Cancer-related symptoms predict psychological wellbeing among prostate cancer survivors: results from the PiCTure study.

BACKGROUND: Prostate cancer treatments are associated with a range of symptoms and physical side-effects. Cancer can also adversely impact on psychological wellbeing. Because many prostate cancer-related symptoms and side-effects are potentially modifiable, we investigated associations between symptoms and psychological wellbeing among prostate cancer survivors. METHODS: Postal questionnaires were distributed to men diagnosed with prostate cancer 2-18 years previously identified through cancer registries. General and prostate cancer-specific symptoms were assessed using the EORTC QLQ-C30 and QLQ-PR25, with higher symptom scores indicating more/worse symptomatology. Psychological wellbeing was assessed by the DASS-21. Associations between symptoms and each outcome were investigated using multivariate logistic regression, controlling for socio-demographic and clinical factors. RESULTS: A total 3348 men participated (response rate = 54%). Seventeen percent (95%CI 15.2%-17.9%), 16% (95%CI 15.1%-17.8%) and 11% (95%CI 9.5%-11.8%) of survivors scored in the range for depression, anxiety and distress on the DASS scales, respectively. In multivariate models, risk of depression on the DASS scale was significantly higher in men with higher urinary and androgen deprivation therapy (ADT)-related symptoms, and higher scores for fatigue, insomnia and financial difficulties. Risk of anxiety on the DASS scale was higher in men with higher scores for urinary, bowel and ADT-related symptoms and fatigue, dyspnoea and financial difficulties. Risk of distress on the DASS scale was positively associated with urinary, bowel and ADT-related symptoms, fatigue, insomnia and financial difficulties. CONCLUSIONS: Cancer-related symptoms significantly predict psychological wellbeing among prostate cancer survivors. Greater use of interventions and medications and to alleviate symptoms might improve psychological wellbeing of prostate cancer survivors.

Mode of prostate cancer detection is associated with the psychological wellbeing of survivors: results from the PiCTure study.

PURPOSE: Many men with prostate cancer are asymptomatic, diagnosed following prostate specific antigen (PSA) testing. We investigate whether mode of detection, i.e. 'PSA detected' or 'clinically detected', was associated with psychological wellbeing among prostate cancer survivors. METHODS: A cross-sectional postal questionnaire was administered in 2012 to 6559 prostate cancer (ICD10 C61) survivors up to 18 years post-diagnosis, identified through population-based cancer registries in Ireland. Psychological wellbeing was assessed using the Depression Anxiety Stress Scale-21. Logistic regression was used to investigate associations between mode of detection and depression, anxiety and stress, adjusting for socio-demographic and clinical confounders. RESULTS: The response rate was 54 % (3348/6262). Fifty-nine percent of survivors were diagnosed with asymptomatic PSA-tested disease. Prevalence of depression (13.8 vs 20.7 %; p < 0.001), anxiety (13.6 vs 20.9 %; p < 0.001) and stress (8.7 vs 13.8 %; p < 0.001) were significantly lower among survivors diagnosed with PSA-detected, than clinically detected disease. After adjusting for clinical and socio-demographic factors, survivors with clinically detected disease had significantly higher risk of depression (odds ratio (OR) = 1.46 95 % CI 1.18, 1.80; p = 0.001), anxiety (OR = 1.36 95 % CI 1.09, 1.68; p = 0.006) and stress (OR = 1.43 95 % CI 1.11, 1.85; p = 0.006) than survivors with PSA-detected disease. CONCLUSIONS: These findings contribute to the ongoing debate on benefits and risks of PSA testing and may be considered by policy makers formulating population-based prostate cancer screening policies. The relatively high prevalence of negative psychological states among survivors means that a 'risk-adapted approach' should be implemented to screen survivors most at risk of psychological morbidity for psychological health, and mode of detection could be considered as a risk stratum.

Patient-reported 'ever had' and 'current' long-term physical symptoms after prostate cancer treatments.

OBJECTIVE: To investigate the prevalence of physical symptoms that were 'ever' and 'currently' experienced by survivors of prostate cancer at a population level, to assess burden and thus inform policy to support survivors. PATIENTS AND METHODS: The study included 3 348 men surviving prostate cancer for 2-18 years after diagnosis. A cross-sectional, postal survey of 6 559 survivors diagnosed 2-18 years ago with primary, invasive prostate cancer (ICD10-C61) identified via national, population-based cancer registries in Northern Ireland and Republic of Ireland. Questions included symptoms at diagnosis, primary treatments and physical symptoms (erectile dysfunction [ED]/urinary incontinence [UI]/bowel problems/breast changes/loss of libido/hot flashes/fatigue) experienced 'ever' and at questionnaire completion ('current'). Symptom proportions were weighted by age, country and time since diagnosis. Bonferroni corrections were applied for multiple comparisons. RESULTS: Adjusted response rate 54%; 75% reported at least one 'current' physical symptom ('ever' 90%), with 29% reporting at least three. Prevalence varied by treatment. Overall, 57% reported current ED and this was highest after radical prostatectomy (RP, 76%) followed by external beam radiotherapy with concurrent hormone therapy (HT, 64%). UI (overall 'current' 16%) was highest after RP ('current' 28%; 'ever' 70%). While 42% of brachytherapy patients reported no 'current' symptoms, 43% reported 'current' ED and 8% 'current' UI. 'Current' hot flashes (41%), breast changes (18%) and fatigue (28%) were reported more often by patients on HT. CONCLUSION: Symptoms after prostate cancer treatment are common, often multiple, persist long-term and vary by treatment method. They represent a significant health burden. An estimated 1.6% of men aged >45 years are survivors of prostate cancer and currently experiencing an adverse physical symptom. Recognition and treatment of physical symptoms should be prioritised in patient follow-up. This information should facilitate men and clinicians when deciding about treatment as differences in survival between radical treatments is minimal.

Psychometric evaluation of the EORTC QLQ-PR25 questionnaire in assessing health-related quality of life in prostate cancer survivors: a curate's egg.

PURPOSE: The EORTC QLQ-PR25 was primarily developed to measure disease-specific health-related quality of life (HRQoL) of prostate cancer (PCa) patients undergoing active treatment. The growing number of cancer survivors has focussed interest on assessing survivors' HRQoL. We evaluated psychometric properties of the EORTC QLQ-PR25 questionnaire amongst PCa survivors. METHODS: A postal questionnaire, including the QLQ-PR25, was administered to 6559 PCa survivors 2-18 years post-diagnosis, identified through population-based cancer registries in Ireland; 3348 participated. The QLQ-PR25 has been suggested to have five multi-item subscales measuring urinary (US), bowel (BS) and hormone treatment-related symptoms (TS), sexual activity (SA) and sexual functioning (SF), and a single item measuring bother due to using incontinence aids (IA). Reliability analysis, divergent validity, discriminant validity (compared to EORTC QLQ-C30, DASS-21 and EuroQoL EQ-5D-5L), and exploratory and confirmatory factor analysis (EFA, CFA) were undertaken. RESULTS: The percentage of survivors completing QLQ-PR25 subscales was: US-79 %; IA-20 %; BS-83 %; TS-86 %; SA-87 %; and SF-26 %. Reliability was acceptable (Cronbach's α > 0.7) for three subscales (US, SA, SF). The instrument discriminated well between clinically distinct groups, especially those defined by primary treatment(s) and stage at diagnosis. The SA and SF subscales showed good discriminant validity compared to QLQ-C30, DASS-21 and EQ-5D-5L; other subscales did not. EFA reproduced a near fit to the proposed factor structure. CFA confirmed this. CONCLUSION: This is the largest ever QLQ-PR25 validation study. When used in PCa survivors, although the proposed factor structure was confirmed, some of the subscales (e.g. BS and TS) showed poor reliability, a lack of discriminant validity and moderate levels of item non-response.

Nonlinearity of cationic aromatic amine sorption to aluminosilicates and soils: role of intermolecular cation-π interactions.

Through the study of substituted anilines and benzylamines, we demonstrated that cooperative cation-π, π-π, and van der Waals interactions can increase aromatic cationic amine sorption to Na/Ca-montmorillonite well beyond the extent expected by cation exchange alone. Cationic amines exhibiting cooperative interactions displayed nonlinear S-shaped isotherms and increased affinity for the sorbent at low surface coverage; parallel cation exchange and cooperative interactions were noted above a sorption threshold of 0.3-2.3% of exchange sites occupied. Our experiments revealed the predominance of intermolecular cation-π interactions, which occurred between the π system of a compound retained on the surface via cation exchange and the cationic amine group of an adjacent molecule. Compounds with greater amine charge/area and electron-donating substituents that allowed for greater electron density at the center of the aromatic ring showed a greater potential for cation-π interactions on montmorillonite surfaces. However, benzylamine sorption to nine soils, at charge loadings comparable to the experiments with montmorillonite, revealed no significant cooperative interactions. It appears that cation-π interactions may be likely in soils with exceptionally high cation exchange capacities (>0.7 mol charge/kg) and low organic matter contents, abundant in montmorillonite and other expanding clay minerals.

Uptake of breast screening is influenced by current religion and religion of upbringing.

Research has shown that individuals with a current religious affiliation are more likely to use preventive health services. The aim of this study was to determine whether breast screening uptake in Northern Ireland is higher amongst women with a current affiliation to an organised religion and, for those with no current affiliation, to examine whether their religion of upbringing is associated with uptake of breast screening. The Northern Ireland Longitudinal Study (NILS) was used to link Census and national breast screening data for 37,211 women invited for routine breast screening between 2001 and 2004. Current religious affiliation, religion of upbringing and other demographic and socio-economic characteristics were as defined on the Census form. Multivariate logistic regression was used to determine the relationship between religion affiliation and attendance. Uptake of breast screening is about 25% lower for those without a current religious affiliation. There are modest differences between Catholics and Protestants, with the latter about 11% more likely to attend for screening. For those with no current religion, the religion of upbringing appears to positively influence attendance rates. These differences remain after adjustment for all of the socio-demographic and socio-economic factors that have been shown to influence uptake rates of breast screening in the UK to date. Record linkage is an efficient way to examine equity across demographic characteristics that are not routinely available. The lower uptake amongst those with no religious affiliation may mean that screening services may find it difficult to maintain or improve uptake rate in an increasingly secularised society.

Using record linkage to monitor equity and variation in screening programmes.

BACKGROUND: Ecological or survey based methods to investigate screening uptake rates are fraught with many limitations which can be circumvented by record linkage between Census and health services datasets using variations in breast screening attendance as an exemplar. The aim of this current study is to identify the demographic, socio-economic factors associated with uptake of breast screening. METHODS: Record linkage study: combining 2001 Census data within the Northern Ireland Longitudinal Study (NILS) with data relating to validated breast screening histories from the National Breast Screening System. A cohort was identified of 37,059 women aged 48-64 at the Census who were invited for routine breast screening in the three years following the Census. All cohort attributes were as recorded on the Census form. RESULTS: The record linkage methodology enabled the records of almost 40,000 of those invited for screening to be analysed at an individual level, exceeding the largest published survey by a factor of ten. This produced a more robust analysis and demonstrated (in fully adjusted models) the lower uptake amongst non-married women and those in the lowest social class (OR 0.74; 95%CI 0.66, 0.82), factors that had not been reported earlier in the UK. In addition, with the availability of both individual and area information it was possible to show that the much lower screening uptake in urban areas is not due to differences in population composition suggesting unrecognised organisational problems. CONCLUSIONS: Linkage of screening data to Census-based longitudinal studies is an efficient and powerful way to increase the evidence base on sources of variation in screening uptake within the UK.

Are caregiving responsibilities associated with non-attendance at breast screening?

BACKGROUND: Previous research showed that deprived individuals are less likely to attend breast screening and those providing intense amounts of informal care tend to be more deprived than non-caregivers. The aim of this study was to examine the relationship between informal caregiving and uptake of breast screening and to determine if socio-economic gradients in screening attendance were explained by caregiving responsibilities. METHODS: A database of breast screening histories was linked to the Northern Ireland Longitudinal Study, which links information from census, vital events and health registration datasets. The cohort included women aged 47 - 64 at the time of the census eligible for breast screening in a three-year follow-up period. Cohort attributes were recorded at the Census. Multivariate logistic regression was used to examine the relationship between informal caregiving and uptake of screening using STATA version 10. RESULTS: 37,211 women were invited for breast screening of whom 27,909 (75%) attended; 23.9% of the cohort were caregivers. Caregivers providing <20 hours of care/week were more affluent, while those providing >50 hours/week were more deprived than non-caregivers. Deprived women were significantly less likely to attend breast screening; however, this was not explained by caregiving responsibilities as caregivers were as likely as non-caregivers to attend (Odds Ratio 0.97; 95% confidence intervals 0.88, 1.06). CONCLUSIONS: While those providing the most significant amounts of care tended to be more deprived, caregiving responsibilities themselves did not explain the known socio-economic gradients in breast screening attendance. More work is required to identify why more deprived women are less likely to attend breast screening.

Long-term health-related quality of life of prostate cancer survivors varies by primary treatment. Results from the PiCTure (Prostate Cancer Treatment, your experience) study.

PURPOSE: Men are living longer with prostate cancer. In a two-country study, we investigated the health-related quality of life (HRQoL) of prostate cancer survivors up to 18 years post-diagnosis. METHODS: Postal questionnaires were administered in 2012 to 6559 prostate cancer (ICD10 C61) survivors 2-18 years post-diagnosis, identified through population-based cancer registries in Ireland. HRQoL was measured using QLQ-C30 and QLQ-PR25. HRQoL, functional and symptom scores were compared by primary treatment(s) using multiple linear regression. RESULTS: Fifty-four percent responded (n = 3348). After controlling for socio-demographic and clinical factors, global HRQoL varied significantly by primary treatment (p < 0.001); compared to radical prostatectomy (RP), survivors who received androgen deprivation therapy alone (ADT; p < 0.001) or external beam radiotherapy (EBRT) without concurrent ADT (p = 0.001) had significantly lower global HRQoL. The global HRQoL of men who received brachytherapy (p = 0.157), EBRT with concurrent ADT (p = 0.940) or active surveillance/watchful waiting (p = 0.388) was not significantly different from men treated with RP. There were statistically and clinically significant differences in general (fatigue, pain, dyspnoea, appetite loss, constipation, diarrhoea, financial difficulties) and disease-specific symptoms (sexual, urinary, bowel, ADT) by primary treatment. Fatigue and insomnia scores were high for survivors in all treatment groups. CONCLUSIONS: Prostate cancer survivors' long-term HRQoL varied with primary treatment. IMPLICATIONS OF CANCER SURVIVORS: Population-based information regarding statistically and clinically significant treatment effects on long-term global HRQoL, symptom burden and functionality should be provided during treatment decision-making. Screening for symptoms and utilising interventions during long-term follow-up may improve survivors' HRQoL.

Variation in mortality by country of birth in Northern Ireland: a record linkage study.

The study of health differences between those residing in the same country but originating in different countries is a potential source of insight into the causes of ill-health. Within Northern Ireland, those born in England, Wales, the Republic of Ireland and outside of the British Isles have a lower mortality risk than the Northern Ireland born; however, these differentials are largely explained by the demographic and socio-economic characteristics of these migrants. Conversely, the Scottish born residing in Northern Ireland have higher mortality than the Northern Ireland born, especially from ischemic heart disease, suggesting that the Scottish immigrants maintain the health disadvantage of their country of birth.

A surgeon's case volume of oesophagectomy for cancer does not influence patient outcome in a high volume hospital.

The aim of this study is to assess if individual case volume of oesophageal resections influences the operative mortality rate in a high volume hospital. Between June 1994 and June 2006, 252 total thoracic oesophageal resections (75% male, mean age 63 years) were performed by five surgeons in tertiary referral centre. Operative approach was standardised in all cases and consisted of left thoracolaparotomy, resection of all intrathoracic and abdominal oesophagus and left cervical incision for anastomosis. Operative mortality, defined as in-hospital death irrespective of length of stay, was compared among consultants and also trainees. A total of 207 operations were performed by five consultants with nine deaths (4.3%) compared to two deaths after 45 operations by 17 trainees (4.4%) [Fisher's exact test, P=0.61 (CI=0.84-1.26)]. Individual case volume for consultants ranged from 5 to 10.5 cases/years [chi2-test, P=0.34 (CI=0.89-1.29)] with 0-5.4% mortality rate [chi2-test, P=0.24 (CI=0.96-1.19)]. Overall hospital volume ranged from 17 to 57 cases/years. This study confirms that surgeons with appropriate training in oesophageal resection may get good results despite lower individual case volumes when a standardised approach is taken in an institution with a high case volume.