Background: Well-documented reports of patients' experiences with different treatments are important for helping localised prostate cancer (LPC) patients choose among the available treatment options. Objective: To document differences in patient-reported outcomes (PROs) following radical prostatectomy (RP), external beam radiotherapy (EBRT), brachytherapy (BT), and active surveillance (AS), and to evaluate how these PROs and other factors are associated with treatment decision regret. Design, setting, and participants: A prospective, observational, multicentre study of men diagnosed with LPC (stage cT1-2) during 2014-2016. Outcome measurements and statistical analysis: Patients completed validated PRO measures (Quality of Life Questionnaire Core 30 [QLQ-C30], Quality of Life Questionnaire prostate cancer-specific module [QLQ-PR25], Decision Regret Scale, and the Memorial Anxiety Scale for Prostate Cancer) before treatment and at 3, 6, and 12 mo after treatment. Mixed-effect models were used to describe different PRO patterns. Results and limitations: The analytic cohort included 434 men (AS = 32%; RP = 45%; EBRT = 12%; BT = 10%). Follow-up response rates were above 90%. At 1-yr follow-up, (1) men who had received RP reported significantly (p < 0.01) more urinary incontinence, sexual dysfunction, hormonal/masculinity-related symptoms, and less emotional distress; (2) those having received EBRT reported more sexual dysfunction, hormonal/masculinity-related symptoms, and physical distress; and (3) those having received BT reported more urinary obstruction and irritation symptoms, compared with patients under AS. Irrespective of the treatment modality, 23% of the patients reported clinically relevant treatment regret (99% confidence interval, 17-28%). Multivariate correlates of decision regret were hormonal/masculinity-related symptoms, educational level, and positive surgical margins. Conclusions: Post-treatment physical and psychosocial functioning was significantly associated with specific treatment modalities and pretreatment functioning. Regret was relatively frequently reported by patients who experienced unwanted physical, psychosocial, and oncological outcomes. Greater efforts should be made to understand whether carefully educating patients about the possible consequences and effectiveness of treatments may help limit the feeling of treatment regret. Patient summary: In men with localised prostate cancer, regret about the treatment choice was more common among those who experienced more treatment-related symptoms during the year after treatment. (C) 2018 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Information about prostate cancer patients’ experiences with their treatment is crucial to optimize shared decision-making. This study examined unmet expectations in prostate cancer patients and their association with decision regret. We conducted a prospective, observational, multi-center study of men diagnosed with localized prostate cancer between 2014 and 2016. Questionnaires were completed at baseline (pre-treatment), and up to 12 months after treatment. Unmet expectations were reported as the proportion of patients who experienced side effects as worse than expected. Linear regression analysis was used to identify factors associated significantly (p ≤ 0.05) with unmet expectations and its association with decision regret. At 1-year follow-up, the majority of the patients (71%, 210/296) reported at least one unmet expectation. The proportion of patients who reported worse than expected erectile problems was 56%, recovery period = 29%, urinary problems = 28%, fatigue = 24%, and bowel problems = 17%. Unmet expectations were comparable between treatment groups, except for fatigue. A passive role in the decision-making process (eta squared (η2) = 0.02) and higher scores on the decisional conflict scale (η2 = 0.02) were associated with more unmet expectations, and unmet expectations were associated with decision regret (η2 = 0.08). Unmet expectations are common among men treated for localized prostate cancer. Involving patients in the treatment decision-making process and offering additional counseling to patients who indicate uncertainty about their decision, may help to avoid unmet expectations. The current study emphasizes the need for involving prostate cancer patients in the decision-making process in order to mitigate unmet expectations.

Most men with low-risk prostate cancer have several treatment options. Since there is no clear evidence that one option is better than another in terms of overall survival, the decision-making process is mainly guided by patients’ values and preferences . Therefore, patients with prostate cancer are increasingly engaged in the process of treatment decision-making. The purpose of this thesis was to: (1) describe factors that influence the treatment decision-making process (Chapter 2-3); and (2) explore how treatment decisions influence patients’ health-related quality of life after treatment (Chapter 4-6). In Chapter 2, we describe that the majority of patients with low-risk prostate cancer poorly understood the differences in disease recurrence, overall survival and risks of side effects among the various treatment options. More than half of the patients inaccurately perceived surgery as being more effective than radiotherapy in terms of risk of disease recurrence. Most patients underestimated the risks of side-effects following surgery compared to radiotherapy. And most patients overestimated the likelihood of eventually needing to start definitive treatment after a period of active surveillance. These misperceptions were less common in patients who consulted a radiotherapist or a clinical nurse specialist, and more common in men with elevated levels of emotional distress. In Chapter 3 we report that patients with localized prostate cancer who were actively involved in treatment decision-making had more knowledge about prostate cancer, experienced less decisional conflict, and less regret than patients who reported having experienced passive involvement. Additionally, patients who experienced less involvement than preferred experienced higher levels of decisional conflict. Therefore, our findings support a policy of encouraging all localized prostate cancer patients to be actively involved in the decision about their treatment. In Chapter 4 we describe differences in patient-reported physical and psychological functioning after treatment. Twelve months after treatment, surgery was associated with urinary incontinence, sexual dysfunction, and declined feelings of masculinity; external beam radiotherapy was associated with sexual dysfunction, hormonal/masculinity-related symptoms, and physical distress; and brachytherapy was associated with more urinary obstruction and irritative urinary symptoms, when compared to patients who started active surveillance. Decisional regret was comparable among treatment options. However, men who experienced hormonal/masculinity-related symptoms, who had less formal education and/or men with positive surgical margins reported more regret about the treatment decision. This information can be used to inform future patients about the benefits and risks of each treatment option. After surgery some patients experience biochemical recurrence (a PSA level that is not below 0). These patients are offered additional radiotherapy (salvage radiotherapy). The optimal timing to start this treatment is unknown. We observed that a longer interval (i.e. more time) between surgery and salvage radiotherapy was associated with significantly better sexual and urinary function (Chapter 5). Many men with prostate cancer will become long-term survivors (alive ≥ 5 years post-diagnosis). In Chapter 6 we evaluated differences in the prevalence of mental health problems between prostate cancer survivors and age-matched men from the general population. Long-term prostate cancer survivors had poorer mental health than men of a comparable age from the general population without a history of prostate cancer.

OBJECTIVE: To assess the accuracy of patients' perceptions of the risks associated with localised prostate cancer treatments (radical prostatectomy [RP], radiotherapy [RT], and active surveillance [AS]), and to identify correlates of misperceptions. PATIENTS AND METHODS: We used baseline data (questionnaires completed after treatment information was provided but before treatment) of 426 patients with newly diagnosed localised prostate cancer who participated (87% response rate) in a prospective, longitudinal, multicentre study. Patients' pretreatment perceptions of differences in adverse outcomes of treatments were compared to those based on the literature. We used univariate and multivariate linear regression to identify correlates of misperceptions. RESULTS: About two-thirds (68%, n = 211) of the patients did not understand that the risk of disease recurrence is comparable between RP and RT. More than half of the patients did not comprehend that RP patients are at greater risk of urinary incontinence (65%, n = 202) and erectile dysfunction (61%, n = 190), and less at risk of bowel problems (53%, n = 211) compared to RT patients. Many patients overestimated the risk of requiring definitive treatment following AS (45%, n = 157) and did not understand that mortality rates following AS, RP, and RT are comparable (80%, n = 333). Consulting a radiotherapist or a clinical nurse specialist was positively associated with, and emotional distress was negatively associated with, better understanding of the risks (P < 0.05), although effect sizes were small. CONCLUSION: Prior to choosing treatment, most patients with prostate cancer poorly understood the differences in treatment risks. Greater efforts should be made to better understand why these misperceptions occur and, most importantly, how they can be corrected.

OBJECTIVES:To assess the accuracy of patients' perceptions of the risks associated with localised prostate cancer treatments (radical prostatectomy [RP], radiotherapy [RT], and active surveillance [AS]), and to identify correlates of misperceptions.PATIENTS AND METHODS:We used baseline data (questionnaires completed after treatment information was provided but before treatment) of 426 patients with newly diagnosed localised prostate cancer who participated (87% response rate) in a prospective, longitudinal, multicentre study. Patients' pretreatment perceptions of differences in adverse outcomes of treatments were compared to those based on the literature. We used univariate and multivariate linear regression to identify correlates of misperceptions.RESULTS:About two-thirds (68%, n = 211) of the patients did not understand that the risk of disease recurrence is comparable between RP and RT. More than half of the patients did not comprehend that RP patients are at greater risk of urinary incontinence (65%, n = 202) and erectile dysfunction (61%, n = 190), and less at risk of bowel problems (53%, n = 211) compared to RT patients. Many patients overestimated the risk of requiring definitive treatment following AS (45%, n = 157) and did not understand that mortality rates following AS, RP, and RT are comparable (80%, n = 333). Consulting a radiotherapist or a clinical nurse specialist was positively associated with, and emotional distress was negatively associated with, better understanding of the risks (P < 0.05), although effect sizes were small.CONCLUSION:Prior to choosing treatment, most patients with prostate cancer poorly understood the differences in treatment risks. Greater efforts should be made to better understand why these misperceptions occur and, most importantly, how they can be corrected.

In this month's issue of European Urology, Tyson et al. [1] described whether differences in patient-reported functional outcomes between patients who received radical prostatectomy (RP, n = 1291) and external beam radiotherapy (EBRT, n = 662) varied by localised prostate cancer (PCa) risk group. Among the patients who participated in this large longitudinal, population-based, prospective study (Comparative Effectiveness Analysis of Surgery and Radiation [CEASAR]), 39% had low-risk disease, 43% had intermediate-risk disease, and 19% high-risk disease. The authors reported a clinically significant interaction effect between treatment and PCa risk group for sexual function. That is, in patients who received RP, sexual function 3 yr following treatment was significantly more favourable in patients who had low-risk PCa than in those with high-risk PCa (mean [95% confidence interval {CI}], low-risk = 39 [37–42], high-risk = 32 [28–35]; p < 0.001; proportion of patients who reported sexual dysfunction: low-risk = 65%, high-risk = 78%). This difference was, however, not classified as clinically relevant (ie, a difference of ten points or more). In patients who received EBRT, the difference between patients with low-risk and high-risk PCa was classified as clinically relevant (low-risk = 52 [95% CI, 47–56]; high-risk = 38 [33–42]; p < 0.001; proportion of patients who reported sexual dysfunction: low-risk = 67%, high-risk = 82%). Unlike sexual function, cancer severity did not significantly modify the effect of treatment on urinary incontinence, hormone, bowel, and urinary irritaive domains. Therefore, the authors conclude that patients with high-risk tumours should be counselled differently about possible sexuality-related quality of life outcomes than patients with low-risk PCa.

PURPOSE:The aims of this study were to 1) describe preferred and experienced roles in treatment decision making among patients with localized prostate cancer, 2) identify how often the roles experienced by patients matched their preferred roles and 3) determine whether active involvement in decision making regardless of role preferences or concordance between preferred and experienced roles would be the strongest predictor of more favorable patient reported outcomes.MATERIALS AND METHODS:In this prospective, multicenter, observational study we obtained serial questionnaire data from 454 patients with newly diagnosed, localized prostate cancer (cT1-cT2, or Gleason 7 or less and prostate specific antigen 20 ng/ml or less). Questionnaires were completed prior to treatment and at the 3, 6 and 12-month posttreatment followups. Clinical data were obtained from the patient medical records. Active involvement and role concordance were operationalized using the CPS (Control Preferences Scale). ANOVA and effect sizes (small and medium Cohen d = 0.2 and 0.5, respectively) were used to compare patient knowledge of prostate cancer, decision conflict, decision regret and overall health related quality of life.RESULTS:Of the patients 393 (87%) reported having been actively involved in treatment decision making. However, 78 patients (17%) indicated having had less or more involvement than preferred. Active involvement was significantly associated with more prostate cancer knowledge (d = 0.30), less decision conflict (d = 0.52) and less decision regret (d = 0.34). Role concordance was also but less strongly associated with less decision conflict (d = 0.41).CONCLUSIONS:Our findings support a policy of encouraging all patients with localized prostate cancer regardless of their stated role preferences to be actively involved in the treatment decision.

Objective: The purpose of this study was to identify factors associated with mental health(MH) problems in prostate cancer(PC) survivors. Toward this end, we evaluated(1) differences in the prevalence of MH problems between PC survivors and age-matched men from the general population (GenPop) and (2) correlates of MH in PC survivors and the GenPop.Methods and materials: In this observational case-control study, we age-matched PC survivors(n = 644, alive > 5 y after diagnosis of a stageI-IV carcinoma) recruited from Dutch community hospitals (Patient Reported Outcomes Following Initial treatment and Long-term Evaluation of Survivorship registry) with GenPop peers(n = 644) selected from a population-based sample recruited in general practices (NIVEL). MH was operationalized using the 5-item Mental Health Inventory of the Short Form Health Survey(SF-36). Potential correlates of MH included sociodemographic characteristics, health-related quality of life scores, and clinical characteristics(PC survivors only). We used analysis of (co) variance and chi-square tests to address the 2 research questions.Results: We observed clinically relevant MH symptoms in 14% of the PC survivors and 6% of the GenPop controls(P < 0.01, odds ratio = 2.45 [1.66-3.62]). The most important correlates of lower MH scores in the PC survivors were being widowed, a lower educational level, lower general health perceptions, more bodily pain and urinary bother, and less sexual satisfaction. The most important correlates of lower MH scores in the GenPop were as follows: lower general health perceptions, more role limitations because of physical problems, and more bodily pain.Conclusions: Our results indicate that long-term PC survivors have poorer MH, as assessed by the 5-item Mental Health Inventory questionnaire, than men of a comparable age from the GenPop without a history of PC. Attention to potentially modifiable factors associated with MH problems in PC survivors, such as urinary function and its related bother, bodily pain, and sexual satisfaction, may help to prevent or limit MH problems in this survivor population. (C) 2017 Elsevier Inc. All rights reserved.

The review by Gandaglia et al . (1) clearly shows that we are in the process of drawing a roadmap towards the use of postprostatectomy radiotherapy. The outline is clear: we know that some patients benefit from the combination of surgery and radiotherapy, and we know that these patients have an increased risk of side effects. However, at this moment, the roadmap also shows a lot of gaps; we don’t have clear evidence which patients will really benefit, and there is no clarity about the optimal treatment delivery.

Commentary on : Chen RC, Basak R, Meyer AM, et al . Association between choice of radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance and patient-reported quality of life among men with localised prostate cancer. JAMA 2017;317:1141–50. Many patients with prostate cancer are diagnosed with low-risk disease only, for whom the benefit of surgery or radiation on life expectancy may be very limited, while still bringing the risk of side effects.1 2 Therefore, patients with low-risk prostate cancer are currently offered the option of active surveillance. This strategy delays therapy with curative intent until progression occurs, or it may completely avoid radical treatment.3 As a result, in the treatment decision-making process of patients newly diagnosed with prostate cancer, up-to-date and preferably personalised information about the possible positive and negative effects of the treatment options is vital. Chen and colleagues conducted a US population-based, observational study on 1141 men diagnosed with mostly localised prostate …

Many studies investigate HPV vaccine acceptability, applying health behavior theories to identify determinants; few include real uptake, the final variable of interest. This study investigated the utility of the Health Belief Model (HBM) in predicting HPV vaccine uptake in Kenya, focusing on the importance of promotion, probing willingness to vaccinate as precursor of uptake and exploring the added value of personal characteristics. Longitudinal data were collected before and after a pilot HPV vaccination program in Eldoret among mothers of eligible girls (N = 255). Through pathway modeling, associations between vaccine uptake and the HBM constructs, willingness to vaccinate and adequate promotion were examined. Adequate promotion was defined as a personal evaluation of promotional information received. Finally, baseline cervical cancer awareness and socio-demographic variables were added to the model verifying their direct, mediating or moderating effects on the predictive value of the HBM. Perceiving yourself as adequately informed at follow-up was the strongest determinant of vaccine uptake. HBM constructs (susceptibility, self-efficacy and foreseeing father’s refusal as barrier) only influenced willingness to vaccinate, which was not correlated with vaccination. Baseline awareness of cervical cancer predicted uptake. The association between adequate promotion and vaccination reveals the importance of triggers beyond personal control. Adoption of new health behaviors might be more determined by organizational variables, such as promotion, than by prior personal beliefs. Assessing users’ and non-users’ perspectives during and after implementing a vaccination program can help identifying stronger determinants of vaccination behavior.

BACKGROUND:The impact of salvage radiotherapy (SRT) and its timing on health-related quality of life (HRQoL) in prostate cancer patients is still unclear. OBJECTIVE:To compare the HRQoL of patients who underwent SRT with that of patients who underwent radical prostatectomy (RP) only and to investigate whether SRT timing is associated with HRQoL. DESIGN, SETTING, AND PARTICIPANTS:All SRT patients (n=241) and all RP-only patients (n=1005) were selected from a prospective database (2004-2015). The database contained HRQoL and prostate problem assessments up to 2 yr after last treatment. OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS:Mixed effects growth modelling adjusting for significant differences in patient characteristics and baseline HRQoL was used to analyze the association between: (1) "treatment" (RP-only vs SRT) and (2) "timing of SRT" with changes in HRQoL. RESULTS AND LIMITATIONS:SRT patients showed significantly (p<0.05) poorer recovery from urinary, bowel, and erectile function after their last treatment (clinically meaningful difference for urinary and erectile function). Patients with a longer interval (≥ 7 mo) between RP and SRT reported significantly better sexual satisfaction after SRT (p=0.02), and a better urinary function recovery (p=0.03). Limitations of the study include the nonrandom design and the variability in timing of HRQoL measurements. CONCLUSIONS:Up to 2 yr after treatment, SRT patients reported poorer HRQoL in several HRQoL domains compared with RP-only patients, but not in overall HRQoL. Delaying the start of SRT after RP may limit the incidence and duration of urinary and sexual problems. Nevertheless, decisions regarding SRT timing should also be based on the potential benefits in disease recurrence. PATIENT SUMMARY:Patients who receive radiotherapy after surgery may experience poorer urinary, bowel, and erectile function compared with patients who undergo surgery only. Although more research is needed, delaying radiotherapy seems to limit its impact on urinary and sexual functioning.

Two multilevel meta-analyses, consisting of 10 studies and 33 effect sizes (N=796 subjects) and 6 studies and 22 effect sizes (N=1179 subjects) were conducted to examine the effects of the EQUIP intervention on the level of sociomoral development and recidivism, respectively; moderating effects of participant, program, and study characteristics were also examined. A significant overall effect on sociomoral development was found (d=.27). The effect of EQUIP on sociomoral development was moderated by the sample size: studies with a larger sample size had smaller effect sizes. For recidivism, a non-significant overall effect size (d=.13) was attributable to strong moderator effects by gender (a significant effect for girls of d=.55), year of publication (older studies yielded smaller effect sizes), ethnicity (smaller effects in non-Caucasians), and especially region, indicating that studies conducted in the USA (showing high treatment integrity) were more effective (d=.32) than studies conducted outside the USA (showing low or negligible treatment integrity, d=−.31). These results suggest the importance of considering potential effects of study, participant characteristics, and program integrity when delivering EQUIP.

The objective of this study is to qualify the relationship between sexual and reproductive health (SRH) and educational attainment in eastern and southern Africa (ESA). We hypothesize that the regional level of globalization is a moderating factor in the relationship between SRH and educational attainment. Using retrospective data from Kenya, Malawi, Tanzania, and Zambia, the associations between SRH (eight indicators), educational attainment, and globalization were examined using multilevel logistic regression analysis. It was found that the model fit for every SRH outcome indicator increased significantly after including the interaction between globalization and educational attainment, supporting the hypothesis. Depending on the level of globalization, three types of relationships between education and SRH were found: (1) for the indicators more than four children, intercourse before 17 years, first child before 20 years, and one or more child died education is risk-decreasing, and the reduction is stronger in more globalized regions; (2) for the indicators condom use at last intercourse and current contraceptive use education is risk-decreasing, and the reduction is stronger in less globalized regions; (3) for the indicators HIV positive and more than four lifetime sexual partners education is risk increasing, but only in less globalized regions. In conclusion, these effects are related to three types of access: (1) access to services, (2) access to information, and (3) access to sexual networks. The findings highlight the relevance of globalization when analyzing the association between SRH and education, and the importance of structural factors in the development of effective SRH promotion interventions.