Measuring the psychosocial impact of population‐based prostate‐specific antigen testing for prostate cancer in the UK

Abstract

OBJECTIVE To evaluate the psychosocial impact of participation in a population‐based prostate‐specific antigen (PSA) testing programme, akin to screening, and to explore the relationship between urinary symptoms reported before PSA testing and the response to the subsequent PSA result. PATIENTS AND METHODS This prospective questionnaire study was nested within the case‐finding component of the ProtecT (prostate testing for cancer and treatment) feasibility study (ISRCTN20141297). Men aged 50–69 years from 18 general practices in three cities in the UK completed the Hospital Anxiety and Depression Scale (HADS), the Short Form‐12 (SF‐12) Health Survey, and the International Continence Society ‘male’ (ICSmale) questionnaires before giving consent for a PSA test in a community clinic (baseline). Men with an ‘abnormal’ PSA result returned for further investigation (including biopsy) and repeated these questionnaires before biopsy. RESULTS At baseline, study participants had similar levels of anxiety and depression to the general male population. There was no increase in the HADS scores, or reduction in the SF‐12 mental health component summary score, on attendance at the biopsy clinic after receiving an ‘abnormal’ PSA result. Urinary symptoms were associated with levels of anxiety and depression before receiving a PSA result (baseline), but were not associated with anxiety and depression at biopsy independently of baseline scores. Therefore changes in anxiety or depression at biopsy did not appear to differ between those with and without urinary symptoms. CONCLUSIONS This study confirms the findings of other studies that the deleterious effects of receiving an abnormal PSA result during population screening are not identified by generic health‐status questionnaires. Comparisons with outcomes of studies measuring cancer‐specific distress and using qualitative research methods raise the question of whether a prostate cancer screening‐specific instrument is required. However, a standardized measure of anxiety identified differences at baseline between those who did and did not report urinary symptoms. These findings suggest that it might be advisable to better inform men undergoing PSA testing about the uncertain relationship between urinary symptoms and prostate cancer, to minimize baseline levels of psychological distress.

The measurement of psychological distress in men being investigated for the presence of prostate cancer

“…The level as well as prevalence of depression was lower than of anxiety, with the prevalence of anxiety and depression being 4-7 and 1.4% respectively, using a threshold score of 11 and above for the HADS subscales; the cut-off level first described by Zigmond and Snaith 15 for 'definite cases'. These levels and prevalence of both anxiety and depression are similar to population norms for UK men, not matched for age, 19 as well as to other reports of PSA screening 4,11 and from men with a diagnosis of early prostate cancer. 5 However, a recent review of the validity of the HADS stated that an optimal balance between sensitivity and specificity (0.80 each) for both HADS-A and HADS-D could be achieved by using a cut-off score of 8 þ .…”

“…There is a high incidence of psychiatric disturbance reported in women who were recently diagnosed with breast cancer. 1 There have been conflicting reports however, with regard to the prevalence of mental health disturbance in men being investigated and treated for prostate cancer; with some studies reporting a high (50-64%) prevalence of anxiety, 2,3 whereas others report low levels in men being investigated 4 or treated for early localized prostate cancer 5 that are no different from those of a matched normal population. In addition, other reports suggest that men with advanced prostate cancer had significantly greater psychological distress as compared to those with early stage disease.…”

“…These include PSA-itis (anxiety related to the knowledge of serum PSA) 9 and PSA-dynia (a state of emotional or physical distress due to an elevated PSA level). 10 Reports from the Rotterdam trial (a participant in the European Randomized Study of Screening for Prostate Cancer) 11 and the ProtecT (Prostate Testing for Cancer and Treatment) Study 4 however have shown no significant change in anxiety levels during PSA screening. Most men in the United Kingdom do not undergo PSA screening, but have a PSA test, either on self-request or on request by their general practitioner (GP) as part of investigations for LUTS.…”

Impact of prostate cancer testing: an evaluation of the emotional consequences of a negative biopsy result

“…In an earlier longitudinal study of men being screened for prostate cancer, Gustafsson et al (1995) reported that cortisol level (indicating the degree of emotional stress) was highest immediately before being informed of the biopsy result, although levels decreased somewhat 2 weeks later in those who received a benign biopsy result. Other studies have concluded that testing for prostate cancer had little or no effect on men's psychological health (Brindle et al, 2006;Awsare et al, 2008). These studies relied on the Hospital Anxiety and Depression Scale (HADS) (Zigmond and Snaith, 1983), which was designed to detect clinical cases of anxiety and depression.…”

“…Increases in negative mood have been found in studies of women with abnormal but benign results for breast (Lowe et al, 1999;Aro et al, 2000) and ovarian (Andrykowski et al, 2004) cancer. Although studies of men undergoing PSA testing have shown no significant effect on anxiety for those receiving an abnormal PSA result (Essink-Bot et al, 1998;Brindle et al, 2006;Carlsson et al, 2007), it has been reported that those who receive a benign biopsy have thought and worried more about prostate cancer (McNaughtonCollins et al, 2004;Fowler et al, 2006;Katz et al, 2007). However, these latter studies were small and relied on unvalidated measures for these outcomes.…”