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Prostate Cancer Survivors' and Partners'
Self-Reports of Health-Related Quality of Life,
Treatment Symptoms, and Marital Satisfaction
2.55.5 Years After Treatment
Michael E. Galbraith, RN, PhD, Adam Arechiga, MA, Jose Ramirez, MA,
and Leli W. Pedro, RN, DNSc, OCN
Key Points . . .
Purpose/Objectives: To describe health-related quality of life (QOL),
health status, and marital satisfaction of couples as much as 5.5 years
after treatment for prostate cancer.
The diagnosis, treatment, and survivorship issues for prostate
Design: Survey with longitudinal, comparative, and predictive ele-
cancer affect a couple's relationship and, thus, health-related
ments.
quality of life (QOL).
Setting: A tertiary care nonprofit medical center in the southwestern
United States.
Sexuality and intimacy are critical aspects of health-related
Sample: Convenience sample of prostate cancer survivors (192 en-
QOL for men with prostate cancer and their partners.
rolled, 137 completed) and their partners (126 enrolled, 104 completed).
Information to realistically anticipate and manage couples'
Men averaged 70 years of age, women 66. Most men (86%) and women
sexual and relational challenges and to explore options to fa-
(89%) were white, and 71% had at least some college education.
cilitate marital satisfaction is needed to enhance QOL for men
Methods: Questionnaires were mailed annually. Women were enrolled
with prostate cancer and their partners.
3.5 years after their partners were treated. Study participants received
separate questionnaire packets.
Oncology nurses can play a central role in the assessment,
Main Research Variables: Health-related QOL, health status including
planning, and evaluation of couple-centered strategies to sup-
post-treatment symptoms, and marital satisfaction.
port and enhance sexuality and intimacy.
Findings: Men's health-related QOL, general physical health, and vital-
ity decreased; urinary and sexual post-treatment symptoms increased.
Men were concerned about their sexual functioning although few sought
treatment. Couples' health-related QOL and marital satisfaction were
diagnosis and treatment can have long-term effects on men
associated more closely than their health status.
physically, psychologically, and emotionally (American
Conclusions: Regardless of type of treatment, health-related QOL
and general health tend to decrease for prostate cancer survivors; men
Cancer Society, 2005; Fan, 2002; Jakobsson, Hallberg, &
in watchful waiting tended to have poorer health outcomes. Men are
concerned about sexual functioning, yet few are taking steps to remedy
problems. Couples' health-related QOL and marital satisfaction are linked;
Michael E. Galbraith, RN, PhD, is faculty in the School of Nursing at
however, health status indicators are less associated.
Oregon Health and Science University, Southern Region, in Portland,
Implications for Nursing: Nurses are in a key position to assess
and adjunct faculty in the Department of Psychology at Loma Linda
health-related QOL and sexual functioning concerns for prostate cancer
University in California; Adam Arechiga, MA, and Jose Ramirez, MA,
survivors and their partners.
both are doctoral students in the Department of Psychology at Loma
Linda University; and Leli W. Pedro, RN, DNSc, OCN  , is faculty
in the School of Nursing at Oregon Health and Science University,
P
rostate cancer is the most common nonskin cancer di-
Southern Region. This research was funded by an ONS Foundation
Grant supported by Aventis Pharmaceuticals and an Intramural Seed
agnosed among men, accounting for an estimated 33%
Money Grant from the School of Nursing at Loma Linda University.
of all cancer cases, with more than 232,090 new cases
(Submitted July 2004. Accepted for publication October 5, 2004.)
diagnosed in 2005. Because the five-year relative survival
rate for early-stage cancer is nearly 100%, the experience of
Digital Object Identifier: 10.1188/05.ONF.E30-E41
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E30
Loven, 2000; Litwin, McGuigan, Shpall, & Dhanani, 1999;
treated for localized prostate cancer has increased substan-
tially since the mid-1990s (Clark et al., 2003; Davis, Kuban,
Skerrett, 2003). In addition, prostate cancer and treatment
Lynch, & Schellhammer, 2001; Germino et al., 1998; Hu et
can affect both members of the couple over time, especially
al., 2004; Lee, Hall, McQuellon, Case, & McCullough, 2001;
in the areas of sexuality, sexual functioning, and communi-
cation (Crowe & Costello, 2003; Harden et al., 2002; Jani &
McPherson, Swenson, & Kjellberg, 2001; Penson & Litwin,
Hellman, 2003; Litwin, Melmed, & Nakazon, 2001; Malcarne
2003b; Ptacek, Pierce, & Ptacek, 2002). In general, health-re-
lated QOL does not differ greatly among the most commonly
et al., 2002; Monturo, Rogers, Coleman, Robinson, & Pickett,
used treatment modalities. However, the type and severity
2001; Navon & Morag, 2003; Penson, Litwin, & Aaronson,
of treatment-related symptoms differ among the treatment
2003; Walsh, Marschke, Ricker, & Burnett, 2000).
groups (Bacon, Giovannucci, Testa, & Kawachi, 2001; Gal-
The purpose of this four-year follow-up study was to de-
scribe the health-related quality of life (QOL) and prostate
braith, Ramirez, & Pedro, 2001; Incrocci et al., 2002). Men
cancer treatment-specific symptoms among men who had
who have received surgery have fewer bowel-related com-
plications, yet tend to experience more urinary incontinence,
received various treatments for early-stage prostate cancer and
irritation, and blockage. Patients treated with different forms
were in extended survivorship 2.55.5 years following their
of radiation report more gastrointestinal, bowel, and rectal
initial treatment. In addition, associations among partner's
side effects. Both groups report diminished sexual function-
health-related QOL, health status, and marital satisfaction
ing; however, surgical patients complain of more sexual side
were examined.
effects during the first few months after treatment (Egawa et
Literature Review
al., 2001; Robinson et al., 2002; Steineck et al., 2002).
Reports of sexual dysfunction following prostate cancer
Long-Term Sequelae for Prostate Cancer Survivors
treatment range from 33%98% and have a direct and negative
effect on health-related QOL and intimate relationships (Althof,
The main treatments recommended for early-stage prostate
2002; Dahn et al., 2004; Kirschner-Hermanns & Jakse, 2002;
cancer are radical or laparoscopic prostatectomy and various
Lilleby et al., 1999; Schover et al., 2002b; Schwartz, Covino,
forms of external beam radiation or brachytherapy. However,
Morgentaler, & DeWolf, 2000). Although many men seek pro-
many seek other forms of treatment such as proton beam
fessional help for their sexual dysfunction, these attempts did
therapy, cryoablation, or alternative therapies (Bahn et al.,
not resolve the underlying problems that may affect their inti-
2002; Blana, Walter, Rogenhofer, & Wieland, 2004; Cho-
mate lives (Bertero, 2001; Bokhour, Clarke, Inui, Silliman, &
dak, 1998; Diefenbach et al., 2003; DiPaola, Kumar, Hait,
Talcott, 2001; Eton, Lepore, & Helgeson, 2001; Harrod, 2003).
& Weiss, 2001; Eng, Thomas, & Herman, 2002; Peschel &
Sexual dysfunction in this population is complex (Cooperberg
Colberg, 2003; Ponholzer, Struhal, & Madersbacher, 2003;
et al., 2003); however, researchers and clinicians have focused
Touijer & Guillonneau, 2004; Zelefsky & Eid, 1998; Ziet-
primarily on erectile dysfunction and have not addressed issues
man, 2002). Currently, many different options exist for the
of self-concept, desire, fantasy, or everyday interactions with
treatment of prostate cancer, but few comparisons across
intimate partners (Schover et al., 2002a).
treatment groups have demonstrated how men's lives are af-
Although most longitudinal studies have focused on sur-
fected over time (Pickles, 2004; Turini, Redaelli, Gramegna,
vival and morbidity, some have focused on long-term QOL
& Radice, 2003).
outcomes (Bacon et al., 2001; Bahn et al., 2002; Kim et al.,
Physical symptoms associated with the treatment of prostate
2001; Zietman, 2002). Most prostate cancer survivors report
cancer affect the man's health-related QOL and, consequently,
substantial adverse urinary, bowel, and sexual health out-
that of his partner in numerous ways (Althof, 2002). Radical
comes two to four years after treatment, but some report QOL
prostatectomy can produce impotency rates ranging from 20%
as more stable (Lee et al., 2001; Litwin, 2003; Litwin et al.,
80%, even when nerve-sparing procedures are used (Debruyne
2001; Wei et al., 2002). Few research studies have followed
& Beerlage, 2000; Mirone, Imbimbo, Palmieri, Longo, &
patients with prostate cancer or couples longitudinally beyond
Fusco, 2003). Incontinence rates vary widely, yet often are de-
five years post-treatment (Penson et al., 2003).
scribed as very high immediately after surgery and can continue
postoperatively (Drachenberg, 2000; Jani & Hellman, 2003;
Prostate Cancer and Couples
Talcott et al., 1998). External beam radiation treatment for pros-
Prostate cancer affects all members of a family, not just
tate cancer can cause injury to the pelvic bed and neurovascular
the patient, although few studies have reported on the dyadic
bundles, which can produce erectile dysfunction in 6%84%
experience (Feldman-Stewart, Brundage, & Mackillop, 2001;
of patients. Additionally, 25%65% complained of long-term
Giese-Davis, Hermanson, Koopman, Weibel, & Spiegel, 2000;
bowel complications such as diarrhea, urgency, bleeding, and
Northouse, Templin, Mood, & Oberst, 1998; Skerrett, 2003;
urinary or sexual problems depending on the dose and type of
Wai-Ming, 2002). Men and women respond differently to
radiation received (Incrocci, Slob, & Levendag, 2002; Zelefsky
the stress of a cancer diagnosis. Men tend to use more active
& Eid, 1998). These symptoms may not manifest for as many as
problem-solving strategies that may change long-established
two to five years following treatment (Lilleby, Fossa, Waehre,
roles for the couple (Carlson, Ottenbreit, St Pierre, & Bultz,
& Olsen, 1999; Peschel & Colberg, 2003; Potosky et al., 2000;
2001; Feldman-Stewart et al.; Lavery & Clarke, 1999; Shields,
Shrader-Bogen, Kjellberg, McPherson, & Murray, 1997; Wei
Travis, & Rousseau, 2000). Even if treatment is successful,
et al., 2002; Yarbro & Ferrans, 1998).
the quality of the couple's relationship may be altered greatly
Long- and Short-Term Health-Related Quality
(Malcarne et al., 2002).
of Life Following Prostate Cancer Treatment
Some researchers have noted that partners of patients with
The number of studies describing the health-related QOL
prostate cancer experience even more psychological distress
and related psychosocial factors for men who have been
than their mate, which currently is not well understood (Carl-
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E31
Sample
son, Bultz, Speca, & St. Pierre, 2000; Kiss & Meryn, 2001;
Perez, Skinner, & Meyerowitz, 2002; Sestini & Pakenham,
A total of 192 men who had received treatment at a ter-
2000). Fewer than half of men believed their partner supported
tiary facility in San Bernardino County in region five of the
them in their efforts to find help for their sexual dysfunction
California Statewide Cancer Reporting System and who had
(Neese, Schover, Klein, Zippe, & Kupelian, 2003). However,
participated in an earlier prostate cancer QOL study were
partners may be most helpful by focusing on putting impo-
invited to participate (see Galbraith et al., 2001). No age or
tence into perspective and reassuring their spouses (Maliski,
race limitations or known cognitive disabilities existed, and
Heilemann, & McCorkle, 2001). Being part of a strong,
participants were able to speak, write, or understand English.
positive relational dyad can buffer against psychological dis-
The patients had been treated with watchful waiting, surgery,
tress for patients with prostate cancer (Banthia et al., 2003).
or some form of radiation. Radiation treatment included (a)
Partners of patients with prostate cancer may feel the need
conventional external beam, (b) proton beam therapy, (c) stan-
for more family-centered information to be better prepared to
dard protocol mixed-beam that was a combination of proton
support their spouses after treatment (Butler, Downe-Wam-
beam therapy and external beam radiation (7475 Gy), (d)
boldt, Marsh, Bell, & Jarvi, 2000; Maliski et al.).
low-dose mixed beam (70 Gy), or (e) high-dose mixed-beam
radiation (75 Gy) (Slater et al., 1999; Yonemoto et al., 1997).
Study Framework
Additionally, 3.5 years after the men had been treated, 126 of
their partners agreed to participate and were enrolled.
Health-related QOL for patients with prostate cancer is com-
At the 5.5-year post-treatment data collection point, 137
prised of psychological, biophysical, functional, environmental,
(71%) of the 192 men initially invited to participate in the
and social factors. Each person experiences specific symptoms
study still remained active. Likewise, 104 (83%) of the 126
related to these factors, which directly influence ongoing self-
women initially invited to participate were still in the study.
evaluations of his or her health status. This process enables men
This represented an attrition rate of 29% for the men and 17%
to determine the extent of the effect of diagnosis and treatment
for the women. In the initial study, the overall attrition rate
on their lives. Patients assess their health status by comparing
was 17% (Galbraith et al., 2001). The attrition rate for men
actual life experience to what is normal for them and then
had slowed over the course of the four-year follow-up study,
determining which consequent adaptations are required (King
and the rate of dropout for the women was similar to the
et al., 1997; Padilla, Mishel, & Grant, 1992; Penson & Litwin,
dropout rate observed in the earlier study. Additionally, over
2003b; Wilson & Cleary, 1995).
the course of the study, 20 men died, 4 from prostate cancer,
Cancer survivorship is comprised of lasting and complex
6 from illnesses such as cardiac disease and other cancers, and
combinations of physical, psychological, and social effects for
10 from unknown causes.
patients with cancer extending long after treatment has been
completed (Dow, 1990). Mullan (1985) further suggested that
Instruments
cancer survivorship has distinct seasons in which long-term
Quality-of-Life Index: This instrument was designed to as-
survivors are challenged with physical, emotional, and inter-
sess health-related QOL among patients with cancer (Padilla et
personal sequelae that result from the diagnosis, treatment,
al., 1983). It assesses biophysical symptoms, psychological and
and recovery process beyond five years after treatment.
social factors, and general QOL. The QOL Index contains 14
The family systems theory suggests that the impact of can-
items and uses a 100-mm linear analog scale on which partici-
cer is felt by the entire family, not just the identified patient.
pants indicate with an X their response to each item. The posi-
Family members may be influenced directly and indirectly by
tion of the X is measured, and the distance from the left anchor
the impact of the diagnosis and subsequent treatments. Con-
is used for analysis. An example of the two end points that serve
sequently, the entire family environment and social system
as anchors for the linear analog scale is "none" or "not at all" to
must incorporate the experience into various system-related
"normal for me." Internal consistency was reported to be 0.88.
activities such as intimacy and communication, as well as
The measure was selected for the proposed study because it dis-
finding functional and emotional balance (Minuchin, 1974;
criminates well between patients with cancer and nonpatients,
Morse & Fife, 1998; Wilson & Cleary, 1995).
the linear analog is easy for older patients to use, the measure
Long-term physical symptoms from prostate cancer treat-
has been used previously with patients with prostate cancer, and
ment can include impotence, incontinence, sexual dysfunc-
it takes only 510 minutes to complete.
tion, and long-term bowel and bladder complications such
Medical Outcomes Study General Health Survey: This
as diarrhea, urgency, bleeding, or cystitis. Additionally, these
survey contains 36 items that represent eight health concepts:
outcomes may occur several years following treatment (Albert
physical functioning; physical, emotional, and social role func-
et al., 2003; Galbraith et al., 2001; Jani & Hellman, 2003;
tioning; vitality; mental health; bodily pain; and general health.
Penson & Litwin, 2003a; Talcott, 2003; Yarbro & Ferrans,
Reliability coefficients for the scales range from 0.810.88,
1998). Therefore, prostate cancer survivors may continue to
and the instrument differentiated well between patients who
experience treatment-related late side effects that can affect
were ill and the general population (Stewart, Hays, & Ware,
many factors associated with their health-related QOL and
1988). Scores are summed with reversed items being recoded
that of their partner for years after the initial treatment.
so that higher scores reflect better health. The instrument takes
Methods
approximately 10 minutes to complete and has been used in a
variety of studies including those with patients with prostate
cancer.
This follow-up longitudinal survey design study had
Southwest Oncology Group Prostate Treatment-Specific
descriptive, correlational, predictive, and comparative ele-
Symptoms Measure: This 19-item measure was developed
ments.
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E32
specifically to compare treatment-related symptoms that can
groups. Growth curve analyses estimate slopes and intercepts
for each subject despite missing data or cases.
result from any prostate cancer treatment strategy (Moinpour,
Post-hoc contrasts were used to examine differences among
Hayden, Thompson, Feigl, & Metch, 1990). Symptoms in-
cluded were related to bowel, bladder, and sexual functioning.
the groups at each year. Differences must be viewed in light of
Items are scored on Likert-type and binomial scales and can
progressively smaller-cell Ns; caution should be exercised in
be used individually. Items related to specific bowel, bladder,
interpreting the findings. Attention should be given to trends
and sexual functioning were combined into three subscales.
rather than specific findings. In addition, smaller-cell Ns may
Reliability coefficients for the three subscales ranged from
contribute to larger differences that are not significant. For
0.420.93. The scale took approximately 10 minutes for the
a complete summary of the trends in differences among the
men to complete.
seven prostate cancer treatment groups, see Table 2.
Dyadic Adjustment Scale: This instrument was designed
Quality of Life
to assess the quality of marriage and other similar dyads and
QOL generally decreased among the groups over the four
satisfaction with the relationship (Spanier, 1976). The 32-item
years (F [1, 178] = 27.5, p < 0.001) (see Figure 1). At 5.5
scale is constructed of four empirically supported components
years, the men who were in the watchful-waiting group had
of consensus, satisfaction, cohesion, and affectional expres-
sion. Items are scored on Likert-type scales, and the range of
lower QOL scores than the men in the conventional radiation
total scores for the measure is 0151, with higher numbers
group or the low-dose mixed-beam radiation group.
representing increased marital adjustment and satisfaction.
Health Status
The internal consistency reliability coefficient for the mea-
Physical functioning declined overall among all the groups
sure is 0.96, and it takes approximately 1520 minutes to
complete.
over the four years (F [1, 180] = 11.63, p < 0.001) (see Figure
2A). However, the men did not decline significantly in their
Procedures
ability to perform their physical (see Figure 2B) or emotional
The men in this study participated in a previous prostate
roles (see Figure 2C) over the course of the study. The men
cancer QOL study and agreed to annual follow-up (Galbraith
in the low-dose mixed-beam radiation group tended to score
et al., 2001). A cover letter, questionnaire, and self-addressed
higher in their ability to perform their physical role functions
stamped envelope were mailed annually to the men. Spouses
than men in the surgery group.
or partners of the men who were participating in the study were
Differences were found among the groups in their emo-
tional role functioning (F [6, 293] = 2.52, p = 0.02) at 2.5
contacted by telephone and invited to take part in the annual
years. The men in the low-dose mixed-beam radiation group
follow-up. If they expressed interest, they received a packet
had fewer role limitations caused by emotional problems at
via mail that included a consent form, questionnaire, and self-
2.5 years than did the men in the watchful-waiting group.
addressed envelope for the return of study-related materials.
Vitality also decreased overall among all of the groups (F [1,
Before each annual mailing, telephone contact was made with
181] = 12.71, p < 0.001) (see Figure 2D). Again, at 2.5 and
study participants reminding them to expect the questionnaire
3.5 years, men in the low-dose mixed-beam radiation group
packet in a week or two. Each participant received his or her
reported higher vitality scores than men who had received
own packet to encourage individual responses and provide
proton beam therapy only.
confidentiality. They were reminded to complete their own
An overall change in mental health was not reported over
questionnaire and assured their responses would not be shared
the four years of the study (see Figure 2E); however, 4.5 years
with their partner.
after treatment, men who had received low-dose mixed-beam
Findings
radiation reported better mental health than men who were in
the watchful-waiting group even though they did not report
The average age of the men was 70 years, with the partici-
the largest difference. Note the positive, upward trend in
pants in the watchful-waiting group being the oldest and the
mental health for the surgery and proton beam therapy groups
surgical patients being the youngest (F(6) = 5.1, p < 0.001).
although it did not reach significance.
Eighty-eight percent of the men were married or partnered.
Social functioning differed among the groups (F [6, 298] =
Seventy-one percent had at least some college education, and
2.16, p = 0.05). The watchful-waiting group reported the low-
est scores 2.5 and 3.5 years following treatment (see Figure
36% had annual incomes of over $50,000, with the men in
2F), but no significant trends or differences in bodily pain
the proton beam therapy group reporting the highest incomes
c2 = 20.7, p = 0.002). Most men were white (86%); however,
were noted (see Figure 2G).
Hispanic (6%), black (5%), and Asian (2%) men, as well as
General health decreased in all groups over the four years
those of undisclosed ethnicity (1%), were represented in the
of the study (F [1, 181] = 112.02, p < 0.001). Men in the low-
sample.
dose mixed-beam radiation group tended to report higher
The average age of the partners enrolled 3.5 years post-
scores than men in the watchful-waiting group at 2.5, 3.5, and
4.5 years (see Figure 2H).
treatment was 66 years, and 66% were college educated. The
majority of the partners were white (89%), although Hispanics
Treatment-Specific Symptoms
(7%), blacks (2%), and Asians (2%) also were represented
Gastrointestinal (GI) symptoms differed among the par-
(see Table 1).
ticipant groups (F [6, 286] = 2.92, p = 0.009). At 2.5 years,
To accommodate for missing data and attrition of study par-
ticipants over a multiple-year follow-up study, growth curve
men in the low-dose mixed-beam radiation group reported
analyses (Khattree & Naik, 1999) were used to describe the
fewer GI symptoms than men in the high-dose mixed-beam
performance of the outcome variables among the treatment
radiation group. In general, men in the low-dose mixed-beam
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E33
Table 1. Selected Demographic Characteristics for the Seven Treatment Groups
--
Married or
Yearly Income Less
X Age
Some College
White
Black or
Partnered (%)
Treatment Group
(Years)
(%)
Than $50,000 (%)
(%)
Hispanic (%)
76
Watchful waiting
62
Men (n = 21)
76
52
181
10
Women (n = 8)
74
38
100
96
Surgery
75
Men (n = 39)
67
58
182
16
Women (n = 22)
65
68
186
19
94
Conventional radiation
69
Men (n = 18)
72
65
171
24
Women (n = 11)
66
36
173
18
95
Proton beam therapy
44
Men (n = 21)
72
85
195
15
Women (n = 15)
69
67
187
13
87
Standard protocol mixed-beam radiation
53
Men (n = 37)
71
78
195
15
Women (n = 22)
65
73
191
19
76
Low-dose mixed-beam radiation
68
Men (n = 25)
69
76
184
12
Women (n = 20)
65
65
100
87
High-dose mixed-beam radiation
67
Men (n = 31)
68
81
190
17
Women (n = 27)
62
67
185
15
N = 192 men and 125 women
radiation group reported GI symptoms at a rate similar to men
ful-waiting group typically reporting the most symptoms at
5.5 years (see Figure 3C).
in the surgery group (see Figure 3A).
Overall, urinary symptoms increased over the course of the
Symptom Trends Among the Groups
study (F [1, 181] = 4.28, p = 0.04). However, this trend was
Treatment-specific symptoms were measured using re-
driven by three of the seven groups, with men in the watch-
ful-waiting group reporting the most urinary symptoms (see
sponse options ranging from 15, with lower scores indicating
Figure 3B). In general, sexual symptoms tended to remain
few or no problems and higher scores indicating more severe
high (F [1, 178] = 10.04, p = 0.002), with men in the watch-
problems. The means for urine symptom scales ranged from a
Table 2. Summary of Differences Among the Seven Prostate Cancer Treatment Groups in Outcome Measures Over Four Years
3.5 Years
Outcome Measure
5.5 Years
4.5 Years
2.5 Years
LD versus MB
Health-related quality of life
LD versus WW
LD versus WW
LD*, C versus WW
Health statusa
LD versus C*
Physical functioning
LD versus WW*
MB versus PB
WW versus PB
LD versus C
Physical role functioning
LD versus WW*
MB versus WW*
LD versus S
LD versus WW
Emotional role functioning
LD versus WW**
MB versus C
MB versus WW*
LD versus WW*
Vitality
LD versus PB**
LD versus WW
LD versus WW*
LD versus WW*
Mental health
LD versus WW
LD versus WW**
LD versus WW
LD versus WW**
Social functioning
LD versus WW***
LD versus WW
C, LD versus WW
LD versus MB*
Bodily pain
S versus MB*
PB versus WW
WW versus MB
LD versus WW**
General health
LD versus WW*
LD versus WW**
LD versus MB
Treatment-specific symptomsb
LD versus WW*
Urinary
LD versus WW**
S versus WW*
C versus WW**
WW versus HD*
Gastrointestinal
S versus HD**
S versus C*
S versus C*
MB versus WW
Sexual
HD versus WW
LD versus WW
MB versus WW*
N = 192
* p < 0.05, ** p < 0.01, *** p < 0.001
The treatment group listed first has the highest health-related quality of life and health status scores; the group listed second has the lowest scores.
a
The treatment group listed first reported the lowest number of symptoms; the group listed second reported the highest number of symptoms.
b
C--conventional radiation; HD--high-dose mixed-beam radiation; LD--low-dose mixed-beam radiation; MB--standard protocol/mixed-beam radiation; PB--proton
beam radiation; S--surgery; WW--watchful waiting
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E34
who reported no sexual activities in the prior month, 60%
62
indicated it had bothered them at least "some" to "a lot,"
whereas 23% indicated the lack of sexual activities had not
bothered them at all.
60
Couples' Experiences
58
The levels of association on outcome measures among
couples' self-reports of QOL, marital satisfaction, and health
status were evaluated by using the men's scores in a regres-
56
sion equation to predict their partner's scores on the same
variable. Additionally, the number of comorbidities for each
54
member of the couple was used as a covariate to lessen the
effect of differences in physical status. After removing the
variance associated with the covariates, the partial correla-
52
tion coefficient r was a measure of the uniquely shared vari-
ance between a man and his partner on each of the outcome
50
measures.
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
At 3.5 years, the couples' QOL (partial r = 0.44, p < 0.01),
Years Since Treatment
marital satisfaction (partial r = 0.83, p < 0.01), and emotional
role functioning (partial r = 0.30, p < 0.05) were significantly
Watchful waiting
correlated. At 4.5 years, the couples' QOL (partial r = 0.36,
Surgery
p < 0.05) and marital satisfaction (partial r = 0.94, p < 0.01)
Conventional radiation
also were significantly associated (see Table 4).
Standard protocol mixed-beam radiation
Proton beam radiation
Discussion
Low-dose mixed-beam radiation
Quality of Life
High-dose mixed-beam radiation
The findings of diminishing QOL over time are consistent
Higher scores indicate increased health-related quality of life.
a
with other studies on prostate cancer survivors (Talcott, 2003).
In general, men in the low-dose mixed-beam radiation group
Figure 1. Health-Related Quality of Life
tended to report better QOL scores than men in the watch-
ful-waiting group. However, the average age of men in the
low of 1.5 for the low-dose mixed-beam radiation and surgery
study was around 70 years; as a result, the aging process can
groups to a high of 2.2 for men in the watchful-waiting group.
cause poorer health outcomes overall in addition to surviving
Similarly, the means on the GI symptom scales ranged from
prostate cancer (Van Andel, Visser, Hulshof, Horenblas, &
a low of 1.2 for the surgery and watchful-waiting groups to a
Kurth, 2003).
high of 1.6 for the high-dose mixed-beam radiation, conven-
In the current study, no overall differences were found
tional radiation, and standard protocol mixed-beam radiation
among the treatment groups as Sprangers (1996) suggested,
groups. However, a different pattern emerged for sexual symp-
but regardless of the symptoms, people often view their QOL
toms. The scores ranged from a low of 3.6 for the standard
as more favorable because they do not compare their current
protocol mixed-beam radiation group to a high of 4.3 for the
perceptions to pretreatment conditions. Rather, they compare
men in the watchful-waiting group (see Table 3).
themselves to their current self-image.
After examining individual sexual symptom items, men in
Health Status
all of the treatment groups had substantial concerns. When
asked about their ability to have erections, only 7% reported
Only scores on three of the eight health status scales
that their erections were adequate for normal intercourse,
significantly declined over the four years of the study
whereas 66% indicated they were not able to achieve an erec-
among the seven treatment groups, specifically in physical
tion adequate to allow for penetration. Only 4% had surgical
functioning, vitality, and general health. This supports other
interventions for impotence, and 27% had received other
findings that demonstrate stability of self-reported health-
treatments for erectile dysfunction.
related QOL and health status over time (Lee et al., 2001).
Although approximately a quarter of the sample reported
Additionally, significant differences were found among the
that they had received nonsurgical treatment for erection
treatment groups in emotional role and social functioning
dysfunction, 54% reported "moderate" to "very high" inter-
over the time frame of the study. In general, the low-dose
est in sexual activities whereas only 25% reported "low" or
mixed-beam radiation group faired better than men in the
"very low" interest. Twelve percent stated that their ability to
other treatment groups, especially in pain, vitality, physical
function sexually was "good" to "very good," but 42% stated
functioning, and both emotional and physical role function-
that their ability to function was "very poor." Only 3% were
ing. Men in the watchful-waiting group tended to report
"very satisfied" with their sexual activities or functioning,
poorer outcomes than the other treatment groups over the
yet 62% reported they were "not very satisfied" or "not at
four years of the study, especially in QOL, general health,
all satisfied" with either their sexual abilities or functioning.
and physical, emotional, and social role functioning. This is
Fifty-eight percent reported that they had not had any sexual
consistent with the perspective that men who opt for watch-
activities or intercourse during the prior month. Of those men
ful waiting sometimes have worse health outcomes (Pickles,
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E35
80
84
70
79
60
74
50
69
64
40
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
Years Since Treatment
Years Since Treatment
A. PHYSICAL FUNCTIONING
B. PHYSICAL ROLE FUNCTIONING
75
90
70
80
65
70
60
60
55
50
50
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
Years Since Treatment
Years Since Treatment
C. EMOTIONAL ROLE FUNCTIONING
D. VITALITY
93
82
90
80
87
78
84
76
81
74
78
72
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
Years Since Treatment
Years Since Treatment
F. SOCIAL ROLE FUNCTIONING
E. MENTAL HEALTH
Standard protocol mixed-beam radiation
Low-dose mixed-beam radiation
Watchful waiting
Proton beam radiation
High-dose mixed-beam radiation
Surgery
Conventional radiation
Higher scores represent better functioning.
a
Higher scores represent more vitality.
b
Higher scores represent better mental health.
c
(Continued on next page)
Figure 2. Health Status Outcome Measures
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E36
73
85
68
82
63
79
58
76
53
73
70
48
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
Years Since Treatment
Years Since Treatment
G. BODILY PAIN
H. GENERAL HEALTH
Standard protocol mixed-beam radiation
Low-dose mixed-beam radiation
Watchful waiting
Proton beam radiation
High-dose mixed-beam radiation
Surgery
Conventional radiation
Higher scores represent less pain.
d
Higher scores represent better health.
e
Figure 2. Health Status Outcome Measures (Continued)
2004). However, men enrolled in this study had been treated
latt, Lockyer, & Macdonagh, 2003; Neese et al., 2003). Few
or followed for early-stage prostate cancer; therefore, these
men reported being able to have normal sexual relations, and
even fewer reported that they were satisfied with their sexual
findings may not apply to men who have a more advanced
functioning. Nearly two-thirds of the men indicated that they
stage of disease.
were not able to achieve erections that were adequate for in-
Treatment-Specific Symptoms
tercourse, and more than half said that they had not had any
Self-reported urinary and sexual symptoms increased over
sexual relations in the past month. Almost 60% of the men
the course of the study, with men in the watchful-waiting
said that they were bothered "some" or "a lot" by their lack
group having the most concerns. Men in the low-dose mixed-
of sexual activities, but only about a quarter of the sample
beam radiation group reported the fewest urinary concerns at
indicated that they had received nonsurgical treatment for
2.5 and 3.5 years after treatment, yet expressed more concerns
impotency. This indicates a critical need for information and
than the surgical group at 4.5 and 5.5 years. Initially, the men
assistance for this group of men. Although these men were
who had received either low- or high-dose mixed-beam radia-
challenged in their ability to function sexually, most reported
tion tended to report fewer sexual symptoms. However, sexual
they still were interested in sex and bothered by this dimin-
ished functioning. Twenty-three percent indicated they were
concerns tended to increase for the high-dose mixed-beam
not bothered at all with their lack of sexual activities, which
radiation group. This is consistent with Penson et al.'s (2003)
is consistent with other findings reporting that even though
findings that radiation treatment for prostate cancer initially
survivors of prostate cancer are among the aging population,
tends to result in fewer sexual side effects than other treat-
ments, but men's self-reported sexual and urinary symptoms
most men continue to be concerned with maintaining an ac-
tive sex life (Crowe & Costello, 2003; Harden et al., 2002;
should be followed over time.
Harrod, 2003).
Men in the watchful-waiting group primarily accounted for
differences among the treatment groups in GI symptoms over
Couples' Experiences
the four years of the study. Men in other radiation groups,
The researchers expected that couples' health-related
such as the high-dose mixed-beam radiation, conventional
QOL, marital satisfaction, and health status would be asso-
radiation, and standard protocol mixed-beam radiation, also
ciated, which was supported partially. Their health-related
tended to report more GI symptoms than other treatment
QOL and marital satisfaction were associated 3.5 and 4.5
groups over the course of the study.
years after initial prostate cancer treatment, but that associa-
Trends of Increased Sexual Concerns
tion did not persist 5.5 years post-treatment. However, the
Overall, men in the study indicated that they were more
sample size had decreased by the 5.5-year data collection
concerned with sexual issues than other prostate cancer
point and may not have been adequate to demonstrate a
treatment-related side effects. This trend has been supported
significant association.
by other studies that indicate men continue to have sexual
Few significant relationships were found among the eight
challenges after treatment (Jenkins et al., 2004; Meyer, Gil-
dimensions of the couples' self-reported health status. Perhaps
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E37
Table 3. Average Scores of Symptoms Over the Four-Year
1.8
Time Period of the Study
Symptom Type
1.6
Type of Treatment
Gastrointestinal
Urinary
Sexual
Watchful waiting
1.2
2.2
4.3
1.4
Surgery
1.2
1.5
3.7
Conventional radiation
1.6
1.7
3.8
Proton beam therapy
1.4
1.6
3.9
1.2
Standard protocol mixed-
1.6
1.6
3.6
beam radiation
Low-dose mixed-beam
1.3
1.5
3.7
1.0
radiation
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
High-dose mixed-beam
1.6
1.7
3.8
Years Since Treatment
radiation
A. GASTROINTESTINAL SYMPTOMS
N = 192
Note. Scores on symptom scales range from 15, with higher scores indicat-
2.1
ing more symptoms.
1.9
each member of the couple viewed his or her health status as
more of an individual experience, whereas marital satisfac-
tion and overall health-related QOL may have been seen as
1.7
influencing the couple as a whole. Other research in the area
of health-related QOL in couples has demonstrated that al-
though the health experience of one member of a couple may
1.5
influence the other, each person has individual health concerns
and needs (Harden et al., 2002; Neese et al., 2003).
1.3
Clinical Implications
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
Years Since Treatment
The primary objectives of this study were twofold. The
B. URINARY SYMPTOMS
first objective was to follow the QOL of men 2.55.5
years after their initial treatment for prostate cancer. The
second objective was to determine how much the men's
4.5
health-related QOL, health status, and marital satisfaction
predicted their partners' outcomes on the same variables. In
general, regardless of the type of treatment they received,
their health-related QOL decreased over the course of the
4.0
study. This finding is consistent with other reports that as
people age, they tend to experience additional health chal-
lenges that translate into poorer health outcomes (Van Andel
et al., 2003).
3.5
The men in the watchful-waiting group tended to report
that they experienced as many, if not more, prostate-related
symptoms than those who had received surgery or some form
of radiation. Watchful waiting continues to be a viable option
3.0
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
6.0
for men who have slow-growing disease or less than a 10-year
Years Since Treatment
life expectancy (Pickles, 2004). However, the findings in this
C. SEXUAL SYMPTOMS
study support the idea that men who are not seeking one of
the active treatments for early-stage prostate cancer are still
at risk for problematic health symptoms. Although watchful
Watchful waiting
waiting is one of the treatment options available to patients
Surgery
with prostate cancer, it must be the correct choice for each
Conventional radiation
Standard protocol mixed-beam radiation
individual patient (Wallace, Bailey, O'Rourke, & Galbraith,
Proton beam radiation
2004).
Low-dose mixed-beam radiation
Overall, sexual concerns remained high for men in the
High-dose mixed-beam radiation
study. Other researchers have found that sexual issues remain
salient for men even though they are aging (Van Andel et al.,
Higher scores represent more symptoms.
a
2003). Most men were concerned about sexual issues and
Figure 3. Treatment-Specific Symptoms
reported low satisfaction with their sexual functioning, but
ONCOLOGY NURSING FORUM VOL 32, NO 2, 2005
E38
Table 4. Partial and Zero-Order Correlations Among Couples' Health-Related Quality of Life, Relationship Satisfaction,
and Health Status at 3.5, 4.5, and 5.5 Years Post-Treatment
3.5 Years
4.5 Years
5.5 Years
Partial
Zero-Order
Zero-Order
Partial
Zero-Order
Partial
Outcome Measures
Correlations
Correlations
Correlations
Correlations
Correlations
Correlations
Health-related quality of life
0.44***
0.51
0.40
0.27*
0.27
0.36***
Dyadic Adjustment Scale relationship
0.83***
0.83
0.87
0.37*
0.47
0.94***
satisfaction
Medical Outcomes Study
Physical functioning
0.28***
0.29
0.12
0.18*
0.15
0.11***
Physical role functioning
0.10***
0.13
0.02
0.10*
0.11
0.05***
Emotional role functioning
0.30***
0.35
0.09
0.19*
0.19
0.13***
Vitality
0.12***
0.23
0.09
0.05*
0.04
0.12***
Mental health
0.07***
0.03
0.01
0.04*
0.02
0.01***
Social functioning
0.10***
0.22
0.10
0.07*
0.08
0.10***
Bodily pain
0.17***
0.20
0.00
0.30*
0.24
0.01***
General health
0.18***
0.20
0.01
0.10*
0.12
0.01***
N = 126 couples
* p < 0.10, ** p < 0.05, *** p < 0.01
relatively few sought treatment. This is of particular interest
sexual problems and consequently individualize their sexual
in that the study was conducted during a time period where
assessment if they know patients have been treated or are
erectile dysfunction medications became available, but not all
being followed for prostate cancer. They can offer sugges-
tions related to possible treatment or educational options that
men who have received prostate cancer treatment respond to
these medications (Meuleman & Mulders, 2003). However,
would be appropriate for couples. In addition, nurses can as-
additional treatments are available, and healthcare providers
sess the partner as well. Sexuality is a critical component of
should follow up with their patients to determine treatment ef-
health-related QOL and marital satisfaction; therefore, these
ficacy. Additionally, if men were continuing to report that they
issues should not be ignored simply because patients are
were not satisfied with their sexual life, alternative methods
older. Sexuality and intimacy issues continue to be relevant,
to approach this issue should be explored.
regardless of age. With this increased focus on meeting the
Prostate cancer clearly affects both members of a couple,
information, communication, intimacy, and educational needs
but how couples manage this challenge is less clear. Some
of couples surviving prostate cancer, nurses can affect how
investigators and clinicians have identified issues that are
men and their partners live with the long-term challenges that
salient to couples surviving prostate cancer, yet fewer have
prostate cancer and treatment bring to their health-related
looked at interventions designed to assist couples as they
QOL and relationship experiences.
navigate this experience (Maliski et al., 2001; Monturo et
The authors gratefully acknowledge the Departments of Radiation and
al., 2001; Neese et al., 2003). Nurses are in a prime position
Urology at Loma Linda University in California and express their appre-
to help couples with some of these challenges. Not only can
ciation to research assistants Erin Bantum, MA, Robert Hull, MA, Valinda
nurses educate couples about potential long-term conse-
Lee, BA, and Hsinya Chichester, PsyD.
quences of prostate cancer treatment, they also can follow
up to determine whether the information was useful and
Author Contact: Michael E. Galbraith, RN, PhD, can be reached
help them access additional resources if needed. Advanced
at galbraim@ohsu.edu, with copy to editor at rose_mary@earthlink
practice nurses could increase their awareness of potential
.net.
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