Daily life and life quality 3 years following prostate cancer treatment

How life is perceived by men treated for prostate cancer years after surgery is little known from a Swedish perspective. There are extensive descriptions of medical-physical symptoms such as urinary, bowel and sexual dysfunction from quantitative inquiries [1]. Less is described from a qualitative perspective based on the men’s descriptions. From a nursing perspective, results from combined method studies describing both quantity and quality aspects on prostate cancer sequels are lacking, though they would be useful as they contain a wide area of information and constitute a solid ground for knowledge. Such knowledge is essential in relation to treatment and communication with patients over the years and not only shortly after surgery.

In Sweden the average annual increase of prostate cancer over the last 10 years is 0.2%. The introduction of PSA testing explains the large increase in the late 90s and early 2000s. The incidence has decreased during the last few years and there were 10 317 new cases reported in 2009 [2]. Because the illness is common, men with prostate cancer are often met in both in- and out-patient nursing care settings.

Men’s perception of the impact of the illness, and treatment side effects, is related to the individual man’s ability to handle life issues in general. The more life is perceived to have meaning, the better the chances are of handling a life-threatening event such as a cancer diagnosis. An often applied theoretical foundation for analysing cancer care experiences is the salutogenic concept developed by Antonovsky. Antonovsky proposed the salutogenic concept to explain why people stay healthy during extreme life-changing conditions. Antonovsky developed the Orientation to life questionnaire, referred to as the Sense of Coherence scale, SOC, to measure people’s ability to handle different life situations [3]. The SOC scale measures a person’s ability to perceive comprehensibility, manageability and meaningfulness in life and is considered to be a person-related characteristic that also influences the person’s ability to cope [4]. In an article from northern Sweden of men and women (n = 837 n = 882, respectively) with stomach trouble, identified illnesses (stroke, cardiac infarction, diabetes, anti-hypertension treatment) and a disease-free control group, a correlation was found between low SOC scores and poor perception of health, low social support and low emotional support [5]. Whether men treated for prostate cancer rate their sense of coherence high and weather there is a correlation to life quality is sparsely known.

When measured as a quantitative dimension, health-related quality of life is often used in prostate cancer care as an outcome of cancer illness per se, as assessment of treatment for various levels of malignancy and in connection with a variety of aspects [6, 7]. In prostate cancer care, generic instruments for assessment of health-related life quality are often applied, together with disease-specific questionnaires such as the EORTC Quality of life Questionnaire [8] and the QLQ PR25 [9], measuring prostate cancer-specific questions on urination, stomach and sexual impairment. Outcomes of such quantitative studies give a structured and rigorous picture of how life is perceived during and after treatment, and of treatment side effects at a group level. Measurement results are often compiled from a large number of participants [10]. We agree with Gacci et al. that result from this and other studies contribute to the clinicians’ ability to counsel long-term prostate cancer survivors. In a quantitative study by Johansson et al. (n = 481), men with prostate, men and women with gastrointestinal cancer and, women with breast cancer rated their quality of life comparable to a general sample. A small difference was seen in the investigation group compared to the ‘normal’ population control group at baseline and the difference levelled out in three months’ time [11]. However, Jakobsson et al., found lower levels of general life quality among men with prostate cancer (n = 155) compared to men in the general population [12]. Zenger also found lower ratings among men with prostate cancer compared to a general population sample (n = 265) [1]. If ratings fluctuate over time is however not presented in the studies. Fluctuation over time is found in the work of Taminiau-Bloem et al. who reported major changings in answering from baseline to follow up, in a sample of 50 cancer patients in aspects underlying OQL appraisal of e.g. taking a short walk, pain, fatigue, worry and overall quality of life [13]. Their finding calls for caution when giving attention to both quantitative and qualitative follow-up assessment. Quantitative studies complemented with a qualitative approach at an individual level, including side effects from treatment and general handling of illness sequels and health care actions, are lacking and this is a shortcoming for individual nursing and healthcare treatment. The aim of this study was to describe men’s experiences of life following prostate cancer from health-related quality of life and a salutogenic perspective and, to complement quantitative data with qualitative descriptions.

Thirty-six men were consecutively asked to participate in the longitudinal study. Twenty-one men accepted, forming a convenient sample [21]. The men whom declined participation stated age, no time or no interest as reasons. Men participating were between 53 and 85 years old, 18 were married and three were widowers or lived alone. Most men had a nine-year education level, i.e. elementary school level, and 11 men were still working. At time of the first data collection it was between 1 and 2 years since the treatment started. Gleason scores were between 3 to 9 and PSA levels between 0.5 to 13.2 at time of diagnosis. Eleven men had had a radical prostatectomy, 6 hormonal treatments, and 4 men had had external beam radiation. There was four drop outs from the study over the three years.

The result from this study is to be regarded within a mode of analytical generalization, and only occasional generalisations can be made outside the sample [21]. There are threats to internal validity with regard to sampling, because the men in the study are few and were probably the healthiest and most fit to participate in the study. They were also younger than the average man with prostate cancer. However, their ratings and stories are of equal value, as are those in a worse functional and emotional state, and contributes similarly to the building up of evidence-based knowledge regarding prostate cancer. To strengthen internal validity, two sources of evidence were used with a time interval between, self-rated quantitative data and qualitative interview data. The instruments used, HLQOL C-30, PR 25 and SOC-scales are well known and have proofed to be sound and reliable. There are only four drop outs in all over the three years.

Threats to reliability are mostly due to small sampling. The in-depths interviews were performed with a trained interviewer (LJ) and the use of the directed content analysis which added to previous research results did account for reliability and sensitivity in data collection. Larger samples with robust quantitative design have presented results in line with ours [22‐24].

The result section is presented in a way that claims an ability of complementing qualitative with quantitative findings which could be questioned. Quantitative questions are not put to patients in the way they are presented in the questionnaires and when qualitative findings are presented as complements this is done as a results of the researchers. Our study show that the result from the combination of methods revealed aspects from quantitative ratings that where not all mentioned in the interviews and aspects raised in interviews were also others than in the quantitative assessment, confirming and complementing results and also verifying the chosen design.

From a quantitative perspective, the most startling result is the relatively high rating of overall health/life quality and functioning that seemed to be mildly touched by the cancer disease and treatment after three years. In a Swedish study, (n = 481), of men and women with cancer (prostate, breast, colorectal and, gastric cancer), and with various treatments, the rating for quality of life was comparable to our study in the first year of assessment. Ratings in that study did not differ for a period of 24 months [11], whereas life quality ratings in our study significantly increased over the three years. This is in line with results from other studies of cancer survivors showing high quality of life in men living with prostate cancer two years after treatment [25]. Reasonably this phenomenon relates to having regained ‘normal’ lives and the survival of cancer.

The qualitative interviews complemented the quantitative perspective and also gave a picture of a good life with high life quality. The finding is important with regard to clinical practice and how questionnaire results are considered in practice. When quantitative and qualitative results are measured parallel this gives a detailed foundation for action. A combination between quantitative and qualitative measures also minimizes the risk of mistaking patients’ opinions and highlights what needs they themselves put in the foreground.

Sexual functioning decreased over the years, not followed by decreased sexual activity, which did not. This was interpreted to show that the men still experienced their sexual functioning at relatively high level at the start of their treatment even if they reported low sexual activity and that the sexual functioning worsened over the years with a sexual activity on the same level as before. In a Swedish study (n = 80) of Wahlgren et al. with men ≥ 6 months after radiation therapy scorings are in comparison though with a less spread in our sample. The comparison is complicated since their descriptive statistics are presented differently from ours [26]. Our findings, from the quantitative assessment, are in line with interview finding, i.e. sexual life functioning had decreased and was missed, but in contrast to having survived cancer and considering other sides of life to be good, impact from shortcomings in sexual life were overlooked.

In the interviews, there was very little mentioned of problems with fatigue, pain, nausea and vomiting even if such problems are well known in prostate cancer care. We expected symptom scales and single items to show high degree of functioning and few problems considering the years that had passed since treatment started. This expectation was confirmed. The different areas of functioning were in line with interview findings, i.e. was scored to show a high grade of functioning, and these findings are coherent with a national stratified sample of men and women without a cancer diagnosis (n = 3 919) [20], representing a ‘normal’ amount of dyspnoea and diarrhoea. Symptom of dyspnoea increased and, is surprising. It may well be that symptoms comes from co-morbidity not assessed in the study. Over all, the men’s quantitative ratings were confirmed in the qualitative interview findings.

Sense of Coherence scores were medium to high for the sample and consistent over the three year. There was also a statistical correlation between cognitive functioning and quality of life over the three years and between cognitive functioning and fatigue from year two to three. This is in line with ratings from earlier studies [12]. Our results confirm that high SOC is a determinant for a perception of good health and generally high quality of life in that e.g. all functioning rates and life quality were high in the sample. We also suggest that the high SOC is confirmed in the interview interpretation stating that the men said to be in good ‘health’ and to be handling their life with prostate cancer sequels. For the interview findings of high sense of coherence, they support earlier research results from, among others, Nilsson et al., who found a high SOC score related to high perceived health, social and emotional support [5].

To limit the influence of bias, Hsieh and Shannon suggest the use of a theory to guide the discussion of the findings. Therefore, we chose to apply the shifting perspectives model by Paterson [27], on qualitative findings. The model is building on the assumption that living with a chronic illness is an on-going process without end, in which people experience an ever-changing perspective of their illness, which makes it possible for them to make sense of their experiences. Perspectives of illness contain both illness and wellness and people put the former or latter in the foreground at different times of the illness period. Perspectives of illness also determine how people act and respond to their next of kin, caregivers, and different situations. It is the perspective of illness, not the illness it selves, that forms the way people behave, showing a behaviour that may be irrational in the eyes of others. The men, who had survived prostate cancer, may be said to live with a chronic illness, even though they are medically declared healthy, in that they explained how they lived with a constant risk of relapse. When analyzing the results in relation to the shifting perspectives model, the results make sense. It seemed to be natural for the men to state some presence of physical problems and at the same time state good health with high life quality. This is underpinned by Paterson, who argues that patients’ perspectives may be shifting over time and between different situations.

In the study, the men were putting illness in the foreground close to surgery, when still in hospital, and the first weeks at home. Their stories tell of physical and existential issues that they wanted to talk about to the staff. However, the staff was busy and had little time for patients’ problems. The importance of staff talking to patients is described by Telford et al., who suggested that staff should actively listen to patients’ stories, and that they should refrain from categorizing all patients with the same illness in the same way [28].

The men remembered the diagnosis event vividly. That is not surprising, considering they were presented with a life-threatening cancer diagnosis. Little is known about what reactions are determinants for the ability of coping with a cancer diagnosis and handling its consequences in men with prostate cancer. Halbert et al. found that even though men are making an active effort to suppress their thoughts about cancer, they are also trying to make sense of their diagnosis. The authors found that married men and men with a high educational level seemed to handle the message of cancer better than those living alone and with low educational level [29]. In our study, most men were married, however with limited educational background. Having a spouse was an important source of support, not only at the time of diagnosis but throughout the rest of their lives and, may have contributed to sense making. The men’s stories highlighted the importance for staff to create the diagnosis events into a friendly and humanitarian atmosphere. There should be no time limits for the event and the physician and nurse attending should be well atoned to the patients’ reactions and questions.

Breaking the news of cancer to adult children was a difficult task that made a deep impression on the men. The emphasis on this aspect is a new finding revealed in this study and not recognized in our previous work. When confronted with their children’s sadness, they felt an extra existential burden on themselves. This also gave grounds for thoughts of death and the end of life. When at home, the men were striving to come back to their former life and, relied on spouses and children for communication and physical help, if needed. To get help was complicated by the fact that they did not want to put extra burden on the children.

The men avoided telling their story to people who countered with stories of their own that were often terrible stories with lethal outcome. Talking to fellow patients seemed natural, and gave some comfort. After the first months with physical shortcomings and surgical aftermaths, they slowly found their way back to ‘normality’. Willener and Hantikainen found (n = 11) that men were satisfied with their lives already after three to four months after prostatectomy, even if they were impotent and some of them had to wear diapers at the time of interview [30]. This is in line with our earlier statement that a knowledge of a successful curative treatment gives hope of survival and do not mean the end of life.

The aim of this study was to describe men’s experiences of life following prostate cancer from health-related quality of life and a with a salutogenic perspective and, in an extended part of the study, complement quantitative data with qualitative descriptions. Our results show that the men’s life situation was interpreted to be good. Over the years, a shifting perspective to wellness was the dominant perspective, because the men said they had regained a good life, yet in a new way. The men’s sense of coherence seamed to support their handling of life three years after prostate cancer treatment. The interpretation is supported in the study by quantitative results showing a high degree of functioning. The men’s experiences give hope and confidence to men in the same situation and their next of kin and, to the staff caring for men with prostate cancer. Results also support the shifting perspectives model of chronic illness.