Authors Smith AB, Butow P, Olver I et al.
Review Date October 2015
Citation J Cancer Surviv 2015: DOI 10.1007/s11764-015-0468-5 (Epub ahead of print)
Testicular cancer (TC) is not very common, being diagnosed in about 700 Australian men each year; however, in men aged 18-39 years it is the second most common form of cancer. As TC has a very good cure rate (over 95%), there are increasing numbers of TC survivors living with the effects of the cancer and its treatment and the possibility of recurrence. Given the young age of diagnosis of TC, men live with the sequelae for many years. In this context, it’s important to understand the long-term impacts of TC and the possible predictors of poorer outcomes to help men live with the physical and psychological effects.
This Australian study aimed to establish the prevalence, severity, and correlates of psychological distress and poor health-related quality of life (HRQOL) in TC survivors.
Men who had completed active treatment for TC between 6 months and 5 years previously, showed no evidence of active current disease, and were 18 years of age or older were recruited from 14 Australian cancer centres from September 2009 to February 2011. Men were invited to participate by their treating clinicians during consultations or via invitation letters.
Participants completed either a postal or an online self-report questionnaire including measures of demographic characteristics, disease factors, and treatment, psychological distress (i.e., depression, anxiety, and stress; DASS21), generic health-related quality of life (HRQOL; SF-36v2), TC-specific HRQOL (EORTC QLQ-TC26), coping (MAC), social support (DUFSS), and unmet needs (CaSUN).
Responses to the validated scales were scored using standard algorithms. DASS21 subscale scores and SF-36v2 domain and component summary scores (physical – PCS and mental – MCS) were converted to norm-based scores to allow comparison with population norms. Regression analysis was used to assess correlates of the outcome variables: the DASS21 subscales and SF-36v2 PCS and MCS scores.
Of 486 eligible TC survivors, 347 were contactable and 244 (70% of contactable and 50% overall response) completed the questionnaire. The majority of participants (67%) were aged between 26 and 35 years and 53% had treatment within the past 2 years. Most (77%) had some form of adjuvant treatment following orchidectomy.
Compared with normative population data, a moderately higher proportion of TC survivors reported moderate or more severe anxiety (19% vs 13%; p=0.007), depression (20% vs 13%; p=0.001) and stress (17% vs 13%; p<0.001) but the general population data were not age-adjusted so caution is needed when making these comparisons. Mean anxiety and depression scores were also statistically significantly higher in TC survivors compared to age-standardised data for the general population but the effect sizes were small.
TC survivors had significantly lower scores on several aspects of generic HRQOL, with the greater differences shown for the mental compared to the physical domains. The most problematic TC-specific HRQOL issues were concern about fertility (31%), fear of recurrence (30%) and uncertainty about the future generally (29%).
In multiple regression analyses, the strongest correlates of psychological distress and impaired generic HRQOL were psychosocial (e.g., helpless/hopeless coping and lower social support) rather than disease or treatment factors. Higher levels of treatment side effects were associated with higher anxiety (p<0.001) and stress (p=0.002) and less frequent sexual activity was related to greater stress (p=0.002).
Generally, TC survivors appear to experience mild psychological distress and HRQOL impairments, while a vulnerable subgroup experience more severe morbidity. The fact that a helpless/hopeless coping style was the only variable related to all 3 psychological distress measures and poorer overall mental HRQOL indicates there may be a need for extra support for men using this type of coping strategy. On the other hand, social support was related to psychological well-being. There is a need to identify TC survivors at risk of poorer outcomes and for interventions to target the areas of greatest impairment (i.e., psychological distress and mental HRQOL).
Points to Note
- This study of 244 Australian men who have had treatment for testicular cancer showed that many men are faring well psychologically and physically but there is a small proportion with high levels of distress.
- Associations of distress with a helpless/hopeless coping style and lower levels of social support suggest some possible intervention to help men manage TC sequelae.
- Interventions such as cognitive behavioural therapy may help to reduce helplessness/hopelessness and participation in cancer support groups could help with improving social support. Online support could be an option for men not interested in support groups.
- The study was limited by: a low response rate; the lack of a control group such that comparisons were with population norms that may not have been directly comparable to this group of participants; cross-sectional data precluded determining the direction of reported associations; and data were self-reported.
- More research is needed on interventions to help men with TC manage psychological and HRQOL impacts.