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PAPER
Care‐related predictors for negative intrusive thoughts after
prostate cancer diagnosis—data from the prospective LAPPRO trial
Thordis Thorsteinsdottir
1,2,3
|Heiddis Valdimarsdottir
4,5
|Arna Hauksdottir
6
|
Johan Stranne
7
|Ulrica Wilderäng
1
|Eva Haglind
8
|Gunnar Steineck
1,9
1
Division of Clinical Cancer Epidemiology,
Department of Oncology, Institute of Clinical
Sciences, Sahlgrenska Academy at University
of Gothenburg, Gothenburg, Sweden
2
Faculty of Nursing, School of Health
Sciences, University of Iceland, Reykjavík,
Iceland
3
Research Institute in Emergency Care,
Landspitali University Hospital, Reykjavík,
Iceland
4
Department of Oncological Sciences, Mount
Sinai School of Medicine, New York, NY, USA
5
Department of Psychology, Reykjavik
University, Reykjavik, Iceland
6
Center for Public Health Sciences, School of
Health Sciences, University of Iceland,
Reykjavik, Iceland
7
Department of Urology, Sahlgrenska
University Hospital, Gothenburg, Sweden
8
Department of Surgery, Institute of Clinical
Sciences, Sahlgrenska Academy at University
of Gothenburg, SSORG ‐Scandinavian Surgical
Outcomes Research Group, Sahlgrenska
University Hospital/Östra, Gothenburg,
Sweden
9
Division of Clinical Cancer Epidemiology,
Department of Oncology–Pathology,
Karolinska Institutet, Stockholm, Sweden
Correspondence
Thordis Thorsteinsdottir, Faculty of Nursing,
University of Iceland, Eirberg v/ Eiríksgötu,
101 Reykjavík, Iceland.
Email: thordist@hi.is
Abstract
Objective Negative intrusive thoughts about one's prostate cancer have been associated with
depressive mood and impaired quality of life among prostate cancer patients. However, little is
known about possible predictors for negative intrusive thoughts among this group. We aimed
to identify health‐and care‐related predictors for such thoughts among a population of men
newly diagnosed with prostate cancer and undergoing radical prostatectomy.
Methods In the LAPPRO‐trial, 3154 men (80%) answered study‐specific questionnaires at
admission and 3 months after surgery. Questions concerned socio‐demographics, health,
uncertainty, preparedness for symptoms, and the outcome—negative intrusive thoughts. Associ-
ations between variables were analyzed by log‐binominal and multivariable approach.
Results The strongest predictor of negative intrusive thoughts at admission to surgery was
uncertainty of cure, followed by binge drinking, poor physical health, antidepressant medication,
not being prepared for urinary symptoms, age under 55, and physical pain. Reporting it not
probable to obtain urinary symptoms after surgery lowered the odds. Negative intrusive thoughts
before surgery were the strongest predictor for such thoughts 3 months later followed by uncer-
tainty of cure, physical pain, younger age, living alone, and poor self‐reported physical health.
Conclusions Our findings showed an association of preoperative uncertainty of cure as well
as low preparedness for well‐known surgery‐induced symptoms with higher occurrence of
negative intrusive thoughts about prostate cancer. Future studies should examine if interventions
designed to have healthcare professionals inform patients about their upcoming prostatectomy
reduce patients' negative intrusive thoughts and thereby, improve their psychological well‐being.
KEYWORDS
clinical trial, intrusive thoughts, oncological sugery, prostate cancer, psychological well‐being
1|INTRODUCTION
Challenging news, such as the diagnosis of cancer, may evoke diverse
responses. Population‐based studies have revealed men's risk for
suicide
1,2
and psychological distress after the diagnosis of prostate can-
cer.
3,4
While some adjust well to the diagnosis and treatment, others
are in need of psychiatric support.
5,6
Because of widespread and/or
routine PSA‐screening, more and more men are diagnosed and treated
for prostate cancer.
7,8
Prostate cancer has traditionally been seen as an
old‐man's disease. However, younger men diagnosed seem to experi-
ence greater decline in urinary and sexual function following prostatec-
tomy, more bother due to these symptoms, poorer mental health than
older men,
9
and may differ in other responses to diagnosis.
Recent studies indicate that men, diagnosed with prostate cancer,
may express their mental health with more variability than reflected by
Eva Haglind was the principal Investigator of the LAPPRO trial (Controlled Trials
Nr. ISRCTN06393679)
Gunnar Steineck is the deputy Principal Investigator
Received: 12 June 2016 Revised: 19 December 2016 Accepted: 22 December 2016
DOI 10.1002/pon.4359
Psycho‐Oncology 2017; 1–9 Copyright © 2016 John Wiley & Sons, Ltd.wileyonlinelibrary.com/journal/pon 1
traditional mental‐health assessment tools.
10,11
In an analysis of a
subgroup from the LAPPRO trial, we found that negative intrusive
thoughts,defined as involuntary negative thoughts about the cancer that
appeared suddenly and repeatedly and were unwelcome, were related to
lower self‐assessed quality of life, symptoms of anxiety, and depressive
mood, before and after prostatectomy.
12
In accordance to other studies,
intrusive thoughts could be a symptom of psychological distress related
to prostate cancer diagnosis,
13–15
and a target for medical or psycholog-
ical interventions.
16
Less is known about the predictors for such
thoughts, health‐or care‐related. Low preparedness for negative life‐
events has been related to distress among men
17
and negative attitudes
towards treatment outcomes may affect mental health after prostate
cancer diagnosis.
18–20
Therefore, the aim of the study was to identify
nonmodifiable and modifiable care‐related factors, “predictors,”for
reporting negative intrusive thoughts during primary prostate cancer
treatment in a group of Swedish men.
2|METHODS
In the LAPPRO‐trial (ISRCTN06393679), all men planned for open and
robot‐assisted laparoscopic radical prostatectomy at 14 urological
departments in Sweden, and who gave consent were prospectively
included between September 1, 2008 and November 7, 2011.
21–23
TABLE 1 Characteristics of the evaluable participants (n=3154) undergoing surgery for prostate cancer in the LAPPRO‐trial
N%
Age categories
37‐55 years 427 13.6
56‐79 years 2723 86.4
Level of education
Primary school 588 18.6
Secondary school, 3 years 924 29.3
Upper secondary school 383 12.1
College/University 1189 37.7
Other/missing 70 2.2
Cohabitation
Married or living with partner 2650 84.0
Living alone, but has partner 215 6.8
Living alone, no partner 271 8.6
Missing 18 0.6
Widower 117 3.8
Employment status before surgery
Employed 1686 53.5
Unemployed 42 1.3
Retired 1235 39.2
On short‐or long‐term sick leave 74 2.8
Other/missing 97 3.1
Residence
Rural 453 14.4
Village or town 1301 41.3
City (population > 500,000) 1371 43.5
Abroad (not in Sweden) 11 0.4
Birth country other than Sweden 173 5.5
Clinical stage, before surgery
Non‐palpable tumor (T1) 1846 58.8
Palpable tumor (T2/T3) 1213 38.6
Missing 81 2.6
Physical pain, at least once a week 645 20.5
Self‐assessed physical health, poor to moderate 1243 39.6
Co‐existing illnesses one or more, total 1613 51.1
Drinking 6 glasses of alcohol, at least once a week 178 5.7
First sign of prostate cancer, PSA elevation 2568 84.2
Surgical technique
Open surgery 790 25.0
Robot‐assisted laparoscopy 2364 75.0
2THORSTEINSDOTTIR ET AL.
TABLE 2 The associations of demographic and health‐and care‐related variables with negative intrusive thoughts about prostate cancer before and after prostatectomy as a result of a univariate analysis
(n= 3154)
Negative Intrusive Thoughts at Least once a Week or more often
Before Surgery 3 months after Surgery
No./Total No. (%) Prevalence Ratio (95% CI) No./Total No. (%) Prevalence Ratio (95% CI)
Age
56‐79 years 938/2703 (35%) 1.0 568/2716 (21%) 1.0
37‐55 years 196/427 (46%) 1.32
a
(1.17‐1.48) 131/426 (31%) 1.47
a
(1.25‐1.73)
Education
Shorter than university 673/1932 (35%) 1.0 418/19441 (22%) 1.0
University 459/1185 (39%) 1.11
a
(1.01‐1.22) 277/1185 (23%) 1.09 (0.95‐1.24)
Cohabitation
Married or living with partner 947/2632 (36%) 1.0 565/2643 (21%) 1.0
Living alone 183/484 (38%) 1.05 (0.93‐1.19) 131/485 (27%) 1.26
a
(1.07‐1.49)
Non‐widower 1079/2967 (37%) 1.0 668/2980 (22%) 1.0
Widower 40/117 (34%) 0.94 (0.73‐1.21) 22/117 (19%) 0.84 (0.57‐1.23)
Employment status
Employed 660/1015 (39%) 1.0 388/1680 (23%) 1.0
Not employed 436/926 (32%) 0.81
a
(0.74‐0.90) 287/1369 (21%) 0.91 (0.79‐1.04)
Residence
Rural 164/452 (36%) 1.0 90/452 (20%) 1.0
Urban area 967/2664 (36%) 1.00 (0.87‐1.14) 606/2676 (23%) 1.13 (0.93‐1.39)
Co‐existing illnesses
None 519/1531 (34%) 1.0 331/1537 (22%) 1.0
One or more 617/1603 (38%) 1.14
a
(1.03‐1.25) 368/1609 (23%) 1.06 (0.93‐1.21)
Clinical stage (rectal palpation)
Nonpalpable tumor (T1) 635/1835 (35%) 1.0 380/1842 (21%) 1.0
Palpable tumor (T2 or more advanced) 471/1205 (39%) 1.13
a
(1.03‐1.24) 298/1209 (25%) 1.19 (1.05‐1.37)
Self‐assessed physical health before surgery
Good (5‐6/6) 561/1889 (30%) 1.0 338/1894 (18%) 1.0
Poor to moderate (0‐4/6) 571/1235 (46%) 1.56
a
(1.42‐1.71) 356/1239 (29%) 1.61
a
(1.41‐1.83)
Current anti‐depressant medicine
No 1064/2994 (36%) 1.0 652/3007 (22%) 1.0
Yes 69/132 (52%) 1.47
a
(1.24‐1.74) 45/131 (34%) 1.58
a
(1.24‐2.03)
Drinking at least 6 glasses at the same
occasion during the past month
Less than once a week 1032/2932 (35%) 1.0 632/2933 (22%) 1.0
(Continues)
THORSTEINSDOTTIR ET AL.3
TABLE 2 (Continued)
Negative Intrusive Thoughts at Least once a Week or more often
Before Surgery 3 months after Surgery
No./Total No. (%) Prevalence Ratio (95% CI) No./Total No. (%) Prevalence Ratio (95% CI)
At least once a week 93/177 (53%) 1.49
a
(1.28‐1.73) 56/178 (31%) 1.46
a
(1.16‐1.83)
Physical pain during the past month
Less than once a week 818/2457 (33%) 1.0 491/2468 (20%) 1.0
At least once a week 306/643 (48%) 1.43
a
(1.30‐1.58) 204/644 (32%) 1.59
a
(1.39‐1.83)
First sign of prostate cancer
Physical symptoms 179/477 (38%) 1.0 124/480 (26%) 1.0
PSA elevation 919/2551 (36%) 0.96 (0.85‐1.09) 548/2560 (21%) 0.83
a
(0.70‐0.98)
Type of prostatectomy
Open surgery 321/785 (41%) 1.0 174/789 (22%) 1.0
Robot‐assisted laparoscopy 815/2349 (35%) 0.85
a
(0.77‐0.94) 525/2357 (22%) 1.01 (0.87‐1.18)
Negative intrusive thoughts
Seldom or not at all Not applicable Not applicable 250/1992 (13)% 1.0
Once a week or more often 447/1134 (39%) 3.14
a
(2.74‐3.60)
How prepared for prostate cancer
diagnosis
Somewhat to fully 802/2277 (35%) 1.0 497/2284 (22%) 1.0
Not at all 327/838 (39%) 1.11 (1.00‐1.23) 198/839 (24%) 1.08 (0.94‐1.25)
Certain to be cured
Moderate or much certain 966/2869 (34%) 1.0 587/2877 (20%) 1.0
Not or a little certain 163/244 (67%) 1.98
a
(1.79‐2.20) 107/244 (44%) 2.15
a
(1.83‐2.52)
How probable to experience urinary
problems
Somewhat to much probable 1006/2648 (38%) 1.0 624/2657 (23%) 1.0
Not at all probable 118/452 (26%) 0.69
a
(0.58‐0.81) 70/452 (15%) 0.66
a
(0.53‐0.83)
Preparedness for possible urinary problems
Somewhat to fully prepared 834/2467 (34%) 1.0 523/2477 (21%) 1.0
Not prepared 296/647 (45%) 1.35
a
(1.22‐1.50) 174/646 (27%) 1.27
a
(1.10‐1.48)
How probable to experience sexual
problems
Somewhat to much probable 1082/2924 (37%) 1.0 661/2934 (23%) 1.0
Not at all probable 39/152 (26%) 0.69
a
(0.53‐0.91) 29/153 (19%) 0.84 (0.60‐1.18)
Preparedness for possible sexual problems
Somewhat to fully prepared 957/2744 (35%) 1.0 595/2754 (22%) 1.0
Not prepared 168/349 (48%) 1.38
a
(1.22‐1.56) 100/350 (29%) 1.32
a
(1.10‐1.58)
(Continues)
4THORSTEINSDOTTIR ET AL.
The primary hypothesis of the trial was that robot‐assisted technique
would lead to less urinary and sexual symptoms 1 year after surgery.
The data collection covered hospitals, well‐established in performing
radical prostatectomies, from 4 health‐care counties or regions in
Sweden, including the 3 largest regions and for those well‐represented
population, resulting in data on about half of all prostatectomies in the
country during the time period.
23
An external study secretariat
monitored and retrieved all data by questionnaires.
2.1 |Questionnaires
Evaluable participants answered both the first questionnaire at the
time of admission for surgery at the hospital, and the second question-
naire at home after having received the results on tumor stage from
surgery. The study variables were defined, developed, and validated
applying a mixed‐methods and clinometric approach. We developed
the study‐specific questionnaires starting with previously validated
questionnaires from similar populations,
17,24
modifying according to
existing research literature.
25–27
Then new questions on men's experi-
ences were derived from in‐depth interviews. Six prostate cancer
survivors were interviewed at different time‐points after surgery. After
classical content analysis of their narratives, common themes were
recognized and questions on concepts, for example intrusive thoughts,
preparedness and uncertainty, which had rarely been studied before,
were designed. To ascertain reliability and validity of the questionnaires
in this study population, the questionnaires underwent content valida-
tion by clinical specialists, were tested, and validated in 15 face‐to‐face
meetings (“think‐out‐loud”) as well as ina pilot study with prostate cancer
patients (N=100)—a procedure previously described in detail.
23,28
2.2 |Predictors
Care‐related, modifiable, predictors were assessed before surgery by
“How certain are you that the planned surgery will cure you from
prostate cancer?”, if it was probable to experience urinary respectively
sexual symptoms after surgery, and: “How prepared are you for living
with possible urinary symptoms after surgery?”(respective sexual), all
with answers “Not at all”,“Somewhat”,“Moderately”,“Much”. The pre-
dictors were dichotomized as existing or not (“Not at all”), according to
principles from studies with similar questionnaires.
4,17,24,29
Answers to
the question “How did you contact the health‐care system for the first
time regarding your symptoms that lead to your diagnosis?”were defined
as an active contact if “Making a call,”“Writing a letter,”“Going there,”or
“Sent an email”but as nonactive if “Iwascalled”or “Had no symptoms”.
2.3 |Covariates
Specific socio‐demographic and health‐background variables were
chosen as possible covariates with the outcome, ie, nonmodifiable
factors. The cutoff for age, 55 years, reflected that prostate cancer
diagnosed at 55 years and younger may differ from being diagnosed
when older.
8
“Yes”on 1 or several possible co‐existing physical and
mental illnesses was defined as a coexisting illness. Physical health
was reported on a scale anchored from “Worst possible”(0) to “Best
possible”(6), and 5‐6 defined as good health.
17,30
Alcohol consumption
was measured by the following question: “Have you had six glasses or
TABLE 2 (Continued)
Negative Intrusive Thoughts at Least once a Week or more often
Before Surgery 3 months after Surgery
No./Total No. (%) Prevalence Ratio (95% CI) No./Total No. (%) Prevalence Ratio (95% CI)
Contact with health‐care
Active, took contact 371/969 (38%) 1.0 253/973 (26%) 1.0
Nonactive
b
588/1651 (38%) 0.93 (0.84‐1.03) 337/1658 (20%) 0.78
a
(0.67‐0.90)
a
Statistically significant association on 95% confidence level.
b
Nonactive seekers: No physical symptoms leading to diagnosis or were called in for doctor's appointment.
THORSTEINSDOTTIR ET AL.5
more on the same occasion during the past month?”, a picture indicat ed a
glass of standard drinks and the answers reflected the frequency. The
cutoff, “At least once a week,”was set by a definition of binge drinking:
more than five glasses on the same occasion for men.
21,31
Data on tumor
stage (palpable or not) and surgical technique (open versus robot‐
assisted) were derived from clinical‐record forms filled in by urologists.
2.4 |Outcome
Negative intrusive thoughts, were measured by the following question:
“How oftenduring the past monthhave you had negative thoughts about
your prostate cancer, suddenly and unintentionally?”(“Never,”“More
seldom than once a week,”“At least once a week,”“At least three times
aweek,”“At least once a day,”“At least three times a day,”and “At least
seven times a day”). In a previous study, negative intrusive thoughts “At
least once a week”had a strong association with psychological distress
and impaired quality of life,
12
and was therefore chosen as a cutoff here.
2.5 |Statistical analysis
We calculated the percentage of participants in each category of all the
variables. In a univariate analysis, the associations of the dichotomized
categories of the predictor variables as well as the covariates with the
outcome were compared, and prevalence ratios calculated with 95%
confidence intervals. The statistically significant variables from this
analysis were entered into a forward selection regression‐model (the
selection criterion 0.05). Multivariable logistic‐models were then
constructed, calculating odds‐ratios as well as relative ratios, adjusting
for all the variables entered. The statistical analysis was performed in
SAS 9.3 (SAS Institute Inc., Cary, NC, USA).
3|RESULTS
During the inclusion period of the LAPPRO‐trial, 3930 participants had
radical prostatectomy and 3154 men (80%) answered and returned the
questionnaires at the 2 time points (Appendix 1). The first questionnaire
was answered at a mean about 6 months (median 108 days; SD 296) after
confirmed diagnosis but at a median 6 days before surgery (mean 12;
SD 36). The second questionnaire was answered at a median of 90 days
after surgery (mean 101; SD 34). Before surgery, 1136 men (36%) reported
negative intrusive thoughts about their prostate cancer at least once a
week during the past month, as did 699 (22%) 3 months after surgery.
Age at surgery ranged from 37 to 79 years with a mean age of
62.6 years (SD 6.1) (Table 1): fourteen percent were under 55 years
of age, 84% were married or living with a partner, 6% were categorized
as binge drinkers, about 20% had physical pain, and 40% were of poor
physical health before surgery.
TABLE 3 Predictors for negative intrusive thoughts before and after radical prostatectomy resulting from univariate and multivariable regression
analysis
Unadjusted Relative Risk
(95% CI)
Unadjusted Odds‐Ratio
(95% CI)
Multivariable Odds‐Ratio
b
(95% CI) P‐value
d
Predictors for negative intrusive thoughts before surgery
c
37‐55 years
a
1.32 (1.18‐1.48) 1.60 (1.30‐1.96) 1.38 (1.11‐1.74)
a
.004
Poor physical health
a
1.56 (1.42‐1.71) 2.04 (1.75‐2.36) 1.68 (1.41‐1.97)
a
<.001
Coexisting illness 1.13 (1.03‐1.25) 1.22 (1.05‐1.41) 1.10 (0.94‐1.29) .248
Binge drinkingl
a
1.49 (1.28‐1.73) 2.03 (1.50‐2.75) 1.98 (1.43‐2.76)
a
<.001
Antidepressants
a
1.47 (1.24‐1.74) 1.99 (1.40‐2.82) 1.60 (1.09‐2.34)
a
.016
Uncertainty of cure
a
1.98 (1.79‐2.20) 3.96 (3.00‐5.23) 3.26 (2.42‐4.39)
a
<.001
Not probable to experience urinary problems
a
0.69 (0.58‐0.81) 0.58 (0.46‐0.72) 0.58 (0.45‐0.74)
a
<.001
Not prepared for urinary problems
a
1.35 (1.22‐1.50) 1.65 (1.39‐1.97) 1.54 (1.24‐1.93)
a
<.001
Not prepared for sexual problems 1.38 (1.22‐1.56) 1.73 (1.39‐2.17) 1.25 (0.94‐1.64) .119
Physical pain 1.43 (1.30‐1.58) 1.82 (1.53‐2.17) 1.44 (1.18‐1.75)
a
<.001
Predictors for negative intrusive thoughts after surgery
c
37‐55 years
a
1.47 (1.25‐1.73) 1.68 (1.34‐2.10) 1.40 (1.06‐1.84)
a
.016
Poor physical health
a
1.61 (1.41‐1.83) 1.86 (1.57‐2.20) 1.30 (1.05‐1.61)
a
.017
Living alone
a
1.26 (1.07‐1.49) 1.36 (1.09‐1.70) 1.32 (1.01‐1.72)
a
.040
Physical pain
a
1.59 (1.39‐1.83) 1.87 (1.54‐2.26) 1.41 (1.11‐1.79)
a
.005
Binge drinking 1.46 (1.16‐1.83) 1.67 (1.20‐2.32) 1.31 (0.87‐1.97) .199
Antidepressants 1.58 (1.24‐2.03) 1.89 (1.30‐2.74) 1.19 (0.74‐1.88) .454
Uncertainty of cure
a
2.15 (1.83‐2.52) 3.05 (2.32‐3.99) 1.89 (1.37‐2.61)
a
<.001
Not probable to experience urinary problems 0.57 (0.53‐0.83) 0.60 (0.46‐0.78) 0.73 (0.53‐1.00) .050
Nonactive health care seeking
a
0.78 (0.68‐0.90) 0.73 (0.60‐0.88) 0.75 (0.61‐0.92)
a
.006
Negative intrusive thoughts before surgery
a
3.14 (2.74‐3.60) 4.53 (3.79‐5.42) 3.56 (2.89‐4.38)
a
<.001
CI, confidence interval.
a
Statistically significant after adjustment (95%confidence level, p< .05).
b
Adjusted for all the shown variables, entered into the multivariate models.
c
Definitions and categorization shown in Table 2.
d
Chi‐square test
6THORSTEINSDOTTIR ET AL.
In Table 2, the prevalence ratios, from univariate regression, for
the associations of potential covariates (eg, socio‐demographic and
health‐related background) and the modifiable factors (predictors) with
negative intrusive thoughts, are shown as assessed and calculated both
before and 3 months after surgery.
In a final multivariable model (Table 3), the statistically significant
factors associated with negative intrusive thoughts before surgery were
uncertainty of cure [OR 3.26, CI 2.42‐4.39], binge drinking [OR 1.98, CI
1.43‐2.76], poor self‐assessed physical health [OR 1.68, CI 1.41‐1.97],
antidepressant medication [OR 1.60, CI 1.09‐2.34], not being prepared
for urinary problems [OR 1.54, CI 1.24‐1.93], physical pain [OR 1.44, CI
1.18‐1.75]. and age under 55 [OR 1.38, CI 1.11‐1.74]. Lower odds were
found when reporting it not probable to experience urinary problems
[OR 0.58, CI 0.45‐0.74]. Higher odds for negative intrusive thoughts
3 months after surgery were found for those reporting negative
intrusive thoughts before surgery [OR 3.56, CI 2.89‐4.38], uncertainty
of cure [OR 1.89, CI 1.37‐2.61], physical pain [OR 1.41, CI 1.11‐1.79],
those under 55 years [OR 1.40, CI 1.06‐1.84], living alone [OR 1.32, CI
1.01‐1.72], and poor self‐assessed physical health [OR 1.30, CI
1.05‐1.61]. The men who had not actively sought health care leading
to diagnosis had lower odds in the final adjusted model [OR 0.75, CI
0.61‐0.92]. Low preparedness for sexual problems was not statistically
significantly associated with having negative intrusive thoughts. The
reduction in prevalence of such thoughts with higher age was found
statistically significant (Appendix 2). Further, the prevalence reduction
between time points was smallest for single men (no partner) and the
prevalence was similar for men with a partner as for widowers.
4|CONCLUSIONS
In this longitudinal study, we found that uncertainty about cure before
the planned prostatectomy, as well as low preparedness for surgery‐
induced urinary problems, was associated with a higher prevalence of
negative intrusive thoughts before surgery. Further, negative intrusive
thoughts before surgery were clearly associated with such thoughts
3 months after surgery. In addition to these possibly modifiable
factors, men younger than 55 years of age, living alone, in poor health
and physical pain more likely had negative intrusive thoughts after
surgery than others.
We studied negative intrusive thoughts as a symptom associated
with lower quality of life, anxiety, and depressive mood at the time
of prostate‐cancer diagnosis and treatment. Our hypothesis and
findings are schematized in Figure 1. In the study, we focused on
identifying factors that may be modified in health‐care. Negative
intrusive thoughts have rarely been studied among men with prostate
cancer, but our results may resemble other studies. For example,
pessimism before treatment was found to be a predictor of decision‐
related distress both before and 2 months after treatment.
18
Our find-
ings revealed a longitudinal association of low expectations for cure, a
kind of pessimism, with negative thoughts. In another study, pessimis-
tic men had difficulties in decision‐making about treatment for local-
ized prostate cancer and were less satisfied with their decision
afterwards.
19
Low expectations for treatment‐efficacy even though
survival prospects are relatively high may indicate uncertainty about
the chosen treatment (surgery).
32,33
Health‐care professionals may
need improved means to communicate the good prospects of surgery
for localized prostate cancer because negative intrusive thoughts may
arise in relation to the uncertainty following the diagnosis.
Preparedness for surgery‐induced symptoms is possibly related to
the patients' expectations of surgery and may influence how they
subsequently experience bother of symptoms. A small prospective
study revealed that expectations regarding urinary outcomes before
surgery reflected the long‐term observed urinary outcome.
20
The
participants in our study, who reported low preparedness for
surgery‐induced urinary symptoms, may possibly not have understood
FIGURE 1 A model revealing the study hypothesis and the findings on the associations between the variables before and after surgery (blue
boxes), suggesting a time point for intervention
THORSTEINSDOTTIR ET AL.7
or integrated the information received before surgery. Stress due to
the cancer diagnosis or the difficult treatment decision, as well as the
information disclosure, may have impaired comprehension and
memory, thereby lowered the preparedness for such symptoms and
increased the negative intrusive thoughts.
34,35
The strong association
between negative intrusive thoughts before and after surgery in our
study, as well as their association to impaired quality of life after sur-
gery as found earlier
12
suggests that an intervention at a time point
close to surgery aimed at increasing preparedness and alleviating such
thoughts may be beneficial (Figure 1).
Our results indicate that in clinical practice, demographic back-
ground as well as prostate‐cancer patients' general health could be
used to identify patients likely to experience negative intrusive
thoughts. We see these background and health‐related factors mainly
as covariates of negative intrusive thoughts and do not suggest that
there is a causal relation. Younger men (aged 37 to 55), constituting
14% in our study, may have fewer peers to share their prostate cancer
experience with, and thus possibly fewer opportunities to express and
alleviate the negative intrusive thoughts than older men. This indicates
that younger men would possibly benefit from active supportive
contact, for example with patient organizations. Another study on
men recently diagnosed with prostate cancer found a similar associa-
tion with age: younger men reported more intrusive symptoms, such
as thoughts, dreams, and memories about the cancer, as well as those
living alone at all ages.
15
Because partners seem to play a significant
role in emotional support as compared to others in the social
network,
36,37
ours and others findings indicate that single men
diagnosed with prostate cancer may need special attention. In our results,
poor general health, including physical pain, antidepressants medication,
and binge drinking increased the odds for negative intrusive thoughts, all
factors that could routinely be noted and acted on in preoperative
care.
10,11
Health‐care professionals planning an intervention to relieve
psychological distress such as negative intrusive thoughts could focus
on vulnerable individuals on the basis of these findings.
The strengths of this study include the prospective trial design, the
large study population, representing men having radical prostatectomy
at 14 hospitals in Sweden during the study period, high compliance, as
well as the short inclusion period, all of which minimize selection‐
induced problems. The participating hospitals were probably well
representative for the population in the 3 largest regions in Sweden.
The questionnaires were collected by a third‐party to prevent inter-
viewer‐related problems.
38
We apply clinical epidemiological methods
and systematically try to recognize the possible causes of bias in each
step of the research process.
28
To minimize measurement errors, an
extensive preparatory phase preceded the study, and patient‐reported
outcome measures were used attempting to avoid discrepancies
versus researcher assessment.
39
The questionnaires were based on
concepts and wordings from men similar to the study population.
Single‐item questions on psychological distress, like our question on
negative intrusive thoughts, have been found to be comparable to
multi‐item scales in epidemiological studies among Swedish testicular
cancer survivors as well as in a general population‐sample in the
US.
30,40
The study questionnaires were validated in face‐to‐face meet-
ings and a pilot study. The validity of the outcome variable, negative
intrusive thoughts, was further verified by analyzing participants'
written responses describing their negative thoughts.
12
We thus
strived for a clear definition of the concepts studied.
The limitations of the study include that the results based on single
item measurements may have more variability than with standardized
scores on psychological distress. Although, this would only dilute the
relationships under study. Potential confounders on the associations
studied, are the information about prostate cancer diagnosis and treat-
ment as well as the patients' treatment decision‐process. National guide-
lines in Sweden, includingthe actual practices for patient information and
communication, could however reduce this confounding effect. Further,
because of nonrespondents, we cannot comment on the association of
the factors among the nonevaluable patients who constituted 20% of
the study population. The generalization of the results to other countries
than Sweden may be compromised by cultural‐specific factors.
In prostate cancer, mortality rates in relation to incidence are
low.
32,33
Surgery, the most common treatment for localized prostate
cancer, is only recommended when cure is possible but often affects
urinary and sexual health. In our study, we found a relationship of being
uncertain of cure before surgery as well as not prepared forwell‐known
surgery‐induced symptoms with a higher incidence of negative intru-
sive thoughts about prostate cancer. Younger age and poor health
before surgery were also associated with the occurrence of negative
intrusive thoughts, a symptom related to impaired quality of life.
ACKNOWLEDGEMENTS
We would like to express our gratitude to all the participating men. The
authors are grateful to the members of the LAPPRO steering
committee, local investigators at the participating urological
departments, and the personnel at the LAPPRO‐trial secretariat for
provision of study material and administrative support.
CONTRIBUTORS
Design: TT, HV, EH, GS. Data‐collection: TT, JS, EH, GS. Data‐analysis:
TT, HV, UW, EH, GS. Interpretation: TT, AH, JS, HV, EH, GS. Statistical
analysis: UW. Writing and revision: All authors.
CONFLICT OF INTEREST
The paper represents original work that has not been published before.
None of the authors have any direct or indirect commercial or financial
incentive associated with the publishing of the article. The authors
have full access and control of the primary data of the study. The data
will be available for review if requested. The Regional Ethical Review
Board approved the trial.
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SUPPORTING INFORMATION
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supporting information tab for this article.
How to cite this article: Thorsteinsdottir T, Valdimarsdottir H,
Hauksdottir A, Stranne J, Wilderäng U, Haglind E, Steineck G.
Care‐related predictors for negative intrusive thoughts after
prostate cancer diagnosis—data from the prospective LAPPRO
trial. Psycho‐Oncology. 2017. doi: 10.1002/pon.4359
THORSTEINSDOTTIR ET AL.9
