Design of the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study (NC ProCESS)

Differences in Rural Versus Urban Patients With Prostate Cancer in Diagnosis and Treatment: An Analysis of a Population-Based Cohort

PURPOSE

Patients living in rural communities have greater barriers to cancer care and poorer outcomes. We hypothesized that rural patients with prostate cancer have less access and receive different treatments compared with urban patients.

METHODS

We used a population-based prospective cohort, the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study, to compare differences in prostate cancer diagnosis, access to care, and treatment in patients by geographic residence. The 2013 rural-urban continuum code (RUCC) was used to determine urban (RUCC 1-3) versus rural (RUCC 4-9) location of residence.

RESULTS

Patients with rural residence comprised 25% of the cohort (364 of 1,444); they were less likely to be White race and had lower income and educational attainment. Rural patients were more likely to have <12 cores on biopsy (47.1% v 35.7%; P < .001) and less likely (40.8% v 47.6%; P = .04) to receive multidisciplinary consultation. We observed significant differences in treatment between urban and rural patients, including rural patients receiving less active surveillance or observation (22.6% v 28.7%), especially in low-risk cancer (33.2% v 40.7%). On multivariable analysis that adjusted for patient and diagnostic factors, rural residence was associated with less use of active surveillance or observation over radical treatment (ie, surgery or radiation therapy; odds ratio, 0.49 v urban; P < .001) in patients with low-risk cancer.

CONCLUSION

Patients with prostate cancer who live in rural versus urban areas experience several differences in care that are likely clinically meaningful, including fewer cores in the diagnostic biopsy, less utilization of multidisciplinary consultation, less use of active surveillance, or observation for low-risk disease. Future studies are needed to assess the efficacy of interventions in mitigating these disparities.

Telehealth use and perceptions among prostate cancer survivors

BACKGROUND

Reasons underlying disparities in telehealth use among cancer survivors are unknown.

METHODS

We surveyed a sociodemographically diverse population-based cohort of 487 prostate cancer survivors regarding their use and perceptions of telehealth during the COVID-19 pandemic.

RESULTS

Overall, only 28.5% of survivors had used telehealth at the time of survey and just 10% felt care through telehealth is comparable to that of an in-person visit. Still, over 55% felt telehealth is a good option for initial consultations or basic care and 15% felt more likely to use telehealth since the pandemic. After adjusting for other socioeconomic factors, survivors with lower education (≤high school vs. any college) had marginally lower use of telehealth (risk ratio [RR], 0.65 [95% CI, 0.42-1.01]) and lower probability of feeling more likely to use telehealth since the pandemic (RR, 0.39 [95% CI, 0.20-0.77]).

CONCLUSIONS

Differences in survivor perceptions of telehealth by education level highlight new insights underlying disparities in telehealth use and potential targets for interventions.

Cardiovascular disease prevention and management of pre-existent cardiovascular disease in a cohort of prostate cancer survivors

PURPOSE

Cardiovascular disease (CVD) is a common cause of mortality among men with prostate cancer. However, receipt of preventive care and management of pre-existent CVD has not been well studied in prostate cancer survivors.

METHODS

This study examined a prospective cohort of men newly diagnosed with localized prostate cancer between 2011 and 2013 throughout North Carolina linked to Medicare and private insurance claims and clinical data from the Veterans Affairs (VA). In patients without pre-existent CVD, the primary outcome was a composite measure of annual preventive care (blood glucose screening, cholesterol level testing, and ≥ 1 primary care provider visit). In patients with pre-existent CVD, the primary outcome was annual cardiologist visit; blood glucose, cholesterol level testing, and primary care visits were also assessed.

RESULTS

Our sample comprised 492 patients successfully linked to insurance claims and/or VA data, among whom 103 (20.9%) had pre-existent CVD. Receipt of preventive care declined from 52.7% (95% confidence interval [CI], 47.7 to 57.6%) during the first year after prostate cancer diagnosis to 40.8% (95% CI: 33.7 to 48.4%) during the third year. Among patients with pre-existent CVD, only 23.4% (95% CI: 13.6 to 37.2%) visited a cardiologist in all 3 years. Black men were more likely than White men to visit a cardiologist the first year (risk ratio [RR] = 1.72, 95% CI: 1.10 to 2.71).

CONCLUSION

In a population-based cohort of prostate cancer survivors, receipt of CVD preventive care declined over time, and frequency of cardiologist-led management of pre-existent CVD was low.

IMPLICATIONS FOR CANCER SURVIVORS

There is a need to improve clinical strategies for reducing cardiovascular risk and managing pre-existent CVD in prostate cancer survivors.

Patient Decision-Making Factors in Aggressive Treatment of Low-Risk Prostate Cancer

Background

Active surveillance (AS) is underutilized for low-risk prostate cancer. This study examines decision-making factors associated with AS vs aggressive treatment in a population-based cohort of low-risk patients.

Methods

Newly diagnosed patients (n = 599) were enrolled through the North Carolina Central Cancer Registry from 2011 to 2013 and surveyed regarding 5 factors that may impact treatment decision making: perceived cancer aggressiveness, aggressiveness of treatment intent, most important goal (eg, cure, quality of life), primary information source, and primary decision maker. We examined the association between treatment decision-making factors with patient choice for AS vs aggressive treatment using multivariable logistic regression analysis.

Results

This is a sociodemographically diverse cohort reflective of the population-based design, with 37.6% overall (47.6% among very low-risk patients) choosing AS. Aggressive treatment intent (odds ratio [OR] = 7.09, 95% confidence interval [CI] = 4.57 to 11.01), perceived cancer aggressiveness (OR = 4.93, 95% CI = 2.71 to 8.97), most important goal (cure vs other, OR = 1.72, 95% CI = 1.12 to 2.63), and primary information source (personal and family vs physician, OR = 1.76, 95% CI = 1.10 to 2.82) were associated with aggressive treatment. Overall, 88.4% of patients (92.2% among very low-risk) who indicated an intent to treat the cancer “not very aggressively” chose AS.

Conclusions

These data from the patient’s perspective shed new light on potentially modifiable factors that can help further increase AS uptake among low-risk patients. Helping more low-risk patients feel comfortable with a “not very aggressive” treatment approach may be especially important, which can be facilitated through patient education interventions to improve the understanding of the cancer diagnosis and AS having a curative intent.

Receipt of Guideline-Recommended Surveillance in a Population-Based Cohort of Prostate Cancer Patients Undergoing Active Surveillance

PURPOSE

Prospective clinical trials have demonstrated the safety and efficacy of active surveillance for men with localized prostate cancer but also suggested that inadequate surveillance may risk missing an opportunity for cure.

METHODS AND MATERIALS

We used data from a population-based cohort of active-surveillance patients to examine the rigor of surveillance monitoring in the general population.

RESULTS

Among 1419 patients enrolled from 2011 to 2013 throughout the state of North Carolina in collaboration with the state cancer registry and followed prospectively, 346 pursued active surveillance. Only 13% received all guideline-recommended surveillance testing (including prostate-specific antigen, digital rectal examination, and prostate biopsy) within the first 2 years. Furthermore, adherence was <20% in all patient subgroups.

CONCLUSIONS

These findings suggest that "active surveillance" as implemented in the general population may not represent the rigorous monitoring regimens used in the studies that demonstrated the safety of this management approach. More real-world studies on active surveillance are needed.

Mapping the Memorial Anxiety Scale for Prostate Cancer to the SF-6D

PURPOSE

To create a crosswalk that predicts Short Form 6D (SF-6D) utilities from Memorial Anxiety Scale for Prostate Cancer (MAX-PC) scores.

METHODS

The data come from prostate cancer patients enrolled in the North Carolina Prostate Cancer Comparative Effectiveness & Survivorship Study (NC ProCESS, N = 1016). Cross-sectional data from 12- to 24-month follow-up were used as estimation and validation datasets, respectively. Participants' SF-12 scores were used to generate SF-6D utilities in both datasets. Beta regression mixture models were used to evaluate SF-6D utilities as a function of MAX-PC scores, race, education, marital status, income, employment status, having health insurance, year of cancer diagnosis and clinically significant prostate cancer-related anxiety (PCRA) status in the estimation dataset. Models' predictive accuracies (using mean absolute error [MAE], root mean squared error [RMSE], Akaike information criterion [AIC] and Bayesian information criterion [BIC]) were examined in both datasets. The model with the highest prediction accuracy and the lowest prediction errors was selected as the crosswalk.

RESULTS

The crosswalk had modest prediction accuracy (MAE = 0.092, RMSE = 0.114, AIC = - 2708 and BIC = - 2595.6), which are comparable to prediction accuracies of other SF-6D crosswalks in the literature. About 24% and 52% of predictions fell within ± 5% and ± 10% of observed SF-6D, respectively. The observed mean disutility associated with acquiring clinically significant PCRA is 0.168 (standard deviation = 0.179).

CONCLUSION

This study provides a crosswalk that converts MAX-PC scores to SF-6D utilities for economic evaluation of clinically significant PCRA treatment options for prostate cancer survivors.

Utilizing SEER Cancer Registries for Population-Based Cancer Survivor Epidemiologic Studies: A Feasibility Study

BACKGROUND

While the primary role of central cancer registries in the United States is to provide vital information needed for cancer surveillance and control, these registries can also be leveraged for population-based epidemiologic studies of cancer survivors. This study was undertaken to assess the feasibility of using the NCI's Surveillance, Epidemiology, and End Results (SEER) Program registries to rapidly identify, recruit, and enroll individuals for survivor research studies and to assess their willingness to engage in a variety of research activities.

METHODS

In 2016 and 2017, six SEER registries recruited both recently diagnosed and longer-term survivors with early age-onset multiple myeloma or colorectal, breast, prostate, or ovarian cancer. Potential participants were asked to complete a survey, providing data on demographics, health, and their willingness to participate in various aspects of research studies.

RESULTS

Response rates across the registries ranged from 24.9% to 46.9%, with sample sizes of 115 to 239 enrolled by each registry over a 12- to 18-month period. Among the 992 total respondents, 90% answered that they would be willing to fill out a survey for a future research study, 91% reported that they would donate a biospecimen of some type, and approximately 82% reported that they would consent to have their medical records accessed for research.

CONCLUSIONS

This study demonstrated the feasibility of leveraging SEER registries to recruit a geographically and racially diverse group of cancer survivors.

IMPACT

Central cancer registries are a source of high-quality data that can be utilized to conduct population-based cancer survivor studies.

Associations between prostate cancer-related anxiety and health-related quality of life

Background

There are uncertainties about prostate cancer‐related anxiety's (PCRA) associations with health‐related quality of life (HRQOL) and major depression, and these could affect the quality of mental healthcare provided to prostate cancer patients. Addressing these uncertainties will provide more insight into PCRA and inform further research on the value of PCRA prevention. The goals of this study were to measure associations between PCRA and HRQOL at domain and subdomain levels, and to evaluate the association between PCRA and probable (ie, predicted major) depression.

Method

We analyzed secondary cross‐sectional data from the North Carolina Prostate Cancer Comparative Effectiveness & Survivorship Study (NC ProCESS—a population‐based cohort of prostate cancer patients enrolled shortly after diagnosis [between January 2011 and June 2013] and followed prospectively). Patient‐reported measures of PCRA and HRQOL from 1,016 enrollees who participated in NC ProCESS’s 1‐year follow‐up survey were assessed. Outcomes of interests were a) linear correlations between contemporaneous memorial anxiety scale for prostate cancer (MAX‐PC) and Short Form 12 (SF‐12) scores, and b) measures of association between indicators of clinically significant PCRA (ie, MAX‐PC > 27) and probable depression during survey contact (ie, SF‐12 mental component score ≤43).

Results

PCRA measures had notable associations with SF‐12’s mental health subscale (assesses low mood/nervousness [rho = −0.42]) and emotional role functioning subscale (assesses subjective productivity loss [rho = −0.46]). Additionally, the risk of probable depression was significantly higher in participants with clinically significant PCRA compared with those without it (weighed risk ratio = 5.3, 95% confidence interval 3.6‐7.8; P < .001).

Conclusion

Prostate cancer patients with clinically significant PCRA should be assessed for major depression and productivity loss.

Patient-reported sexual quality of life after different types of radical prostatectomy and radiotherapy: Analysis of a population-based prospective cohort

BACKGROUND

Although patients with prostate cancer face many treatment options, to the authors' knowledge the comparative effects of different surgical and radiotherapy (RT) options on sexual function are unclear.

METHODS

In the current study, a population-based cohort of 835 men with newly diagnosed prostate cancer from 2011 through 2013 was recruited throughout North Carolina in collaboration with the Rapid Case Ascertainment system of the North Carolina Central Cancer Registry. All men were enrolled prior to treatment and followed prospectively using the validated Prostate Cancer Symptom Indices (PCSI) instrument. This analysis compares the sexual dysfunction scores of the PCSI among patients who received external-beam RT (EBRT), EBRT with androgen deprivation therapy (ADT), brachytherapy, nerve-sparing radical prostatectomy (RP), and non-nerve-sparing RP. Propensity scores were used to balance patient characteristics across groups, and multiple imputation was used for missing data.

RESULTS

EBRT and brachytherapy resulted in similar PCSI scores through 24 months. Compared with those receiving EBRT, patients treated with EBRT with ADT and RP with or without nerve sparing were found to have worse PCSI scores at all posttreatment time points. Preservation of useful sexual function at 24 months was associated with treatment type, baseline score, and age. Predicted preservation rates were 14.1% to 70.7% for EBRT, 8.4% to 52.3% for EBRT with ADT, 4.7% to 45.3% for nerve-sparing RP, and 4.8% to 34.5% for non-nerve-sparing RP.

CONCLUSIONS

The findings of the current study indicate that RT alone results in the best preservation of sexual function, and brachytherapy provides similar outcomes. RT with ADT and nerve-sparing RP yielded similar outcomes, whereas patients treated with non-nerve-sparing RP experienced the worst sexual function. These results help patients to make decisions among the specific types of surgery and RT they face based on each individual's diagnosis.

Patient-reported Quality of Life Following Stereotactic Body Radiotherapy and Conventionally Fractionated External Beam Radiotherapy Compared with Active Surveillance Among Men with Localized Prostate Cancer

BACKGROUND

Evidence supporting the efficacy of stereotactic body radiotherapy (SBRT) for localized prostate cancer is accumulating, but comparative studies of patient-reported quality of life (QOL) following SBRT versus conventionally fractionated external beam radiotherapy (EBRT) or active surveillance (AS) are limited.

OBJECTIVE

To compare QOL of patients pursuing SBRT and EBRT versus AS.

DESIGN, SETTING, AND PARTICIPANTS

A population-based cohort of 680 men with newly diagnosed localized prostate cancer was prospectively enrolled from 2011 to 2013.

INTERVENTION

SBRT, EBRT without androgen deprivation therapy, or AS.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

QOL was prospectively assessed before treatment (baseline), and at 3, 12, and 24mo after treatment using the validated Prostate Cancer Symptom Indices, which contain four domains: sexual dysfunction, urinary obstruction/irritation, urinary incontinence, and bowel problems. Propensity weighting via logistic regression models was used to balance baseline characteristics, and the mean QOL scores of EBRT and SBRT patients were compared against AS patients as the control group.

RESULTS AND LIMITATIONS

Compared with AS patients, EBRT patients had worse urinary obstructive/irritative symptoms and sexual dysfunction at 3mo, and worse bowel symptoms at 3 and 24mo. SBRT patients had similar scores as AS patients in all domains and across all time points; however, due to small sample size, worse sexual function and urinary incontinence in SBRT patients cannot be ruled out. Further research is needed to assess long-term outcomes.

CONCLUSIONS

In a nonrandomized cohort of men with localized prostate cancer, SBRT appeared to result in favorable QOL results through 2yr of follow-up, but worse sexual function and urinary incontinence compared with AS cannot be ruled out completely. Larger studies with longer follow-up are needed to confirm these findings.

PATIENT SUMMARY

Stereotactic body radiotherapy (SBRT) and active surveillance appear to have similar quality of life outcomes through 2yr, although worse sexual function and urinary incontinence from SBRT cannot be ruled out completely.

Prostate Cancer Patient Characteristics Associated With a Strong Preference to Preserve Sexual Function and Receipt of Active Surveillance

Background

Men with early-stage prostate cancer have multiple options that have similar oncologic efficacy but vary in terms of their impact on quality of life. In low-risk cancer, active surveillance is the option that best preserves patients' sexual function, but it is unknown if patient preference affects treatment selection. Our objectives were to identify patient characteristics associated with a strong preference to preserve sexual function and to determine whether patient preference and baseline sexual function level are associated with receipt of active surveillance in low-risk cancer.

Methods

In this population-based cohort of men with localized prostate cancer, baseline patient-reported sexual function was assessed using a validated instrument. Patients were also asked whether preservation of sexual function was very, somewhat, or not important. Prostate cancer disease characteristics and treatments received were abstracted from medical records. A modified Poisson regression model with robust standard errors was used to compute adjusted risk ratio (aRR) estimates. All statistical tests were two-sided.

Results

Among 1194 men, 52.6% indicated a strong preference for preserving sexual function. Older men were less likely to have a strong preference (aRR = 0.98 per year, 95% confidence interval [CI] = 0.97 to 0.99), while men with normal sexual function were more likely (vs poor function, aRR = 1.59, 95% CI = 1.39 to 1.82). Among 568 men with low-risk cancer, there was no clear association between baseline sexual function or strong preference to preserve function with receipt of active surveillance. However, strong preference may differnetially impact those with intermediate baseline function vs poor function (Pinteraction = .02).

Conclusions

Treatment choice may not always align with patients' preferences. These findings demonstrate opportunities to improve delivery of patient-centered care in early prostate cancer.

Factors influencing prostate cancer treatment decisions for African American and white men

BACKGROUND

Prostate cancer racial disparities in mortality outcomes are the largest in all of oncology, and less aggressive treatment received by African American (AA) patients versus white patients is likely a contributing factor. However, the reasons underlying the differences in treatment are unclear.

METHODS

This study examined a prospective, population-based cohort of 1170 men with newly diagnosed nonmetastatic prostate cancer enrolled from 2011 to 2013 before treatment throughout North Carolina. By phone survey, each participant was asked to rate the aggressiveness of his cancer, and his response was compared to the actual diagnosis based on a medical record review. Participants were also asked to rate the importance of 10 factors for their treatment decision-making process.

RESULTS

Among AA and white patients with low-risk cancer (according to National Comprehensive Cancer Network guidelines), 78% to 80% perceived their cancers to be "not very aggressive." However, among high-risk patients, 54% of AA patients considered their cancers to be "not very aggressive," whereas 24% of white patients did (P < .001). Although both AA and white patients indicated that a cure was a very important decision-making factor, AAs were significantly more likely to consider cost, treatment time, and recovery time as very important. In a multivariable analysis, perceived cancer aggressiveness and cure as the most important factor were significantly associated with receiving any aggressive treatment and were associated with surgery (vs radiation). After adjustments for these factors and sociodemographic factors, race was not significantly associated with the treatment received.

CONCLUSIONS

Racial differences in perceived cancer aggressiveness and factors important in treatment decision making provide novel insights into reasons for the known racial disparities in prostate cancer as well as potential targets for interventions to reduce these disparities.

Quality of life among men with low-risk prostate cancer during the first year following diagnosis: the PREPARE prospective cohort study

As many as 40% of men diagnosed with prostate cancer have low-risk disease, which results in the need to decide whether to undergo active treatment (AT) or active surveillance (AS). The treatment decision can have a significant effect on general and prostate-specific quality of life (QOL). The purpose of this study was to assess the QOL among men with low-risk prostate cancer during the first year following diagnosis. In a prospective cohort study, we conducted pretreatment telephone interviews (N = 1,139; 69.3% response rate) with low-risk PCa patients (PSA ≤ 10, Gleason ≤ 6) and a follow-up assessment 6-10 months postdiagnosis (N = 1057; 93%). We assessed general depression, anxiety, and physical functioning, prostate-specific anxiety, and prostate-specific QOL at both interviews. Clinical variables were obtained from the medical record. Men were 61.7 (SD = 7.2) years old, 82% white, 39% had undergone AT (surgery or radiation), and 61.0% had begun AS. Linear regression analyses revealed that at follow-up, the AS group reported significantly better sexual, bowel, urinary, and general physical function (compared to AT), and no difference in depression. However, the AS group did report greater general anxiety and prostate-specific anxiety at follow-up, compared to AT. Among men with low-risk PCa, adjusting for pretreatment functioning, the AS group reported better prostate-related QOL, but were worse off on general and prostate-specific anxiety compared to men on AT. These results suggest that, within the first year postdiagnosis, men who did not undergo AT may require additional support in order to remain comfortable with this decision and to continue with AS when it is clinically indicated.

Psychometric Evaluation of PROMIS Sexual Function and Satisfaction Measures in a Longitudinal Population-Based Cohort of Men With Localized Prostate Cancer

BACKGROUND

There are multiple treatment options for men with localized prostate cancer that provide similar curative efficacy but differ in their impact on sexual functioning.

AIM

To evaluate the psychometric properties of the Patient-Reported Outcomes Measurement Information System (PROMIS) Sexual Function and Satisfaction (SexFS) measures, including items from versions 1 and 2 of the short forms.

METHODS

A population-based cohort of men across North Carolina completed surveys via phone interviews at baseline (prior to treatment) and at 3, 12, and 24 months after cancer treatment initiation. Surveys included the PROMIS SexFS domains of interest in sexual activity, erectile function, orgasm, and satisfaction and the Prostate Cancer Symptom Indices. Analyses included descriptive statistics, assessment of structural validity using confirmatory factor analysis and item response theory, tests for differential item functioning, assessment of convergent validity using correlations, and evaluation of responsiveness of the PROMIS SexFS measures over time. We hypothesized that men undergoing surgery (prostatectomy) would report the poorest sexual function at the 3-month survey.

RESULTS

Sample size varied by assessment point and ranged from 332‒939 men, consisting of 30% non-white men, and 30% of the sample had a high school degree or less. The items within the PROMIS orgasm domain did not form a unidimensional scale. PROMIS measures of interest in sexual activity, erectile function, and satisfaction were unidimensional and highly correlated with related Prostate Cancer Symptom Indices measures (eg, erectile function, r = 0.84‒0.95). Erectile function in the surgery group declined more at 3 months compared to the no-surgery group (2 points); this difference narrowed at 12 and 24 months after surgery, as the surgery group recovered over time. Results were similar for PROMIS Interest in Sexual Activity and PROMIS Satisfaction scales.

CLINICAL IMPLICATIONS

The PROMIS SexFS measures may be used to identify effective interventions to treat sexual dysfunction and monitor sexual functioning in men with prostate cancer over time.

STRENGTH & LIMITATIONS

This study was limited to men living in North Carolina who could self-report their health-related quality of life in English. However, this study was able to include more men from vulnerable populations by allowing them to self-report over the phone.

CONCLUSION

This study provided strong support for use of the PROMIS SexFS (version 2) measures in men with localized prostate cancer to assess sexual interest, erectile function, and satisfaction over time. Reeve BB, Wang M, Weinfurt K, et al. Psychometric Evaluation of PROMIS Sexual Function and Satisfaction Measures in a Longitudinal Population-Based Cohort of Men With Localized Prostate Cancer. J Sex Med 2018;15:1792-1810.

Symptom and function profiles of men with localized prostate cancer

BACKGROUND

Men diagnosed with localized prostate cancer seek information on how treatment options may impact their health-related quality of life (HRQOL). The authors used latent profile analysis (LPA) to group men according to their symptom burden and functional status and to identify patient characteristics associated with each HRQOL profile.

METHODS

Patients completed the Patient-Reported Outcomes Measurement Information System and the Expanded Prostate Index Composite measures 3 months after treatment initiation. Anxiety, depression, fatigue, sleep disturbance, pain, diarrhea, urinary obstruction, urinary incontinence, erectile function, and sex satisfaction were modeled jointly using LPA, and the analysis was adjusted for covariates to examine associations between patient characteristics and profiles.

RESULTS

One-third of the 373 men were not non-Hispanic white (26% were black). Four LPA profiles were identified. Men who experienced the "best HRQOL" were less likely to receive treatment, to be older, and to smoke. Men in the second best profile experienced symptoms similar to men in the best HRQOL group but reported poor sexual and urinary function, because they were more likely to receive therapy. The third profile included men with increased symptom burden and poor functioning who were likely to undergo prostatectomy and to have increased comorbidity. The "worst HRQOL" group experienced the worst symptoms and the poorest functioning, and these men were more likely to be younger, to have more comorbidities, and to smoke.

CONCLUSIONS

LPA revealed that men who receive the same treatment can experience very different HRQOL impact. Understanding the factors most associated with poorer HRQOL allows clinicians to focus their care on individuals most in need of symptom management and support. Cancer 2018;124:2832-2840. © 2018 American Cancer Society.

eHealth Literacy and Partner Involvement in Treatment Decision Making for Men With Newly Diagnosed Localized Prostate Cancer

PURPOSE/OBJECTIVES

To examine how the eHealth literacy of partners of patients with newly diagnosed prostate cancer affects their involvement in decision making, and to identify the factors that influence their eHealth literacy.
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DESIGN

Cross-sectional exploratory study.
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SETTING

North Carolina.
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SAMPLE

142 partners of men with newly diagnosed localized prostate cancer. 
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METHODS

A telephone survey and descriptive and multiple linear regression analyses were used.
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MAIN RESEARCH VARIABLES

The partners' eHealth literacy, involvement in treatment decision making, and demographics, and the health statuses of the patients and their partners. 
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FINDINGS

Higher levels of eHealth literacy among partners were significantly associated with their involvement in getting a second opinion, their awareness of treatment options, and the size of the social network they relied on for additional information and support for treatment decision making for prostate cancer. The factor influencing eHealth literacy was the partners' access to the Internet for personal use, which explained some of the variance in eHealth literacy.
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CONCLUSIONS

This study described how partners' eHealth literacy influenced their involvement in treatment decision making for prostate cancer and highlighted the influencing factors (i.e., partners' access to the Internet for personal use).
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IMPLICATIONS FOR NURSING

When helping men with prostate cancer and their partners with treatment decision making, nurses need to assess eHealth literacy levels to determine whether nonelectronically based education materials are needed and to provide clear instructions on how to use eHealth resources.

Evaluating measurement invariance across assessment modes of phone interview and computer self-administered survey for the PROMIS measures in a population-based cohort of localized prostate cancer survivors

PURPOSE

To evaluate measurement invariance (phone interview vs computer self-administered survey) of 15 PROMIS measures responded by a population-based cohort of localized prostate cancer survivors.

METHODS

Participants were part of the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study. Out of the 952 men who took the phone interview at 24 months post-treatment, 401 of them also completed the same survey online using a home computer. Unidimensionality of the PROMIS measures was examined using single-factor confirmatory factor analysis (CFA) models. Measurement invariance testing was conducted using longitudinal CFA via a model comparison approach. For strongly or partially strongly invariant measures, changes in the latent factors and factor autocorrelations were also estimated and tested.

RESULTS

Six measures (sleep disturbance, sleep-related impairment, diarrhea, illness impact-negative, illness impact-positive, and global satisfaction with sex life) had locally dependent items, and therefore model modifications had to be made on these domains prior to measurement invariance testing. Overall, seven measures achieved strong invariance (all items had equal loadings and thresholds), and four measures achieved partial strong invariance (each measure had one item with unequal loadings and thresholds). Three measures (pain interference, interest in sexual activity, and global satisfaction with sex life) failed to establish configural invariance due to between-mode differences in factor patterns.

CONCLUSIONS

This study supports the use of phone-based live interviewers in lieu of PC-based assessment (when needed) for many of the PROMIS measures.

Association Between Choice of Radical Prostatectomy, External Beam Radiotherapy, Brachytherapy, or Active Surveillance and Patient-Reported Quality of Life Among Men With Localized Prostate Cancer

Importance

Patients diagnosed with localized prostate cancer have to decide among treatment strategies that may differ in their likelihood of adverse effects.

Objective

To compare quality of life (QOL) after radical prostatectomy, external beam radiotherapy, and brachytherapy vs active surveillance.

Design, Setting, and Participants

Population-based prospective cohort of 1141 men (57% participation among eligible men) with newly diagnosed prostate cancer were enrolled from January 2011 through June 2013 in collaboration with the North Carolina Central Cancer Registry. Median time from diagnosis to enrollment was 5 weeks, and all men were enrolled with written informed consent prior to treatment. Final follow-up date for current analysis was September 9, 2015.

Exposures

Treatment with radical prostatectomy, external beam radiotherapy, brachytherapy, or active surveillance.

Main Outcomes and Measures

Quality of life using the validated instrument Prostate Cancer Symptom Indices was assessed at baseline (pretreatment) and 3, 12, and 24 months after treatment. The instrument contains 4 domains-sexual dysfunction, urinary obstruction and irritation, urinary incontinence, and bowel problems-each scored from 0 (no dysfunction) to 100 (maximum dysfunction). Propensity-weighted mean domain scores were compared between each treatment group vs active surveillance at each time point.

Results

Of 1141 enrolled men, 314 pursued active surveillance (27.5%), 469 radical prostatectomy (41.1%), 249 external beam radiotherapy (21.8%), and 109 brachytherapy (9.6%). After propensity weighting, median age was 66 to 67 years across groups, and 77% to 80% of participants were white. Across groups, propensity-weighted mean baseline scores were 41.8 to 46.4 for sexual dysfunction, 20.8 to 22.8 for urinary obstruction and irritation, 9.7 to 10.5 for urinary incontinence, and 5.7 to 6.1 for bowel problems. Compared with active surveillance, mean sexual dysfunction scores worsened by 3 months for patients who received radical prostatectomy (36.2 [95% CI, 30.4-42.0]), external beam radiotherapy (13.9 [95% CI, 6.7-21.2]), and brachytherapy (17.1 [95% CI, 7.8-26.6]). Compared with active surveillance at 3 months, worsened urinary incontinence was associated with radical prostatectomy (33.6 [95% CI, 27.8-39.2]); acute worsening of urinary obstruction and irritation with external beam radiotherapy (11.7 [95% CI, 8.7-14.8]) and brachytherapy (20.5 [95% CI, 15.1-25.9]); and worsened bowel symptoms with external beam radiotherapy (4.9 [95% CI, 2.4-7.4]). By 24 months, mean scores between treatment groups vs active surveillance were not significantly different in most domains.

Conclusions and Relevance

In this cohort of men with localized prostate cancer, each treatment strategy was associated with distinct patterns of adverse effects over 2 years. These findings can be used to promote treatment decisions that incorporate individual preferences.

Reliability and validity of PROMIS measures administered by telephone interview in a longitudinal localized prostate cancer study

PURPOSE

To evaluate the reliability and validity of six PROMIS measures (anxiety, depression, fatigue, pain interference, physical function, and sleep disturbance) telephone-administered to a diverse, population-based cohort of localized prostate cancer patients.

METHODS

Newly diagnosed men were enrolled in the North Carolina Prostate Cancer Comparative Effectiveness and Survivorship Study. PROMIS measures were telephone-administered pre-treatment (baseline), and at 3-months and 12-months post-treatment initiation (N = 778). Reliability was evaluated using Cronbach's alpha. Dimensionality was examined with bifactor models and explained common variance (ECV). Ordinal logistic regression models were used to detect potential differential item functioning (DIF) for key demographic groups. Convergent and discriminant validity were assessed by correlations with the legacy instruments Memorial Anxiety Scale for Prostate Cancer and SF-12v2. Known-groups validity was examined by age, race/ethnicity, comorbidity, and treatment.

RESULTS

Each PROMIS measure had high Cronbach's alpha values (0.86-0.96) and was sufficiently unidimensional. Floor effects were observed for anxiety, depression, and pain interference measures; ceiling effects were observed for physical function. No DIF was detected. Convergent validity was established with moderate to strong correlations between PROMIS and legacy measures (0.41-0.77) of similar constructs. Discriminant validity was demonstrated with weak correlations between measures of dissimilar domains (-0.20--0.31). PROMIS measures detected differences across age, race/ethnicity, and comorbidity groups; no differences were found by treatment.

CONCLUSIONS

This study provides support for the reliability and construct validity of six PROMIS measures in prostate cancer, as well as the utility of telephone administration for assessing HRQoL in low literacy and hard-to-reach populations.

Involvement in Decision Making and Satisfaction With Treatment Among Partners of Patients With Newly Diagnosed Localized Prostate Cancer

PURPOSE/OBJECTIVES

To examine partner involvement in treatment decision making for localized prostate cancer, congruence between partner involvement and patient preference, reasons for partner noninvolvement, and partner satisfaction with patient treatment
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DESIGN

Cross-sectional exploratory study.

SETTING

100 counties in North Carolina.

SAMPLE

281 partners of men with newly diagnosed localized prostate cancer.

METHODS

Participants completed a phone survey. Logistic regression analyses were used.

MAIN RESEARCH VARIABLES

Partners' involvement in treatment decision making, partner satisfaction with treatment, activities of partner involvement, and reasons for noninvolvement.

FINDINGS

Of the 228 partners (81%) related to decision making, 205 (73%) were very satisfied with the treatment the patients received, and partner involvement was congruent with patient preference in 242 partners (86%). Partners reported several reasons for noninvolvement.

CONCLUSIONS

Most partners engaged in multiple activities during treatment decision making for localized prostate cancer and were satisfied with the patient's treatment. Partner involvement was mostly congruent with patient preference.

IMPLICATIONS FOR NURSING

Partners' active involvement in treatment decision making for localized prostate cancer (e.g., being involved in patients' conversations with doctors) should be encouraged and facilitated for those who prefer this type of decision making. 
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