowing for a broader
sures suppressed anger, with eight items of Likert-like scales
range of affective response than a five-point scale. With the
ranging from 1 (almost never) to 4 (almost always). Scale
addition of the independence domain, the modified Quality-
scores range from 832, with higher scale scores indicating
of-Life Scale had a total of 16 items and ranged from 16112,
more suppressed anger. The Personal Resource Question-
with a higher score indicating better QOL. Internal consis-
naire 85 Part 2 was used to measure perceived social support
tency reliabilities (Cronbach's alpha) were computed for all of
(Weinert, 1987; Weinert & Brandt, 1987). The scale has 25
the scales. All scales met the minimum criteria for internal
items with a seven-point, Likert-like scale ranging from
consistency of 0.7, as suggested by Nunnally (1978).
strongly agree (7) to strongly disagree (1). The items assess (a)
provision for attachment or intimacy, (b) social integration,
(c) opportunity for nurturing behavior, (d) reassurance of worth
Findings
as an individual and in role accomplishments, and (e) the abil-
ity of informational, emotional, and material help. Higher
Of the 132 questionnaires mailed to participants, 97 were
scores indicate greater perceived social support. Depression was
returned for a 73% response rate. Analyses were completed
measured by the 10-item Center for Epidemiologic Studies
on 88 of these respondents, after three subjects of African
Depression 10 Scale (Andresen, Carter, Malmgren, & Patrick,
American origin and six with missing data were deleted.
1994). Scores range from 030, and high scores indicate the
Prostate cancer is a problem for many African American
presence or persistence of depressive symptoms (Andresen et
men. The African American community in Oregon repre-
al.). Health locus of control was assessed with the Internal
sents 1.6% of the total population, which is below the na-
Health Locus of Control (IHLC) Subscale from the Multidi-
tional average of 12.3% (U.S. Census Bureau, 2000). There-
mensional Health Locus of Control (Wallston, Wallston, &
fore, the potential number of African Americans who could
DeVillis, 1978). The IHLC measures health locus of control in-
have responded to this survey was quite small. Given that
ternality with six items on a six-point, Likert-like scale ranging
only three African American men responded to the survey,
from 1 (strongly disagree) to 6 (strongly agree). Scores range
the researchers decided to analyze only the Caucasian
from 636, with higher scores indicating more internal health
sample for this article. The mean age of the sample was 66
locus of control (Wallston et al.).
years. Most men were married, lived with a spouse or part-
The researchers in the present study used the definition pro-
ner, and had a high level of education as compared to state
vided by Young and Longman (1983), who stated that QOL
and local census figures (see Table 2).
RONDORF-KLYM VOL 30, NO 2, 2003
E27
Table 2. Sample Characteristics
The path analysis used to study the patterns of causation
among the set of variables indicated that the model explained
n
Variable
%
72% of the total variance in QOL after radical prostatectomy
(multiple r = 0.847, R2 = 0.717, adjusted R2 = 0.68). The fol-
Marital status (n = 88)
lowing hypothesized direct effects were found: (a) Sexual func-
12
Single
12
tion predicted sexual appraisal, (b) urinary function predicted
11
Separated
11
urinary appraisal, (c) urinary appraisal predicted health locus of
14
Widowed
15
control and was a near-significant predictor of self-esteem and
17
Divorced
18
anger suppression, and (d) mediating variables (i.e., self-es-
74
Married
84
teem, perceived social support, and health locus of control)
Living arrangements (n = 87)
predicted QOL. The following direct effects were found, but
75
Living with spouse or partner
86
were not hypothesized: Age predicted sexual function, and uri-
12
Living with family
12
nary function predicted sexual appraisal (see Table 4).
11
Living with nonfamily
11
The following hypothesized direct effects were not found.
19
Living alone
11
Age did not predict perceived social support and depression.
Income (n = 82)
Decreases in sexual appraisal did not predict decreases in self-
19
< $20,000
14
esteem, perceived social support, or health locus of control.
14
$20,001$30,000
17
Decreases in sexual appraisal did not predict increases in an-
18
$30,001$40,000
10
ger suppression and depression. Decreases in urinary appraisal
17
$40,001$50,000
20
did not predict decreases in perceived social support or in-
34
> $50,001
39
creases in depression. Urinary appraisal and anger suppression
Employment (n = 88)
and depression did not predict QOL. Because the direct effects
47
Retired
54
were equal to the total effects for the psychosocial-mediating
29
Full-time
33
variables, the three mediating variables of self-esteem, per-
17
Part-time
18
ceived social support, and health locus of control that were
12
Unemployed or disabled
12
11
Volunteer
11
found to have significant direct effects also had significant
11
Laid off
11
total effects on QOL.
11
Unable to find work
11
Other indirect effects, or the effects of another mediating
variable on a dependent variable in the model (Polit, 1996),
Occupation (n = 86)
were studied. Age was not found to have an indirect effect
29
Mechanics or construction
34
22
Manager or professional
26
through mediating variables on QOL. The direct effect of uri-
19
Sales or clerical
22
nary appraisal on QOL was not statistically significant. How-
19
Protection, health, farming
10
ever, the total effects, which is the sum of the direct and indi-
14
Service (cleaning, food preparation)
15
rect effects, of this variable on QOL were significant, indicating
13
Self-employed
13
that an indirect relationship was found via the urinary ap-
Educational degree (n = 88)
praisal variable through the variable of health locus of control,
14
No degree
15
with indirect effects on QOL.
17
GED
18
32
High school
36
Discussion
14
Vocational
15
15
Associates
15
These findings reinforce previous research, indicating that
22
Bachelor of arts/science
25
sexual and urinary function are affected adversely by prostate
10
Master of arts/science
11
surgery and that functional changes increase symptom sever-
14
Doctoral
15
ity (Braslis et al., 1994; Herr, 1994; Litwin et al., 1995; Ped-
ersen et al., 1993). The current study, however, made three ad-
ditions to the research in this subject area.
Univariate relationships among all of the independent vari-
Research Implications
ables, as well as the relationship between each independent
variable and the dependent variable, were assessed. Six of the
The research implications are (a) all the variables were in-
10 independent variables had a significant (p < 0.05) zero-
corporated in a causal model to predict QOL after radical
order correlation with the dependent variable QOL, indicating
prostatectomy, whereas previous studies had only incorpo-
a significant univariate relationship with the dependent vari-
rated some of these variables, (b) psychosocial variables in
able (see Table 3). The significant and nonsignificant path
this study were measured in a quantitative manner to provide
coefficients, the product of the dependent variable regressed
input in contrast to previous studies that provided only quali-
on the independent variables, are depicted in Figure 1. The
tative observations, and (c) a broad conceptual definition of
direct effects of an independent variable on the dependent
QOL was used in this study rather than the more restrictive
variable appear in the path diagram as a direct line or path be-
health-related QOL used in previous studies. Although
tween the independent and dependent variables. Patients' rat-
health-related QOL with a focus on the level of physical in-
ing of sexual appraisal may be confounded by other variables.
dependence cannot be discounted, the contribution of the
Urinary incontinence is a frequent side effect of radical pros-
more comprehensive QOL appraisal is meaningful.
tatectomy that may be related to avoidance of sexual activity
Age was found to predict sexual function--a relationship
(Perez, Skinner, & Meyerowitz, 2002).
that had not been hypothesized but supports previous research
ONF VOL 30, NO 2, 2003
E28
Table 3. Zero-Order Correlation of Model Variables
--
Variable
7.
8.
9.
10.
11.
Median
2.
3.
5.
6.
4.
X
11.
Age
0.392** 0.035* 0.210**
0.077
0.094**
0.121**
0.019**
0.066**
0.030**
0.120**
164.67
17.13
12.
Sexual function
0.006**
23.89
1.000** 0.234* 0.436**
0.240*
0.037**
0.101**
0.140**
0.181**
0.156**
122.66
13.
Urinary function
0.027**
0.101**
0.209**
0.114**
172.25
25.13
1.000* 0.363**
-0.852**
0.182**
0.056**
14.
Sexual appraisal
-0.372**
0.083**
0.108**
0.057**
0.172**
0.087**
0.070**
135.51
36.70
1.000**
15.
Urinary appraisal
0.221**
26.85
01.000
0.254**
0.153**
0.042**
0.160**
0.286**
178.41
16.
Self-esteem
0.627**
0.547**
0.076*8
0.669**
133.57
14.89
1.000**
0.271**
17.
Anger suppres-
1.000**
0.341**
0.492**
0.075**
0.410**
113.80
13.75
sion
18.
Social support
1.000** 0.611**
0.061** 0.765**
138.25
21.27
19.
Depression
1.000**
0.176** 0.583**
116.02
15.05
10.
Health locus of
1.000** 0.214**
15.94
124.76
control
11.
Quality of life
1.000**
184.90
13.65
* p = 0.05
** p = 0.01
noting that the aging process affects sexual function (Quinlan,
losses (Braslis et al., 1994; Heyman & Rosner; Lim et al.,
Epstein, Carter, & Walsh, 1991; Smith, 1981; Wagner &
1995). Thus, patients who had more physical side effects from
Green, 1981; Walfisch, Maoz, & Antonovsky, 1984). In ad-
surgery (e.g., impotence, incontinence) were more likely to
dition, both sexual function and urinary function were asso-
experience anger and decreased self-esteem.
ciated significantly and predicted appraisal, which is support-
Perceived social support explained the most variance in
ive of previous findings. The finding that urinary function was
QOL in the current study. These findings substantiate previ-
a predictor of sexual appraisal was not hypothesized.
ous research in community-dwelling residents (Levitt et al.,
Previous research has found that prostate cancer treatment
1987), patients with prostate cancer (Heyman & Rosner,
side effects can provoke a loss of the feeling of control (Hey-
1996), and patients with chronic illness (Anderson, 1995;
man & Rosner, 1996). Similar findings were identified in the
Burckhardt, 1985).
present study where lower urinary appraisal or incontinence
Practice Implications
directly affected subjects' QOL in a negative manner. This
study also demonstrated a near-significant relationship among
Several implications for practice can be derived from this
urinary appraisal and anger suppression and self-esteem,
research. Patients need the following from their clinicians: a
thorough assessment of patients' values that may affect QOL
which corroborated prior research findings that prostate can-
cer treatment side effects may arouse anger and self-worth
before beginning an intervention, research-based evidence
Exogenous
Endogenous Variables
Mediating Variables
Outcome
Variable
Variable
Self-esteem
+0.354
(+0.257)
Anger
suppression
(+0.345)
Sexual
Sexual
0.389
(0.392)
appraisal
function
(+0.553)
Perceived
(+0.280)
Quality
Age
social support
of life
(+0.845)
Urinary
Urinary
appraisal
function
(+0.135)
Depression
Health locus
of control
(+0.397)
Figure 1. Path Analysis for Quality of Life of Men With Prostate Cancer After Prostatectomy
Note. Significant b values are shown with black lines and parentheses. Near-significant b values are shown with dashed lines and without parentheses.
RONDORF-KLYM VOL 30, NO 2, 2003
E29
Table 4. Results for Variables Entered at Each Path
regarding potential side effects of interventions, clear and
Analysis Step
concise information from a variety of sources that addresses
the possible concerns of men and their spouses, and focused
Significance and
counseling that addresses patient-specific problems.
Dependent
Independent
Regression
Prior to treatment, sufficient time must be taken to conduct
Variable
Variable
Coefficients ()
a thorough assessment of patients' values. Clinicians need to
recognize the different values held by patients. Every patient
Sexual function
Age
Significant (0.392)
has different individual needs, as well as different levels of
Urinary function
Age
Not significant (NS)
competence and different abilities to understand complex
medical procedures. Assessing each patient and, if appropri-
Sexual appraisal
Age
NS
ate, the spouse's outlook, will provide clinicians with a better
Sexual function
Significant (0.345)
understanding of the patient's view. Sexual and urinary func-
Urinary function
Significant (0.280)
tion and their appraisal are shown to have negative effects on
Urinary appraisal
Age
NS
psychosocial variables and, subsequently, on QOL after a
Sexual function
NS
radical prostatectomy. The results of this study underscore the
Urinary function
Significant (0.845)
need for clinicians to understand and use patients' views of
Self-esteem
Age
NS
the risks and benefits relating to the radical prostatectomy,
Sexual function
NS
rather than solely focusing on the disease symptoms (Howe,
Urinary function
NS
1994; Kornblith et al., 1994), and to be more thorough in
Sexual appraisal
NS
explaining the potential side effects of incontinence and
Urinary appraisal
Near significant (0.354)
impotence during the consenting process.
Anger suppression
Age
NS
Presentation of research-based evidence regarding potential
Sexual function
NS
side effects of interventions can assist men in their decision-
Urinary function
NS
making process. Taking the time to present all of the treat-
Sexual appraisal
NS
ments and their associated consequences will allow patients to
Urinary appraisal
Near significant (0.389)
fully weigh the risks and benefits relating to their treatment
options. A full, informed assessment of what decisions pa-
Social support
Age
NS
Sexual function
NS
tients need to make to fulfill their QOL desires will help to
Urinary function
NS
determine the options they may be interested in pursuing.
Sexual appraisal
NS
After clinicians discuss the potential for or probability of los-
Urinary appraisal
NS
ing sexual or normal urinary function with patients, patients
then can more accurately evaluate the impact of the interven-
Depression
Age
NS
tion on their QOL. They also should be more prepared to deal
Sexual function
NS
Urinary function
NS
with these problems if indeed one or both become a reality af-
Sexual appraisal
NS
ter treatment. In addition, patients may consider selecting a
Urinary appraisal
NS
treatment option that they believe will minimize the probabil-
ity of loss of sexual function or normal urinary function if the
Age
NS
Health locus of
data support that efficacy is equal among treatment options.
Sexual function
NS
control
Clinicians must provide clear information that will assist
Urinary function
NS
Sexual appraisal
NS
patients in their decision making. Because of the increased
Urinary appraisal
Significant (0.397)
stress during the decision-making process, information may
need to be repeated. Helping patients gain access to informa-
Age
NS
Quality of life
tion is just one example of the teaching role for nurses. How-
Age
NS
Quality of life
ever, the information must be appropriate for each individual
Sexual function
NS
patient. The multiple methods of providing information,
Urinary function
NS
such as with videos, written literature, Web sites, and formal
and informal support groups (e.g., Man-to-Man), can help to
Age
NS
Quality of life
tailor information to an individual's level of comprehension
Sexual function
NS
and understanding. Helping men gain access to information
Urinary function
NS
Sexual appraisal
NS
available from organizations, such as the American Cancer
Urinary appraisal
NS
Society, can assist them in dealing with pertinent issues be-
fore, during, and after diagnosis and treatment for prostate
NS
Age
Quality of life
cancer.
NS
Sexual function
Counseling should focus on understanding prostate cancer
NS
Urinary function
and on four psychosocial domains: the context of men's lives,
NS
Sexual appraisal
NS
Urinary appraisal
the assault on the sense of self, the impact on intimate relation-
Significant (0.257)
Self-esteem
ships, and treatment options and subsequent psychosocial ef-
NS
Anger suppression
fects (Rieker, 1996). Supporting the use of behavioral therapy
Significant (0.553)
Social support
with perineal exercises, pelvic muscle electrical stimulation,
NS
Depression
or biofeedback interventions can provide subjective and ob-
Significant (0.135)
Health locus of
jective control over incontinence (Engberg, 1998). Informal
control
social support from family, friends, and relatives and formal
ONF VOL 30, NO 2, 2003
E30
support groups are important factors in helping to relieve
clinicians are prepared to provide expert physiologic and psy-
anxiety and provide reassurance (Gregoire, Kalogeropoulous,
chological care of patients.
& Corcos, 1997; Guidry, Aday, Zhang, & Winn, 1997; Krause,
The authors gratefully acknowledge the contributions of Carol Burckhardt,
1990).
PhD, RN, professor in the School of Nursing at Oregon Health Sciences Uni-
The search for a balance between a long life and QOL will
versity in Portland, and Clarann Weinert, PhD, RN, professor and the director
continue. This must be an individual decision based on expert
of the Center for Research on Chronic Health Conditions in Rural Dwellers
physical and psychological clinical care of patients who are
at Montana State University in Bozeman.
fully informed of the risks and benefits of treatment. Patients
often express the wish to balance a long life with a quality life.
Author Contact: LouAnn M. Rondorf-Klym, PhD, RN, can be
This goal has a greater possibility of occurring if patients are
reached at rondorfK@ohsu.edu, with copy to editor at rose_mary@
fully informed about the risks and benefits of treatment and
earthlink.net.
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