Copyright © 2013 Asian Pacific Prostate Society (APPS)
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P R O S T A T E
Anxiety level of early- and late-stage prostate cancer
Charles Johanes, Richard Arie Monoarfa, Raden Irawati Ismail1, Rainy Umbas
Departments of Urology and 1Psychiatry, Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jakarta, Indonesia
Purpose: Anxiety can worsen prostate cancer patients’ decision making and quality of life. Early identification of anxiety disorders is
thus very important for excellent prostate cancer treatment. This study aimed to determine the levels of anxiety in patients with early-
stage prostate cancer compared with advanced-stage disease.
Methods: This cross-sectional study was performed at the Department of Urology, ‘Cipto Mangunkusumo’ Hospital, Faculty of Medicine,
University of Indonesia. The subjects were early-stage prostate cancer patients and advanced-stage prostate cancer patients with
bone metastatic lesions proved by bone scan. Comparative analysis was done to analyze anxiety scores assessed by use of an 11-item
modified Memorial Anxiety Scale for Prostate Cancer (MAX-PC) questionnaire. We also assessed the relationship of the MAX-PC score
with age, prostate-specific antigen (PSA) value, number of bone metastases, and pain. Data were analyzed by using SPSS ver. 17 (SPSS
Results: There were 34 subjects with early-stage prostate cancer and 34 subjects with advanced-stage prostate cancer. We found that
the mean anxiety score was significantly lower (P=0.0001) in the early-stage prostate cancer group (8.32±3.65) than in the advanced-
stage prostate cancer group (12.61±4.56). Nine subjects had a pathological MAX-PC score (≥16), of whom 1 subject had early-stage
disease and 8 subjects had advanced-stage disease. Furthermore, there were significant positive correlations (P<0.001) between
MAX-PC score and visual analogue scale pain score (r=0.633), PSA value (r=0.263), and number of bone metastatic lesions (r=0.464).
However, the correlation between age and anxiety score was not significant (P=0.170).
Conclusions: The MAX-PC anxiety score was significantly associated with the stage of prostate cancer. Furthermore, visual analogue
scale pain score, PSA value, and number of bone metastatic lesions can also affect the MAX-PC anxiety score.
Keywords: Prostatic neoplasms, Neoplasm staging, Anxiety disorders, Pain measurement
Prostate Int 2013;1(4):177-182 • http://dx.doi.org/10.12954/PI.13027
Corresponding author: Rainy Umbas
Division of Urology Department of Surgery, Cipto Mangunkusumo Hospital, Faculty of Medicine University of Indonesia, Jl. Diponegoro No.71, Jakarta 10430, Indonesia
E-mail: firstname.lastname@example.org / Tel: +62213923631 / Fax: +62213145592
Submitted: 26 September 2013 / Accepted after revision: 21 November 2013
Prostate cancer is the most common carcinoma among men
in Western countries, and the incidence rate is increasing in
Asian countries . Men diagnosed with prostate cancer have
a higher anxiety level and a higher risk of developing depres-
sion than do healthy men . They also have a tendency for
suicide that is 4 times higher than the risk in healthy indi-
viduals . Prostate cancer patients also experience serious
challenges to their self-esteem [4,5], especially concerning
their masculinity [6,7]. Some of the unpleasant experiences
that prostate cancer patients may have are the fear of bearing
their unpredictable future ; pain; fatigue; nausea (due to
medication); loss of social and physical capabilities, especially
sexual capability, as the result of hormonal therapy ; and
erectile dysfunction, which occurs in 30% to 70% of patients
who undergo prostate surgery [10,11]. The patient’s response
to those unpleasant experiences may be a trigger of anxiety
and depression in this population . Anxiety and depres-
sion also affect the quality of life of patients with prostate
Johanes, et al. Anxiety level of early and late stage prostate cancer patients
cancer, especially those receiving hormonal therapy . Fur-
thermore, anxiety and depression can worsen the patient’s
decision making. For these reasons, early identification of
affective disorders is very important for making good prostate
cancer treatment decisions [4,14]. Unfortunately, only a few
studies about quality of life and the psychological character-
istics of prostate cancer patients have been conducted in Asia
. In general, those studies showed that the anxiety level
of patients with cancer was proportional to the stage of the
disease . The aim of the present study was to determine
the anxiety level of patients with early-stage prostate cancer
compared with that of patients with advanced-stage disease
at our institution.
MATERIALS AND METHODS
The subjects of this study were newly diagnosed patients with
early-stage or advanced-stage prostate cancer registered in
the Department of Urology, “Cipto Mangunkusumo” Hospi-
tal. Advanced-stage prostate cancer was defined as metastatic
prostate cancer proved by bone scan. Exclusion criteria were
subjects who could not communicate or fill out the anxiety or
visual analogue scale (VAS) form.
2. Data collection
Subjects who met the inclusion criteria were requested to
participate in this study. We collected data on age, anxiety scale
score, pain VAS score, number of bone metastatic lesions, and
prostate-specific antigen (PSA) value. Anxiety was assessed by
use of the modified memorial anxiety scale for prostate can-
cer (MAX-PC) and pain was assessed by use of a VAS (score,
1 to 10). The modified MAX-PC questionnaire consisted of 11
questions, which are shown in the Appendix. The MAX-PC
questionnaire was validated in a study assessing anxiety by
Roth et al.  in New York and in a study by Van den Bergh
et al.  in Rotterdam. The number of study subjects was 34
with early-stage prostate cancer and 34 with advanced-stage
prostate cancer. Subjects who had a MAX-PC score ≥ 16 were
classified in the pathological group [17-19]. Approval for this
study was obtained from the health research ethics commit-
tee in the Faculty of Medicine, “Cipto Mangunkusumo” Hos-
pital, University of Indonesia.
3. Data analysis
Data were analyzed and presented in a frequency distribu-
tion table. Comparison of anxiety scores between early-stage
prostate cancer patients and advanced-stage prostate cancer
patients was performed by use of independent t-tests. If the
independent t-test requirement was not met, the Mann-Whit-
ney test was used. The study confounding factors were VAS,
PSA value, number of bone metastatic lesions, and age. The
relationship between age, VAS, and PSA value with the anxi-
ety score was analyzed by using the Pearson correlation test.
If the Pearson correlation test requirement was not met, the
Spearman test was used. The data were analyzed by using the
Statistical Package for the SPSS ver. 17 (SPSS Inc., Chicago, IL,
USA). The analysis was considered significant if the P-value
Of the 68 subjects, there were 34 early-stage and 34 advanced-
stage prostate cancer patients. The mean age of the subjects
was 67.99±8.724 years. The mean MAX-PC score was 10.47±
4.64. Of the 68 subjects, 59 subjects did not have a pathologi-
cal MAX-PC score (MAX-PC score<16). Nine subjects, how-
ever, had pathological MAX-PC scores. Of those 9 subjects,
1 subject was an early-stage prostate cancer patient and 8
subjects were advanced-stage prostate cancer patients. The
mean VAS score was 4.05±1.99. Other characteristics of the
data set can be seen in Table 1.
As stated above, the mean MAX-PC score in this study
was 10.47±4.64, with a median value of 9 (range, 1–23), and
the mean VAS score was 4.05±1.99, with a median value of
4 (range, 1–8). We found a significant difference in the anxi-
ety score and the mean VAS score between the groups with
early-stage and advanced-stage prostate cancer. The mean
anxiety score in the group of early-stage prostate cancer
patients (8.32±3.65) was significantly lower than the mean
anxiety score in the advanced-stage prostate cancer group
(12.61±4.56). Analysis of this relationship is shown in Tables
2 and 3.
The relationship between confounding factors (age, VAS,
PSA value, number of bone metastatic lesions) and the MAX-
Table 1. Subject characteristics in the early- and advanced-
stage prostate cancer groups
No. of bone
NA, not applicable.
Vol. 1 / No. 4 / December 2013
PC score was analyzed by using the Spearman test. This study
found that the correlation between age and MAX-PC was not
significant with no strong positive correlation. Interestingly,
a significant association was found between VAS scores and
the MAX-PC score (P<0.001) with a very strong positive cor-
relation (r=0.633), which could mean that the greater the VAS
score the greater the MAX-PC score. These correlations are
shown in Table 4.
Problems in treating cancer patients include not only the can-
cer itself, but also the quality of life and psychological problems
of patients. Anxiety and depression are the most common
psychological disorders in patients with cancer . It has
been reported that the level of anxiety and depression is high-
er in prostate cancer patients than in healthy men. The MAX-
PC is a valid and reliable method for identifying anxiety re-
lated to prostate cancer [19,20]. In this study, the mean MAX-
PC score was 10.47±4.64. Similar results were reported by
Van den Bergh et al. , who found a mean MAX-PC score
of 9.3±6.8. The analysis of the relationship between prostate
cancer stage and anxiety scores showed a significant differ-
ence in the mean MAX-PC score (P=0.0001) between the ear-
ly-stage prostate cancer group (8.32±3.65) and the advanced-
stage prostate cancer group (12.61±4.56). Vodermaier et al.
 reported the same findings that anxiety symptoms were
more commonly found in metastatic prostate cancer patients
than in nonmetastatic prostate cancer patients.
Another study by Bill-Axelson et al.  suggested that the
hospitalization rate related to psychiatric symptoms (anxiety)
will increase along with the diagnosis of prostate cancer. In
patients with advanced-stage cancer, there would be more
treatment for anxiety with a relative risk of 2.28 (95% confi-
dence interval, 1.45–3.57) compared with early-stage cancer
. The most common metastatic site of prostate cancer is
bone. In prostate cancer, bone metastatic lesions result in lo-
calized pain . In our study, the pain score (VAS) in patients
with advanced-stage prostate cancer was significantly higher
than that in patients with early-stage prostate cancer. In this
study, there were some confounding variables significantly
related to the MAX-PC score (P<0.05). These were the level of
pain (VAS score), PSA value, and number of bone metastatic
lesions. The VAS score was significantly correlated with the
anxiety level (MAX-PC score). Cancer pain in prostate cancer
patients was considered to have a major effect on anxiety level
(r=0.633, P<0.001); therefore, the proper management of
pain is important.
The high level of anxiety could affect patient decision mak-
ing in determining the treatment of choice [19,23]. A study
by Latini et al.  showed that early-stage prostate cancer
patients who have a high level of anxiety tend to make an
early decision for more aggressive therapy compared with
undergoing active surveillance. The existence of this anxiety
disorder along with depression would interfere in daily activi-
ties, reduce the quality of life, and increase the incidence of
suicide of prostate cancer patients [3,7,9]. Factors that could
increase the risk of anxiety in cancer patients are advanced
stage of cancer, previous history of anxiety, lack of family sup-
port, activity limitations due to cancer, other comorbidities,
and unresolved cancer pain . In the National Compre-
hensive Cancer Network distress guideline version 2.2013,
an indication for referring a cancer patient to mental health
services or social work and counseling services is a Distress
Thermometer value of 4 or more with social, family, physical,
emotional, and other medical problems. In assessing prostate
cancer–related anxiety, we have not yet found a cutoff score
Table 2. Analysis of the relationship between prostate cancer
stage and MAX-PC score
Prostate cancer stageMAX-PC value
Values are presented as mean±standard deviation (range).
MAX-PC, memorial anxiety scale for prostate cancer.
Table 3. Comparison of mean VAS pain scores in the early- and
advanced-stage prostate cancer groups
Prostate cancer stageValue
Values are presented as mean±standard deviation (range).
VAS, visual analogue scale.
Table 4. Correlation of MAX-PC scores with age, VAS, PSA value,
and number of bone metastatic lesions
Correlation coefficient with
No. of bone
MAX-PC, memorial anxiety scale for prostate cancer; VAS, visual ana-
logue scale; PSA, prostate-specific antigen.
Johanes, et al. Anxiety level of early and late stage prostate cancer patients
on the MAX-PC for referral to mental health services (psy-
chiatry). Despite some research on the psychological needs
of men with prostate cancer in Asian countries, it is difficult
to draw clear conclusions about the impacts of prostate can-
cer on the psychological health of Asian men with prostate
cancer . Further investigations are required to determine
the cutoff score on the MAX-PC questionnaire for referral to
mental health services.
The limitations of this study were the relatively small num-
ber of study subjects (34 patients in each group) and the lack
of guidelines in terms of psychiatric treatment for patients
with high levels of anxiety. This study also did not examine
the effect of the high level of anxiety on patient quality of life
and their therapy selection. Future studies should be con-
ducted to determine the cutoff value of MAX-PC score for re-
ferral by use of the MAX-PC instrument in combination with
a psychiatric diagnostic instrument, such as the Mini-Inter-
national Neuropsychiatric Interview for The Diagnostic and
Statistical Manual of Mental Disorders (MINI, DSM-IV). The
MINI is a short, structured diagnostic interview developed in
1990 by psychiatrists and clinicians in the United States and
Europe for DSM-IV and International Statistical Classification
of Diseases-10th revision psychiatric disorders .
In conclusion, advanced-stage prostate cancer was sig-
nificantly related to a high level of anxiety (MAX-PC score).
Furthermore, VAS scores, PSA value, and the number of bone
metastatic lesions might affect the anxiety (MAX-PC score)
of patients with prostate cancer. Study of larger populations
should be done to acquire a cutoff value of the MAX-PC score
for better management of mental health issues in prostate
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was re-
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Johanes, et al. Anxiety level of early and late stage prostate cancer patients Download full-text
Appendix. Modified memorial anxiety scale for prostate cancer (MAX-PC). Below is a list of comments made by men about prostate
cancer. Please indicate by circling the number next to each item how frequently these comments were true for you during the past
week; not at all, rarely, sometimes, often
Not at all Rarely
1. Any reference to prostate cancer brought up strong feelings in me.0123
2. Even though it’s a good idea, I found that getting a PSA test scared me.0123
3. Whenever I heard about a friend or public figure with prostate cancer, I got more anxious about my
having prostate cancer.
4. When I thought about having a PSA test, I got more anxious about my having prostate cancer.0123
5. Other things kept making me think about prostate cancer.0123
6. I felt kind of numb when I thought about prostate cancer.0123
7. I thought about prostate cancer even though I didn’t mean to.0123
8. I had a lot of feelings about prostate cancer, but I didn’t want to deal with them. 0123
9. I had more trouble falling asleep because I couldn’t get thoughts of prostate cancer out of my mind.0123
10. I was afraid that the results from my PSA test would show that my disease was getting worse.0123
11. Just hearing the words “prostate cancer” scared me.0123
Modified MAX-PC score ≥16 was the cutoff score for pathological prostate cancer specific anxiety state.
PSA, prostate-specific antigen.