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Association between informed decision-making and mental health-related quality of life in long term prostate cancer survivors

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Association between informed decision-making and mental health-related quality of life in long term prostate cancer survivors

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Content 1 / 19

Association between Informed Decision-Making and Mental Health-Related
Quality of Life in Long term prostate cancer survivors

Rui Liu
University of Southern California

2 / 19

TABLE OF CONTENTS

Page
Title Page 1
Table of Contents 2
Abstract 3
Introduction 4
Materials and Methods 5
Statistical Analyses 7
Results 7
Discussion 8
References 10
Tables 13

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ABSTRACT
Improving mental health-related quality of life after treatment is an important goal for prostate cancer
patients. However, the epidemiologic evidence on what affects the patients’ mental health-related quality
of life has been scarce. The Institute of Medicine has encouraged the use of informed treatment decision
making as a means to improving long term quality of life among cancer survivors. In this study, we
explored the relationship between informed decision making and the long-term mental health quality of
life in prostate cancer patients followed up for more than fifteen years after diagnosis, using the Prostate
Cancer Outcomes Study (PCOS) Long Term Follow-Up Survey. The PCOS started in 1994 with a cohort
of 3,500 men who had been diagnosed with primary invasive prostate cancer. Surveys were conducted at
6 months, 12 months, 2 years, 5 years and 15 years after diagnosis to obtain self-reported information
about these patients' urinary, sexual, and bowel functions, as well as other quality-of-life issues. At 15
years the 1,021 responding patients were asked a series of questions about how they felt about their
prostate cancer treatment decision which was converted into an Informed Decision Making Index. They
also completed the SF-36 from which the overall mental health quality of life summary score was
derived. Using linear regression, our results showed better informed decision-making was associated
with a significantly higher mental health quality of life score at 15 years after diagnosis, after controlling
for the effects of other covariates. These results support the endeavors of improving prostate cancer
patients’ informed decision-making.

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INTRODUCTION
Prostate Cancer is the most commonly diagnosed non-skin cancer. According to the 2005-2009
Surveillance Epidemiology and End Results (SEER) statistics, the overall age-adjusted incidence rate is
about 154.8 per 100,000 men, with lowest incidence in Asian/Pacific Islander (85.4 per 100,000), and
highest in Black (236.0 per 100,000). On average, for a man in the U.S general population, the risk of
getting prostate cancer diagnosed is around 16% (15.9% to 16.15%). It was estimated that about 241,740
men will be diagnosed with prostate cancer in the United Sates, and among them, about 28,170 would die
of the disease in 2012. Clearly, prostate cancer has imposed significant disease burden to males,
especially those over 60 years old.
Efforts have been made to engage patients more in the medical decision-making process by sharing
information on possible treatment options, outcomes, and risks and benefits associated with each, so that
the patient may receive the treatment that is in highest concordance with his personal preferences and
values [1-4]. The Patient Protection and Affordable Care Act of 2010 has encouraged the use of a Shared
or Informed Medical Decision-making (IDM) process in medical care practice involving both the patient
and the physician.
IDM has been defined as a reasoned choice made by a reasonable individual with relevant information
about the advantages and disadvantages of all possible courses of action, in accord with the individual’s
beliefs[5]. It requires the physicians to present relevant clinical information to the patients and engage
them in the medical decision making process. This definition encompasses three components: the
reasoning of choices, the provision of complete and good-quality information, and the individuals’
personal beliefs.
IDM is especially important for prostate cancer patients. Although the clinical trial results demonstrating
the superiority of one treatment option over another was lacking, Gwede et.al found that prostate cancer
patients who experienced high level of IDM would make the same choices if they need to make the
decision again [6]. Men with prostate cancer face a difficult treatment decision due to multiple options
available, each with potentially severe long term effects involving urinary, bowel and sexual function[7].
Knowledge of the potential benefits and risks (i.e. reasoning of choices) associated with each option may
help a patient decide on the most suitable treatment for himself. For example, it was found that both
general and disease specific HRQoL differ by prostate cancer patients’ treatment choices[8].Studies using
the Prostate Cancer Outcomes Study (PCOS) data showed that men who received radical prostatectomy
were more likely to have incontinence and impotence than those underwent radiotherapy 2 years after
treatment [9]; however the differences disappeared by 15 years after treatment [10]. Other studies in
which researchers used decision-aid kits to facilitate the information for IDM, found that better informed
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patients were more likely to choose aggressive treatments [11]; whereas having incomplete information
was associated with additional psychological distress or regrets afterwards [11, 12].
Similar to insufficient understanding of risks and benefits, the discordance of the treatment choice with
the patients’ values and beliefs could also cause post-treatment regrets [13-15]. Aning et.al determined
that a better IDM can not only convey information to the patients, but also help the patients to discover
their beliefs on treatment choices[1]. .
Other studies have found that patients’ psychological distress and quality of feelings were associated with
their IDM [12, 16, 17].Therefore we hypothesized that better IDM for long term prostate cancer survivors
would be positively related to their mental health quality of life outcomes (M-HRQoL). This association
has “not been sufficiently studied” [18]. Using data from the PCOS 15 year follow-up survey, we
examined the relationship between IDM for treatment decisions and Mental-HRQoL independently of
other risk factors for mental HRQoL,

MATERIALS AND METHODS
Study population
The patients previously participated in the PCOS study, a longitudinal prostate cancer patient cohort,
which was initiated by researchers at the National Cancer Institute to investigate how prostate cancer and
its treatments affect the quality of life of men with the disease [19]. Initially, PCOS enrolled 3,533
incident prostate cancer cases (diagnosed with primary invasive prostate cancer) from six participating
Surveillance Epidemiology and End Results (SEER) registry sites, including Los Angeles County,
California; Seattle-Puget Sound, Washington; the metropolitan areas of Atlanta; and the States of Utah,
the States of New Mexico and Connecticut diagnosed from October 1
st
, 1994 through October 31
st
, 1995.
After the establishment of the cohort, the patients were surveyed at six months, one year, two years, five
years, and 15 years after diagnosis. The 15 year survey, consisting of 1,021 surviving participants was
used for this study.

Definitions of variables
Outcome variable: Mental Health Related Quality of Life (M-HRQoL)
The M-HRQoL summary score at 15 years after diagnosis was obtained from the Short-Form with 36
questions (SF-36), which was developed by the Rand Corporation [20]. The SF-36 covers multiple
domains of HRQoL, including the general health, physical, social, emotional, mental, energy, pain and
role-related quality of life. The M-HRQoL summary score was calculated based on self-reported
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questions, including “how many days during the past 30 days was your mental health not good?”, “how
many days have you felt sad, blue or depressed?”, “how many days have you felt worried, tense or
anxious?”, and “how many days have you felt you did not get enough sleep or rest?”. The score ranges
from 0 to 100, and it includes stress, depression, and problems with emotions (Willi Horner-Johnson,
2009).
Informed Decision Making (IDM)
The IDM variable is an index derived from the patients’ agreement level with a series of six clinical
decision-making statements in the 15 year survey questionnaire. For each statement, the scale of answers
ranged from 1 to 5, standing for ‘not at all’, ‘a little bit’, ‘somewhat’, ‘quite a bit’, and ‘very much’,
respectively. The statements included: 1) “I had all the information I needed when a treatment was
chosen for my prostate cancer”; 2) “My doctors told me the whole story about the effects of treatment”; 3)
“I knew the right questions to ask my doctor”; 4) “I had enough time to make a decision about my
treatment”; 5) “I am satisfied with the choices I made in treating my prostate cancer”; and 6) “I would
recommend the treatment I had to a close relative or friend”. We took the arithmetic mean scores of the
answers, and then summed them into a cumulative composite score ranging from 0 to 100.. Based on the
distribution of the IDM scores we divided them into three categories, separating the lowest and highest
20% of index scores as follows: 1) Low (IDM<50); 2) Middle (50<=IDM<=95); and 3) High (IDM>95).
Clinical variables
Clinical variables were obtained from SEER registry data from the time of diagnosis, additional medical
record review conducted as part of the PCOS study, and self-reported information from the PCOS surveys
at various time points. The clinical variables from the SEER data and medical record review included:
initial treatment choice (conservative treatment (i.e. hormone only or watchful waiting), radiation therapy
or prostatectomy) and Gleason score. Self- reported variables included co-morbidity at 15-year (0 as no, 1
and 2 as low, 3 and above as high), bother due to bowel, sexual, urinary bother at baseline and 15-year
follow-up (defined as no problem, small problem, moderate/big problem), and cancer return at 15 years
(no, yes).
Demographics
The demographic variables in PCOS determined at baseline were coded as follows: race/ethnicity (Non-
Hispanic White, Non-Hispanic Black, and Hispanic), age at diagnosis (<51, 51-60, 61-70 years old),
highest education level attained (high school graduate or less, some college, college graduate, some
advanced/graduate training), marital status at baseline (yes, no), and household income level (<30,000,
30,001-50,000, 50,001-75,000, >75,001).
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Statistical Analyses
First, we compared the characteristics of the long term survivors to those who responded to the PCOS
study at baseline, and assessed the differences in the distributions using the chi-square statistic. Secondly,
for the long term survivors, we analyzed the bivariate associations between IDM and other potential
confounders and the mean M-HRQoL summary score. The potential confounders included demographic
variables (i.e. age at diagnosis, education, race, marital status, and household income) and clinical
variables (i.e. Gleason score, treatment choice, co-morbidity, bother due to urinary, sexual, or bowel side
effects, and cancer return). From the bivariate analysis, we selected those associations with a P-value of
Chi-square statistics less than 0.10 to include in the multivariate linear regression model. Finally, we
conducted multivariate linear regression analysis to model the independent impact of these covariates on
the mean M-HRQoL score.
The six SEER survey sites had different sampling weights based on the patient’s age and race/ethnicity.
Therefore, we applied Horvitz-Thompson sample weights (the inverse of the sampling fractions for each
sampling stratum) in the analysis, so that our results could be generalizable to prostate cancer patients in
the population from which they were obtained [10]. All linear regression analyses were conducted, using
the Proc Surveyreg procedure (SAS 9.2, SAS Institute Inc., Cary, NC, USA).
In order to test the effect of IDM on M-HRQoL in different populations, we also carried out a sensitivity
analysis. The sensitivity analysis restricted our study population to those with the most severe functional
and health problems (i.e. those with moderate/big bother with sexual, bowel and or urinary function, or
with 2+ comorbidities, or who experienced cancer spread).

RESULTS
A total of 1,021 men from the PCOS cohort participated in the 15 year survey. In the PCOS follow-up
survey, the respondents were more likely to be younger than older ages, they were more likely to have
undergone the surgical treatment, they were more likely to be Non-Hispanic White, and they were more
likely to have felt satisfactory about their treatment choices.
Compared to baseline participants, the 15-year respondents were significantly more likely to be diagnosed
at younger than older ages, be non-Hispanic white vs. other race/ethnicities, married vs. non-married,
have higher education and income vs. lower levels of these variables, lower comorbidity vs. higher
numbers of comorbid conditions, lower Gleason score vs. higher, and were more likely to have received
aggressive therapy compared conservative therapy than non-respondents at 15 years (Table 1).
Among the three types of bother at baseline, respondents at 15 years were less likely to have initially
reported big problems with sexual function, but more likely to report small problems with urinary
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function compared to non-respondents. No significant differences were seen between baseline bowel
function bother between initial respondents and those completing the 15 year survey. The 15 year
respondents were much more likely to report no cancer recurrence at baseline compared to all initial
respondents.
Among the long term respondents, we examined the bivariate associations between IDM and other
covariates and the mean M-HRQoL summary score (Table 2). IDM and six other covariates were
statistically significantly (p<.05) associated with the M-HRQoL score. Higher mental health scores were
associated with greater IDM scores, lower comorbidity, no spread of cancer to other body areas, lower
levels of bother due to sexual and urinary function at 15 years after diagnosis, and higher education (i.e.
greater than a high school degree). One other variable (treatment type) had a p value of <0.10. Those
patients who received aggressive therapies (i.e. Prostatectomy or radiation therapy) had higher mean M-
HRQoL scores than those receiving conservative therapy. No association was found between age at
diagnosis, race/ethnicity, marital status, and Gleason score with the M-HRQoL score and thus these
variables were not included in the multivariate linear regression model.
All of the included variables, with the exception of treatment type, remained significantly associated with
the mean M-HRQoL score in the multivariable model. After adjusting for the other variables the mean M-
HRQoL score was 56.7 for those with in the highest IDM category compared to 52.0 for those in the
lowest category.

DISCUSSION
As far as we know, this is the first study focusing on the association between self-reported assessments of
IDM and M-HRQoL in long-term prostate cancer survivors at a time well after initial therapy has been
completed. Our results showed that having a higher IDM was associated with better mental health
outcome scores, after accounting for other factors such as sexual, and urinary function bother, and cancer
recurrence which also may affect M-HRQoL. In fact, we found that the IDM score was the strongest
predictor of the M-HRQoL score. Our sensitivity analysis restricted to the most severe cases found that
the positive association between IDM and on M-HRQoL was even more amplified. Thus even among
those with relatively poor outcomes higher mental health scores were associated with higher IDM scores.
As indicated by the Institute of Medicine (IOM), IDM is seen as becoming more important for the long
term quality of life for cancer survivors. However, this association in cancer patients, and for prostate
cancer patients in particular has been understudied... Our finding of a positive association between IDM
and the M-HRQoL score is consistent with other studies examining this relationship, however, as far as
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we know, our study is the first exploring the association between IDM and M-HRQoL in prostate cancer
patients. It was reported that breast cancer with better informed decision making would improve the
accuracy of their prediction of quality of life [21]. Two more recently published papers indicated that the
breast cancer patients who adopted a more active role in decision-making using the informed decision-
making model had higher physical component QoL summary scores [22]. On the other hand, the impaired
psychological domain of quality of life was associated with breast cancer patients’ passive roles in
treatment decision-making [23]. Another study reported no impact of IDM on lung cancer patients’ QoL
in the long run [18].. Moreover, a study in colorectal cancer patients showed better consultation for
decision-making would lead to higher patients’ satisfaction, and higher physical, emotional function
scores [24]. Further studies would be needed to confirm our results in prostate cancer patients.
Sufficient evidence has demonstrated the importance and effectiveness of IDM: having information
regarding possible options of treatment and side effects could reduce the prostate cancer patients’ anxiety
[3], it could even eliminate cancer health disparities[4]. The decision-making aids can better prepare
patients for involvement in treatment decisions, if the prostate cancer patients were not well informed [1].
In terms of strategies, different methods have been proved useful. The use of Print-based decision aid
improved the knowledge and reduced decisional conflict [25]. Men exposed to a web-based informed
decision-making tool were found with improved knowledge about prostate cancer [26].
There are two major limitations of the study. The first is that the data were obtained cross sectionally.
That is, measures of IDM and M-HRQoL were both obtained at the time of the 15 year survey. Therefore,
we faced with the difficulties of temporality in determining the cause and effect, i.e. are better feelings
about IDM at 15 years after diagnosis just coincidental with higher mental health scores at the same time
or did higher IDM directly improve mental health scores over time? Are those men with higher Mental
Health more likely to report favorable IDM scores because of their higher Mental Health? We did control
for other known predictors of mental health and also restricted analyses to those with the poorest health
function and still found a strong association between IDM and mental health. Thus, while we may have
some evidence that long term, retrospective feelings about informed decision making may be associated
with better mental health over time, we weren’t able to test this directly. Secondly, the study is based on
long term survivors, thus the results cannot be generalized to men recently diagnosed and treated.
Compared to the patients at the PCOS baseline, the long term survivors who responded to the 15 year
survey were those who were diagnosed at younger ages, obtained better education, had higher income
were more likely to be treated with surgery, had lower initial comorbidity, and had lower sexual function
bother. While the baseline respondents initially with lower mental health scores may have been less likely
to survive and respond to the long term survey, it is unlikely that those with lower M-HRQoL and higher
IDM would have differential survival compared to those with lower M-HRQoL and lower IDM. Thus,
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while survival bias may affect the generalizability of the results, it would be unlikely to affect the
relationship we found between IDM and M-HRQoL.
In conclusion, we found, from this cross sectional study, that a higher informed decision making score
was positively associated with higher M-HRQoL score, over and above problems with functional bother
and comorbidity. Interventions to assist men diagnosed with prostate cancer make an informed decision
may have long term implications for improved mental health.

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TABLES

Table 1: Selected demographic and clinical characteristics for PCOS patients at baseline and in the long-term follow-up survey
At 6-month survey At 15-year follow-up Chi-Square
Characteristics
Un-weighted
sample size.
Weighted % Dist*. Un-weighted sample
size.
Weighted %
Dist.
Two sample proportion tests
Total Number n =3,173 100% (n=5,995) n =1,021 100
(n=1,902)

Weighted % of Total
Age at Diagnosis
<0.0001
Less than 51 years old
102 (3.21%) 2.31 50 (4.90%) 3.74
51-60 years old
719 (22.66%) 17.32 349 (34.18%) 27.67
61-70 years old
1,249 (39.36%) 42.47 473 (46.33%) 51.84
More than 70 years old
1,103 (34.76%) 37.89 149 (14.59%) 16.74
Race
<0.0001
Non-Hispanic White
2,187 (68.93%) 75.71 765 (74.93%) 80.24
Non-Hispanic Black
539 (16.99%) 13.83 125 (12.24%) 9.79
Hispanic
447 (14.09%) 10.46 131 (12.83%) 9.97
Marital status
<0.0001
Yes
2,499 (78.76%) 79.52 812 (79.53%) 88.68
No
637 (20.08%) 20.48 101 (9.89%) 11.32
Education
<0.0001
High school grad or less
1,358 (42.80%) 41.42 266 (26.05%) 26.29
Some college
756 (23.83%) 24.03 233 (22.82%) 24.79
College graduate
431 (13.58%) 15.16 157 (15.38%) 19.07
Some advanced/graduate training
583 (18.37%) 19.39 255 (24.98%) 29.86
Household total income
$

<0.0001
<30,000
1,288 (40.59%) 43.64 227 (22.23%) 25.09
30,001-50,000
728 (22.94%) 26.50 237 (23.21%) 28.73
50,001-75,000
382 (12.04%) 14.11 167 (16.36%) 19.91
>75,001
443 (13.96%) 15.75 223 (21.84%) 26.27
Treatment Choice
<0.0001
Conservative treatment
965 (30.41%) 31.49 118 (11.56%) 12.76
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Radiation therapy
733 (23.10%) 24.98 181 (17.73%) 19.35
Aggressive prostatectomy
1475 (46.49%) 43.53 713 (69.83%) 67.89
Co-morbidity
<0.0001
Low
752 (23.70%) 22.78 477 (46.72%) 48.84
Medium
1,104 (34.79%) 34.76 283 (27.72%) 28.72
High
1,337 (42.14%) 42.46 214 (20.93%) 22.44
Gleason Score
<0.0001
No biopsy performed
268 (8.45%) 8.57 73 (7.15%) 7.76
G-Score <=6
1,840 (57.99%) 57.44 710 (69.54%) 68.61
G-Score >6
Biopsy negative
1,043 (32.87%)
2 (0.06%)
33.17
0.14
224 (21.94%)
0 (0%)
22.46
0

Unknown
20 (0.63%) 0.67 14 (1.37%) 1.18
Urinary function bother
<0.0001
No problem
1,444 (45.51%) 49.12 435 (42.61%) 42.86
Small problem
1,100 (34.67%) 35.18 399 (39.08%) 40.23
Big problem
511 (16.10%) 15.70 178 (17.43%) 16.91
Bowel function bother
0.36
No problem
2,011 (63.38%) 64.30 589 (57.69%) 59.31
Small problem
846 (26.66%) 27.78 318 (31.15%) 32.10
Big problem
242 (7.63%) 7.93 78 (7.64%) 8.59
Sexual function bother
<0.0001
No problem
703 (22.16%) 24.70 272 (26.64%) 30.37
Small problem
651 (20.52%) 22.24 249 (24.39%) 28.04
Big problem
1,611 (50.77%) 53.06 401 (39.28%) 41.59
Cancer recurrence
<0.0001
No 690 (21.75%) 44.13 815 (79.82%) 80.53
Yes 1,469 (46.30%) 22.95 159 (15.57%) 14.70
No Answer/ Unknown 1,014 (31.96%) 32.93 47 (4.60%) 4.77
*The sampling weights were applied PCOS studies to balance the patient’s age and race/ethnicity
** Some percentages do not total 100 because of rounding.
Missing values for the following variables:
Education: 45 subjects for 6-month, 110 subjects for 15-year;
15 / 19

Marital status: 37 subjects for 6-month, 108 subjects for 15-year;
Income: 332 subjects for 6-month, 167 subjects for 15-year;
Treatment choice: 9 for 15-year;
Co-morbidity: 47 for 15-year;
Sexual function bother: 208 subjects for 6-month, 99 for 15-year;
Urinary function bother: 118 subjects for 6-month, 9 for 15-year;
Bowel function bother: 74 subjects for 6-month, 36 for 15-year;

Table 2: Mean Mental -Health Related Quality of Life (M-HRQoL) scores by selected characteristics (unadjusted and adjusted*)
Selected Characteristics Unadjusted M-HRQoL mean
summary scores (95% CI)
P-value Adjusted M-HRQoL mean
summary scores (95% CI)
Adjusted P-value
IDM (n=1021) <0.0001 <0.0001
IDM <50
51.49 (49.73, 53.25)

52.02 (51.43, 52.62)

50 <=IDM<=95
53.48 (52.59, 54.37)

53.52 (53.20, 53.84)

IDM>95
56.47 (55.50, 57.43)

56.71 (56.31, 57.11)

Age at diagnosis (n=1021)
0.33

<51yr
54.25 (51.87, 56.64)

51-60yr
53.92 (52.95, 54.89)

61-70yr
54.41 (53.45, 55.36)

>70yr
52.37 (50.39, 54.34)

Race (n=1021)
0.53

NH White
54.01 (53.26, 54.77)

NH Black
54.23 (52.51, 55.96)

Hispanic
53.01 (51.27, 54.74)

Education (n=911) 0.01
<0.0001
High school grad or less
51.89 (50.33, 53.46)

52.37 (51.92, 52.83)

Some college
54.27 (52.83, 55.70)

54.43 (53.91, 54.93)

College grad
55.20 (53.78, 56.61)

55.32 (54.60, 56.03)

Advanced / Grad training
54.56 (53.49, 55.64)

54.43 (53.98, 54.89)

16 / 19

Marital status (n=913)
0.29

Yes
53.84 (53.10, 54.58)

No
54.87 (53.08, 56.65)

Comorbidity index
(n=940)
0.0005
<0.0001
No comorbidity
55.40 (54.10, 56.70) 55.08 (54.43, 55.73)
Low comorbidity
54.98 (54.19, 55.77) 55.25 (54.92, 55.58)
High comorbidity
52.09 (50.81, 53.37) 52.30 (51.85, 52.74)
Urinary problem (n=1012)
<0.0001
<0.0001
No problem
56.01 (55.25, 56.78)

55.95 (55.63, 56.27)

Small problem
53.48 (52.45, 54.51)

53.88 (53.52, 54.24)

Big problem
49.77 (47.68, 51.87)

50.16 (49.66, 50.69)

Sexual problem (n=922) 0.007
<0.0001
No problem
54.49 (53.12, 55.87)

54.35 (53.84, 54.86)

Small problem
55.28 (54.21, 56.35)

55.46 (54.98, 55.96)

Big problem
52.93 (51.89, 53.97)

52.98 (52.59, 53.37)

Bowel problem(n=985) <0.0001
<0.0001
No problem
55.93 (55.29, 56.56)

55.95 (55.71, 56.19)

Small problem
51.83 (50.48, 53.19)

52.27 (51.93, 52.60)

Big problem
48.63 (45.47, 51.80)

48.35 (47.81, 48.88)

Gleason Score (n=1021)
0.39

No biopsy performed
54.49 (52.37, 56.62)

G-Score <=6
53.97 (53.23, 54.72)

G-Score >6
53.94 (52.35, 55.54)

Cancer spread to other
body areas(n=1021)
<0.0001
<0.0001
No
54.03 (53.35, 54.71)

54.12 (53.84, 54.41)

Yes
51.13 (48.07, 54.18)

53.39 (52.21, 54.62)

Treatment choices (=1012) 0.06
0.21
prostatectomy
54.39 (53.66, 55.12)

54.23 (53.92, 54.55)

Radiation
53.86 (52.15, 55.57)

54.01 (53.35, 54.68)

Conservative therapy
51.79 (49.73, 53.85)

53.41 (52.54, 54.29)

17 / 19

* The un-adjusted statistics were obtained from ANOVA analysis, while the adjusted statistics were obtained from the predictive values in the
multivariate model

Table 3: Mean Mental -Health Quality of Life (M-HRQoL) scores by selected characteristics (unadjusted and adjusted) for cases likely to have
poorer mental health outcomes* (use for sensitivity analysis)
Selected Characteristics Unadjusted M-HRQoL mean
summary scores (95% CI)
P-value* Adjusted M-HRQoL mean
summary scores (95% CI)
Adjusted P-value
IDM (n=221) <0.0001 <0.0001
IDM <50
46.49 (42.38, 50.59)
47.26 (45.42, 49.11)
50 <=IDM<=95
49.90 (47.17, 52.62)
50.03 (48.72, 51.33)
IDM>95
56.53 (54.36, 58.71)
57.23 (55.56, 58.89)
Age at diagnosis (n=1021)
0.33

<51yr
47.47 (38.03, 56.91)

51-60yr
52.40 (49.49, 55.31)

61-70yr
51.11 (48.17, 54.04)

>70yr
48.46 (43.89, 53.03)

Race (n=1021)
0.53

NH White
50.76 (48.34, 53.19)

NH Black
53.63 (50.67, 56.59)

Hispanic
47.47 (43.81, 51.13)

Education (n=911) 0.0064
<0.0001
High school grad or less
48.51 (44.96, 52.07)

48.44 (46.97, 49.91)

Some college
50.32 (46.63, 54.01)

50.37 (48.82, 51.92)

College grad
56.33 (52.85, 59.81)

54.86 (51.26, 58.46)

Advanced / Grad training
54.09 (50.64, 57.54)

53.98 (51.65, 56.30)

Marital status (n=913)
0.12

18 / 19

Yes
50.79 (48.67, 52.92)

No
54.36 (49.82, 58.90)

Comorbidity index
(n=940)
0.21
0.003
No comorbidity
51.67 (45.68, 57.67) 51.35 (47.81, 54.88)
Low comorbidity
52.97 (50.05, 55.89) 53.48 (51.52, 55.44)
High comorbidity
49.49 (46.85, 52.14) 49.47 (48.23, 50.71)
Urinary problem (n=1012)
0.04
<0.0001
No problem
53.89 (51.52, 56.26)

53.96 (52.77, 55.14)

Small problem
50.19 (47.20, 53.18)

50.49 (48.46, 52.51)

Big problem
48.32 (43.61, 53.03)

47.97 (45.96, 49.97)

Sexual problem (n=922)
0.14

0.002
No problem
50.96 (46.02, 55.91)

50.72 (48.36, 53.09)

Small problem
53.65 (50.03, 57.28)

54.58 (52.20, 56.96)

Big problem
49.27 (46.73, 51.80)

49.67 (48.35, 50.99)

Bowel problem(n=985) <0.0001
<0.0001
No problem
55.01 (53.21, 56.81)

55.14 (54.08, 56.19)

Small problem
47.39 (43.43, 51.34)

47.95 (46.31, 49.59)

Big problem
46.37 (41.50, 51.25)

45.08 (43.76, 46.41)

Gleason Score (n=1021) 0.01

No biopsy performed
53.02 (48.42, 57.63)

G-Score <=6
50.99 (48.76, 53.23)

G-Score >6
50.69 (46.31, 55.07)

Cancer spread to other
body areas(n=1021)
<0.0001
0.0003
No
50.53 (48.57, 52.48)

51.19 (49.97, 52.41)

Yes
54.53 (40.84, 68.21)

50.26 (47.21, 53.31)

Treatment choices (=1012)
0.40

0.012
prostatectomy
51.81 (49.46, 54.16)

54.23 (53.92, 54.55)

Radiation
48.54 (42.71, 54.36)

47.87 (45.60, 50.16)

Conservative therapy
49.59 (45.97, 53.22)

51.77 (50.41, 53.12)

19 / 19

*the subjects in this sensitivity analysis were selected if the patients had most severe functional and health problems (i.e. those with moderate/big bother
with sexual, bowel and or urinary function, or with 2+ comorbidities, or who experienced cancer spread)

Abstract (if available)

Abstract Improving mental health‐related quality of life after treatment is an important goal for prostate cancer patients. However, the epidemiologic evidence on what affects the patients’ mental health‐related quality of life has been scarce. The Institute of Medicine has encouraged the use of informed treatment decision making as a means to improving long term quality of life among cancer survivors. In this study, we explored the relationship between informed decision making and the long‐term mental health quality of life in prostate cancer patients followed up for more than fifteen years after diagnosis, using the Prostate Cancer Outcomes Study (PCOS) Long Term Follow‐Up Survey. The PCOS started in 1994 with a cohort of 3,500 men who had been diagnosed with primary invasive prostate cancer. Surveys were conducted at 6 months, 12 months, 2 years, 5 years and 15 years after diagnosis to obtain self‐reported information about these patients' urinary, sexual, and bowel functions, as well as other quality‐of‐life issues. At 15 years the 1,021 responding patients were asked a series of questions about how they felt about their prostate cancer treatment decision which was converted into an Informed Decision Making Index. They also completed the SF-36 from which the overall mental health quality of life summary score was derived. Using linear regression, our results showed better informed decision‐making was associated with a significantly higher mental health quality of life score at 15 years after diagnosis, after controlling for the effects of other covariates. These results support the endeavors of improving prostate cancer patients’ informed decision‐making.

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Asset Metadata

Creator Liu, Rui (author)

Core Title Association between informed decision-making and mental health-related quality of life in long term prostate cancer survivors

School Keck School of Medicine

Degree Master of Science

Degree Program Applied Biostatistics and Epidemiology

Publication Date 06/17/2014

Defense Date 12/17/2013

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag informed decision‐making,mental health related quality of life,OAI-PMH Harvest,prostate cancer,survivors,Treatment

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Azen, Stanley P. (committee chair), Hamilton, Ann (committee chair), Cockburn, Myles (committee member)

Creator Email liurui@cal.berkeley.edu,ruiliu@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-419926

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Legacy Identifier etd-LiuRui-2556.pdf

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Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

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