Vol.:(0123456789)
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Quali y o Li e Resea ch (2019) 28:677–686
h ps://doi.o g/10.1007/s11136-018-2069-z
Ea ly quali y-o -li e andpsychological p edic o s o disease- ee ime
andsu i al inlocalized p os a e cance
Ulla‑SiskoLeh o1,4,5 · Ma kkuOjanen2· AnnaVäke ä1,5· TadeuszDyba3,6· A poA omaa4·
Pi kkoKellokumpu‑Leh inen1,5
Accep ed: 22 No embe 2018 / Published online: 3 Decembe 2018
© The Au ho (s) 2018
Abs ac
Pu pose The cons uc s e alua ed in in es iga ing associa ion be ween psychosocial ac o s and cance su i al has a ied
be ween s udies, and ac o s ela ed o quali y o li e (QOL) ha e shown con adic o y esul s. We in es iga ed he e ec
o socioeconomic and ea ly QOL and psychological ac o s on disease- ee ime and su i al in localized p os a e cance .
Me hods A consecu i e sample o pa ien s wi h localized p os a e cance (T1–3, N0, M0) ea ed wi h ex e nal beam
adio he apy comple ed alida ed ques ionnai es on coping wi h cance ( he Ways o Coping Ques ionnai e WOC-CA),
ange exp ession ( he Ange Exp ession Scale), li e e en s ( he Li e Expe ience Su ey), and a ious aspec s o QOL ( he
Ro e dam Symp om Checklis , he Dep ession Scale DEPS, he EORTC QLQ-C30, he LENT-SOMA ou come measu e)
app oxima ely 4.5mon hs a e diagnosis. Cox eg ession analyses we e used o de e mine he p edic o s o he disease- ee
and o e all su i al imes measu ed om he da e o diagnosis o he da e o a PSA- elapse and da e o dea h.
Resul s A e con olling o biological p ognos ic ac o s, age, and adju an ho monal he apies, mode a e and high socio-
economic s a us and an inc eased le el o pain p edic ed longe su i al, whe eas an inc eased le el o p os a e-a ea symp-
oms and a igue and, especially, epo s o no/ ew physical symp oms we e p edic o s o a sho e su i al ime. A longe
PSA- elapse- ee ime was p edic ed by Cogni i e A oidance/Denial coping, whe eas p oblems in social unc ioning, hope-
lessness, and an excellen sel - epo ed QOL p edic ed a sho e PSA- elapse- ee ime.
Conclusions Highe socioeconomic s a us was p ognos ic o longe su i al, as p e iously epo ed. Pa ien s wi h a seem-
ingly good QOL ( ew physical complain s, excellen sel - epo ed QOL) had poo e p ognoses. This associa ion may due
o he su i al dec easing e ec o emo ional non-exp ession; pa ien s wi h high emo ional non-exp ession may o e - epo
hei wellbeing in simple measu es, and hus ac ually be in need o ex a a en ion and ca e.
Keywo ds Disease- ee ime· Emo ional non-exp ession· Pa ien - epo ed quali y o li e· P os a e cance · Socioeconomic
s a us· S ess, Psychological· Su i al
In oduc ion
The associa ion be ween psychosocial ac o s and cance
su i al has been con incingly demons a ed only du ing
ecen decades [1–12]. The psychological p ocesses and
cons uc s in es iga ed ha e a ied among s udies [4, 8].
Many o he ea lie s udies we e e ospec i e, biological
p ognos ic ac o s we e no su icien ly con olled o , and
only ce ain ac o (s) we e in es iga ed. In many o he p o-
spec i e s udies, he su i al ollow-up ime was e y sho
*Ulla-Sisko Leh o
ulla-sisk[email p o ec ed]
1 Medical School, Oncology, Uni e si y o Tampe e,
33014Tampe e, Finland
2 Depa men o Psychology, Uni e si y o Tampe e,
33014Tampe e, Finland
3 Finnish Cance Regis y, Pieni Roobe inka u 9,
00130Helsinki, Finland
4 Public Heal h E alua ion andP ojec ion, Na ional Ins i u e
o Heal h andWel a e THL, Manne heimin ie 166,
P.O. Box30, 00271Helsinki, Finland
5 Depa men o Oncology, Tampe e Uni e si y Hospi al, PL
2000, 33521Tampe e, Finland
6 P esen Add ess: Join Resea ch Cen e (JRC), Eu opean
Commission, Building 58A/006, Via En ico Fe mi 2749, TP
581, 21027Isp a, I aly
678 Quali y o Li e Resea ch (2019) 28:677–686
1 3
[4, 8–10, 13, 14]. In addi ion, socioeconomic ac o s we e
no o en aken in o accoun [4, 15, 16].
S udies sugges ha some psychosocial ac o s, such as
emo ional exp ession and psychological s ess, a e mo e
likely o ha e an e ec on su i al compa ed wi h o he
ac o s [4]. Speci ically, emo ional non-exp ession (“ ep es-
sion”) [6, 17–19], hopelessness [7, 20, 21], dep ession [1,
10, 11, 20], and s ess- ela ed psychological ac o s [8,
12, 20] ha e been sugges ed o p edic a sho e su i al,
whe eas social suppo [22] and denial o minimizing coping
esponse o he cance o p edic a mo e a o able p ognosis
[2, 5–8, 12, 21]. Fac o s ela ed o well-being and quali y o
li e (QOL) ha e shown con adic o y esul s [2, 5–7, 9, 23].
In some s udies, a good epo ed QOL has shown an associa-
ion wi h a poo e p ognosis [6, 7, 9].
Among he numbe o s udies in es iga ing he impac o
psychosocial ac o s on cance p og ession, e y ew ha e
deal wi h p os a e cance . Howe e , p os a e cance is he
mos common cance among men in de eloped coun ies,
including Finnish men (h p://www.cance egi s y. i). In
mos coun ies, he a e age age a p os a e cance diagnosis
is g ea e han 70yea s. The incidence is inc easing wo ld-
wide in pa due o he aging popula ions and he widesp ead
es ing o p os a e-speci ic an igen (PSA) [24–27]. Today,
mos p os a e cance s a e de ec ed when hey a e localized
o a mos locally in asi e, and he p ognosis is gene ally
good [24–28].
A majo limi a ion o many p e ious s udies was ha
he e ec o psychosocial ac o s has been in es iga ed
in isola ion om o he ela ed ac o s o p ocesses [4, 13,
29–31]; howe e , he e ec o hese ac o s does no occu
in isola ion. In es iga ing hei impac s sepa a ely esul s
in o e -simpli ica ion and misleading esul s. In pa icula ,
connec ions be ween coping and pe sonali y p ocesses a e
impo an [18, 32, 33]. The e o e, he e ec o psychologi-
cal and psychosocial ac o s and hei ela i e impac can
be iden i ied only when se e al ac o s a e in es iga ed and
analyzed join ly, adjus ing hei e ec s on each o he .
The psychobiological mechanisms ha a e hough o
ha e an impac on cance su i al a e ela ed o psycho-
logical s ess [4, 8, 34, 35]. Acco ding o psychological
s ess heo ies, he e ec s o s ess on heal h ou comes
depend on how a pe son can cope wi h he s ess, cop-
ing being he main media o in he p ocess om s ess ul
e en s o ou comes such as psychological symp oms and
soma ic illness [36, 37]. Social suppo and pe sonali y
ac o s modi y he coping p ocess [38]. In he p ocess-o i-
en ed iew [36, 37, 39], coping is de ined as “ he pe son’s
cons an ly changing cogni i e and beha io al e o s o
manage speci ic ex e nal and/o in e nal demands ha a e
app aised as axing o exceeding he pe son’s esou ces.”
The e a e no in buil assump ions on good o bad coping.
The ac ual coping p ocess e e s o he pe son’s e o s o
educe, minimize, mas e o ole a e he pe son–en i on-
men ansac ion ha has been app aised o be demanding.
Psychological s ess p ocesses ha e been linked wi h bio-
logical immune down- egula ion in cance [34].
Acco ding o a model p oposed o guide esea ch in
psycho-oncology [33], he impac o cance disease and
ea men e ec s a e media ed by pe sonal (including
pe sonali y and coping s yle, adjus men , and sociode-
mog aphic ac o s), medical, social-en i onmen al, and
li e s esso ac o s [3, 12, 29, 33]. The ou comes o hese
pa hways a e QOL and su i al. In pa icula , a pe sonal-
i y- ela ed coping esponse called non-exp ession o nega-
i e emo ion is po en ially associa ed wi h poo e cance
p og ession [4, 7, 17–19, 40]. Non-exp ession o nega-
i e emo ion e e s o a endency o supp ess (i.e., no o
exp ess) nega i e eelings [17, 32], such as ange and ea ,
and leads o less e ec i e coping in s ess ul si ua ions. I
has been desc ibed as being emo ionally con ained and
“main aining a acade o con en men ” in social ela ion-
ships. Rela ed concep s, such as emo ional de ensi eness
(an iemo ionali y, i.e., supp ession and con ol o emo-
ions) has also been ound o p edic educed su i al in
cance [6, 17]. Fu he mo e, he e is a sugges ed cance -
p one Type C esponse s yle [18, 19], which is a mul-
idimensional cons uc ha includes non-exp ession o
nega i e emo ions as a co e elemen , whe e helplessness/
hopelessness in s ess ul si ua ions, and sel -sac i icing,
o e -coope a i e, and appeasing beha io a e added. Type
C esponse s yle has been ound o be associa ed wi h
educed su i al in cance .
We p e iously p esen ed a concep ual model on he psy-
chosocial p edic o s o wellbeing o cance pa ien s [35]. In
he model, we assume ha bo h QOL and su i al a e ou -
comes in a s ess p ocess, which is media ed by psychologi-
cal s ess p ocesses and ini ia ed by cance and ea men .
Coping wi h cance is he main media o in he p ocess,
and social suppo and pe sonali y ac o s modi y he coping
p ocess. Fu he mo e, we assume ha hese p ocesses a e
in e e ed by non-cance li e s esses. We p e iously applied
he model o s udying baseline psychosocial p edic o s o
su i al ou comes in localized melanoma [7, 12] and b eas
cance [6] pa ien s unde 72yea s o age. We iden i ied some
gende di e ences, indica ing ha men may espond o di -
e en ypes o psychosocial ac o s compa ed wi h women
[12].
In he p esen s udy, on he basis o he model and expe i-
ences om ou p e ious s udies, we in es iga ed he base-
line and ea ly p edic o s o disease- ee and o e all su i al
imes in p os a e cance pa ien s o all ages and ea ed wi h
ex e nal beam adio he apy in Finland. We hypo hesized
ha speci ic ac o s in he psychological s ess p ocesses
(pa e ns o coping, ange exp ession ai s, non-cance li e
e en s), and componen s o pa ien - epo ed QOL e alua ed
679Quali y o Li e Resea ch (2019) 28:677–686
1 3
a he ime o p ima y ea men a e associa ed wi h disease-
ee ime and su i al in localized p os a e cance .
Me hods
Pa ien s andp ocedu e
Newly diagnosed T1–3, N0, M0 p os a e cance pa ien s
who we e admi ed o ea men o he Depa men o
Oncology, Tampe e Uni e si y Hospi al (Finland) in 2002
and we e ea ed wi h cu a i e ex e nal beam adio he apy
we e consecu i ely included as eligible pa ien s o he s udy
(n = 104). Pa ien s who we e men ally and physically able o
pa icipa e in a s udy in e iew and comple e ques ionnai es
(no ac i e se e e men al o neu ological disease) and wi h
no p e ious cance disease1 we e in i ed o pa icipa e; 6
pa ien s we e no in i ed because hey could no be in e -
iewed (3 demen ia, 2 consequences o s oke, and 1 acu e
s a e o ano he physical illness), and 3 pa ien s based on a
p e ious cance . Six pa ien s e used o pa icipa e. In he
end, 89 pa ien s (86%) we e in e iewed. An addi ional 3
pa ien s we e excluded om he su i al analyses because
hey had a T4 disease, and 5 pa ien s because hey had
unde wen adical p os a ec omy p io o he adio he apy.
Thus, he inal s udy g oup comp ised 81 pa ien s (Table1).
In Finland, hospi al dis ic s o ganize specialized medical
ca e. Some specialized medical ca e se ices, e.g., oncology,
a e o ganized on he basis o special esponsibili y a eas
o he i e uni e si y hospi als o Finland. Because o his
cen alized cance ca e, nea ly all pa ien s diagnosed in he
egion and ea ed wi h ex e nal beam adio he apy we e
included in he eligible pa ien s.
The pa ien s we e in e iewed a app oxima ely
4.5mon hs ( ange 2–9) a e diagnosis by he same in e -
iewe (a medical s uden , he hi d au ho ) du ing a isi o
he Depa men o Oncology o ex e nal beam adio he apy.
A pa ien was no in e iewed un il wo mon hs a e he
diagnosis o a oid dis u bing he pa ien s in an acu e can-
ce c isis and o achie e a mo e eliable measu emen , and
each pa ien was cu en ly ecei ing ex e nal adio he apy
(65% wi h LHRH analog as neo-adju an ho monal he -
apy). Each in e iew ook app oxima ely 1.5–2.5h. Du -
ing he in e iew he pa ien s comple ed se e al alida ed
ques ionnai es add essing a ious psychological ac o s and
aspec s o pa ien - epo ed well-being and QOL (see, Meas-
u es, below). The pa ien s we e also asked o epo hei
demog aphics, oca ional educa ion, and amily income.
Mos o he measu es we e he same as used in ou p e ious
Table 1 Demog aphic, socioeconomic, disease, and ea men a i-
ables in pa ien s
Va iable N = 81 (%)
Age, mean 66.5yea s (median 68, ange 51–82yea s)
50–59 10 (12)
60–69 48 (59)
70–79 22 (27)
> 80 1 (1)
Ma i al s a us
Single 1 (1)
Ma ied o cohabi ing 68 (84)
Di o ced 7 (9)
Widowed 5 (6)
Child en, mean 2.3
Ha e child en 75 (93)
Voca ional educa ion
None 33 (41)
Voca ional cou ses 7 (9)
Voca ional school 17 (21)
College 17 (21)
Uni e si y educa ion (any) 7 (9)
Yea ly amily income (EUR)
< 17,000 19 (23)
17,000–25,000 22 (27)
25,000–34,000 19 (23)
34,000–42,000 10 (12)
> 42,000 11 (13)
Socioeconomic s a us (SES)
Low 12 (15)
Mode a e 57 (70)
High 12 (15)
Gleason classi ica ion (x + x)
3–4 9 (11)
5 9 (11)
6 28 (35)
7 21 (26)
8 7 (9)
9–10 4 (5)
Uniden i ied 3 (4)
Tumo classi ica ion
T1 28 (35)
T2 29 (36)
T3 24 (30)
Biological iska
Low 28 (35)
Mode a e 31 (38)
High 22 (27)
Radia ion
To al dose Mean 69.9, ange
68.0–70.4
Radia ion o pel ic lymph nodes 8 (10)
1 A p e ious cance was an icipa ed o in luence he psychological
s ess p ocesses ha we e he ini ial esea ch a ge .
680 Quali y o Li e Resea ch (2019) 28:677–686
1 3
melanoma [7, 12] and b eas cance [6] su i al s udies, bu
wo heal h- ela ed QOL measu es ( he EORTC QLQ-C30
[41] and he LENT-SOMA ou come measu e [42]) we e
added in he p esen sample.
Measu es
Cance and ea men da a (s aging, Gleason classi ica ion,
neo-adju an ho monal he apy, and adju an ho monal he -
apy; Table1) and su i al ime and disease- ee ime da a
(da e o diagnosis, da e o dea h, da e o PSA- e i ica ion
o ecu ence o he cance ) we e ob ained om hospi al
medical eco ds.
Socioeconomic s a us was ope a ionalized as a combi-
na ion o oca ional educa ion and yea ly amily income
( o al income o he household). I was classi ied as ‘low᾽
i he pa ien had no occupa ional educa ion and he yea ly
income was < 17,000EUR, ‘mode a e᾽ i he income was
17,000–34,000EUR, and ‘high᾽ i he pa ien had a col-
lege o uni e si y educa ion and/o he yea ly income was
≥ 34,000EUR (Table1).
The measu ed psychological/psychosocial and QOL
domains a e lis ed below:
1. Coping wi h cance was measu ed using he Ways o
Coping Ques ionnai e (WOC), a 50-i em sel - epo
ques ionnai e (scale 0–3 in e e y i em) de eloped “ o
iden i y he hough s and ac ions an indi idual has
used o cope wi h a speci ic s ess ul encoun e ”—he e
any aspec o he p os a e cance since he diagnosis.
We used an i em s uc u e p oposed o o m a cance -
speci ic WOC-CA measu e [43, 44], including he pa -
e ns Focusing on he Posi i e, Dis ancing, Seeking and
Using Social Suppo , Cogni i e A oidance, and Escape
A oidance.
2. The ai s o ange exp ession we e e alua ed using he
Ange Exp ession Scale (AX Scale) [45]. I e e s o “ he
ex en ha an indi idual engages in agg essi e beha -
io s when mo i a ed by ang y eelings” and aps h ee
dimensions: Ange -in (“indi idual di e ences in he
equency ha ang y eelings a e expe ienced bu held
in”), Ange -ou (“... eelings o ange a e exp essed in
agg essi e beha io ”), and Ange con ol (“...an indi id-
ual a emp s o con ol he ou wa d exp ession o ang y
eelings”).
3. S ess ul li e e en s we e eco ded om he p eceding
yea using he Li e Expe ience Su ey (LES) [46], a lis
o 50 e en s add essing bo h he numbe o li e e en s
and hei pe cei ed impac .
4. To measu e pa ien s’ symp oms and hei in ensi y,
we used he Ro e dam Symp om Checklis (RSCL)
[47], which has been de eloped o measu e symp oms
epo ed by cance pa ien s. The RSCL includes 30
symp oms (8 psychological and 22 physical, scale 0–3
in e e y symp om) ha he pa ien s may ha e expe i-
enced du ing he pas week and a sepa a e single i em
index on o e all global quali y-o -li e wi h scale om 1
(ex emely poo ) o 7 (excellen ). The le el o dep essi e
symp oms was measu ed using he Dep ession Scale
DEPS [48], which has been de eloped o sc eening o
dep ession in p ima y heal h ca e se ings and e alua es
10 eelings and dep essi e symp oms (scale 0–3) wi h
a co e age-pe iod o he p e ious mon h. One o he
DEPS symp oms is hopelessness.
5. Heal h- ela ed QOL o he pa ien s was measu ed using
he Eu opean O ganiza ion o Resea ch and T ea -
men o Cance Quali y o Li e Ques ionnai e (EORTC
QLQ-C30)2 e sion 3.0, Finnish ansla ion [41]. The
measu e is di ided in o a global heal h s a us scale, i e
unc ional scales (Physical/Role/Emo ional/Cogni i e/
Social unc ioning) and se e al symp om scales/i ems,
e.g., a igue, nausea, and pain; all e alua ed om he
p e ious week. Local p os a e-a ea symp oms we e e al-
ua ed using a modi ica ion o he LENT-SOMA ou come
measu e (see Foo no e 2) [42], a clinical ool de eloped
o eco d and sco e no mal issue e ec s o adio he apy
(u ina y, bowel, and sexual symp oms and dys unc ion).
The s udy p o ocol was app o ed by he e hical commi -
ee o Tampe e Uni e si y Hospi al, and in o med consen
was ob ained om each pa icipan . The i s au ho is bound
by na ional (The Union o Finnish Psychologis s) and in e -
na ional (Ame ican Psychological Associa ion) e hical codes
o psychology.
The hospi al dis ic was e hnically homogeneous ega ding he age
g oups in ques ion
a Acco ding o nomog am o p os a e cance ecu ence [50]: clas-
si ied as ‘Low isk’ i Gleason ≤ 6 and PSA < 10, ‘Mode a e isk’
i Gleason = 7 o PSA 10–20, and ‘High isk’ i Gleason ≥ 7 o
PSA > 20
Table 1 (con inued)
Va iable N = 81 (%)
Neo-adju an ho monal he apy
None 28 (35)
LHRH analog 53 (65)
Adju an ho monal he apy
Yes 34 (42)
O he ch onic disease/condi ion
Yes 66 (81)
2 The EORTC QLQ-C30 and he LENT-SOMA ou come measu e
we e no used in ou p e ious su i al s udies.
681Quali y o Li e Resea ch (2019) 28:677–686
1 3
S a is ical analyses
Desc ip i e s a is ics, ANOVA, es , and Pea son’s co -
ela ion ( ), we e used o explo e he sample. Reg ession
analysis was used o in es iga e he associa ion be ween
backg ound ac o s, psychological/psychosocial ac o s, and
he QOL indica o s. The Cox p opo ional haza ds eg es-
sion model [49] was used o de e mine he simul aneous
and ela i e con ibu ion o he socioeconomic, psychologi-
cal, and QOL p edic o s on disease- ee and o e all su i al
imes, con olled o age, biological p ognos ic ac o s, and
ho monal ea men . The p edic o a iables we e sepa a ely
es ed o bo h ou comes. P edic o s o he su i al imes
in he Cox models we e conside ed signi ican i he co -
esponding p- alue was < 0.05.
O e all su i al was measu ed om he da e o diagnosis
(da e o PAD) o he da e o dea h and disease- ee ime om
he da e o diagnosis o he da e o a PSA- e i ied elapse,
o he su i al was censo ed a he da e o las ollow-up
(Ma ch 31, 2011). A biological isk classi ica ion in o mild,
mode a e, and se e e o T1–2 umo s [50] (Table1, oo -
no e a) and sepa a ely T3 umo s was used as a biological
p ognos ic ac o . Implemen a ion o neo-adju an ho monal
he apy and adju an ho monal he apy we e used as p og-
nos ic ea men ac o s.
In he Cox models, age, biological p ognos ic ac o s, and
ea men ( he ho monal he apies) we e always included
in he models. Second, we added he socioeconomic s a us
a iable(s) o he models o in es iga e hei impac , and
adjus o hei e ec when in es iga ing he e ec s o he
o he a iables. Thi d, he psychological and QOL indica-
o s (see Measu es; selec ed on he basis o he heo e ical
model [35]) we e added in o he models indi idually and in
a ious combina ions, and ollowing expe iences om ou
p e ious co esponding s udies. To a oid es ing o ela ed
a iables, we in es iga ed hei psychome ic p ope ies and
mu ual associa ions, and selec ed he a iables ha we e he
bes (high C onbach’s Alpha, symme ical dis ibu ion) and
we e leas co ela ed wi h each o he . In some a iables, we
di ided he answe op ions in o wo ca ego ies (no/yes). The
p opo ional haza d assump ion was es ed [51] o speci ic
a iables and globally. S a is ical analyses we e pe o med
using SPSS o Windows 18 and 20, and S a a 11 (S a a-
Co p. 2013. S a a S a is ical So wa e: Release 13. College
S a ion, TX: S a aCo p LP, USA).
Resul s
By Ap il 2011, eigh een (22%) o he 81 pa ien s had died,
and he ollow-up ime was ≥ 8yea s 4mon hs (median 8.54
yea s, 95% CI 31.01–31.25 days; no pa ien s we e los om
he o e all su i al ollow-up). In o ma ion on p og ession
o he p os a e cance , i.e., PSA ollow-up was a ailable o
77 pa ien s, and 18 (23%) o hem had been diagnosed wi h
PSA e i ica ion o p os a e cance elapse. Fi e pa ien s
wi h elapse had died.
Associa ion be ween hepsychological andQOL
a iables
Acco ding o ou heo e ical model [35] (see, In oduc ion),
we in es iga ed i s he associa ion be ween he po en ial
p edic o a iables (backg ound and disease/ ea men a i-
ables, ange exp ession, and coping) and he wellbeing/QOL
indica o s. All he QOL indica o s we e s ongly in e co e-
la ed (p- alues gene ally < 0.001). The e o e, we sepa a ely
in es iga ed p edic o s o he RSCL and he EORTC QLQ-
C30 subscales, and he DEPS. On he whole, he disease and
ea men a iables did no associa e wi h QOL, whe eas
he coping and ange exp ession a iables we e associa ed
wi h se e al wellbeing and QOL indica o s. Highe income
o he amily p edic ed mo e psychological symp oms and
p oblems in Role unc ioning, Emo ional unc ioning, and
Cogni i e unc ioning. Escape coping was associa ed wi h
a poo e and Dis ancing coping wi h a be e psychologi-
cal heal h and sel -pe cei ed QOL, as measu ed by all he
indica o s. The Ange -in ai was associa ed wi h poo e
wellbeing, whe eas Ange con ol was associa ed wi h be e
wellbeing when e alua ed by any o he measu es despi e
social unc ioning.
P edic o s o o e all su i al anddisease‑ ee ime
T3 umo (HR 5.51, 95% CI 0.88–34.45, p = 0.07) and neo-
adju an ho monal ea men (HR 0.26, 95% CI 0.05–1.31,
p = 0.1) we e only weakly associa ed wi h o e all su i al.
Disease- ee ime was no signi ican ly p edic ed by any o
he disease and ea men a iables.
Indi idual associa ions be ween hep edic o
a iables andsu i al ou comes
Lack o oca ional educa ion showed an indi idual asso-
cia ion wi h bo h sho e su i al and disease- ee imes,
and low amily income was associa ed wi h sho e su i al
(Table2). Some indica o s o a good QOL we e indi idu-
ally associa ed wi h poo e ou comes: low le el o epo ed
physical symp oms ( he lowes 18.5% s. he emaining)
was associa ed wi h bo h sho e su i al and disease- ee
imes, and he highes sco e in he single-i em quali y-o -li e
index (‛excellen ’, epo ed by 18.2%) was associa ed wi h a
sho e disease- ee ime. Fu he mo e, inc eased pain and
epo ed numbe o li e e en s we e indi idually associa ed
wi h longe su i al.

682 Quali y o Li e Resea ch (2019) 28:677–686
1 3
Simul aneous impac s o  hep edic o a iables
ono e all su i al
Pa ien s’ mode a e and high socioeconomic s a us p edic ed
longe o e all su i al when adjus ed o he biological and
ea men a iables, wi h mul i a ia e haza d a ios o 0.16
(95% CI 0.05–0.46, p = 0.001) and 0.11 (95% CI 0.02–0.6,
p = 0.015), espec i ely.
When he psychological and QOL a iables we e added
o he model, we ound ha a complex combina ion o a i-
ables p edic ed o e all su i al (Table3). Di e en QOL
measu es exhibi ed ei he a a o able o an un a o able
impac , i.e., an inc eased le el o pain (HR 0.05; 95% CI
0.01–0.32) p edic ed longe su i al, whe eas p os a e-a ea
symp oms (HR 1.18; 95% CI 1.03–1.36), inc eased a igue
(HR 7.08; 95% CI 1.77–28.32), and epo s o no o ew
physical symp oms (HR 9.90; 95% CI 1.48–66.30) we e sig-
ni ican p edic o s o sho e su i al ime. Howe e , when
he o e all quali y-o -li e index ( o al scale 1–7) was es ed
ins ead o he p os a e-a ea symp om scale, i p edic ed a
longe su i al (HR 0.51, 95% CI 0.27–0.95, p = 0.033);
when bo h scales we e included, he e ec o he o e all
QOL was weake (HR 0.56; 95% CI 0.27–1.15, p = 0.113).
Simul aneous impac s o  hep edic o a iables
onPSA‑ elapse‑ ee ime
The PSA- elapse- ee ime was no signi ican ly p edic ed
by any o he biological p ognos ic ac o s, ho monal ea -
men , o socioeconomic s a us. A longe disease- ee ime
was p edic ed by Cogni i e A oidance/Denial coping (HR
0.76; 95% CI 0.59–0.97), whe eas a sho e elapse- ee ime
was seen o pa ien s wi h p oblems in social unc ioning
(HR 3.32; 95% CI 1.45–7.56), hopelessness (HR 8.90; 95%
CI 1.62–48.87), and an excellen sel - epo ed QOL (HR
47.31; 95% CI 6.35–352.33) (Table4).
Table 2 Measu es wi h
s a is ically signi ican
indi idual associa ions wi h
o e all su i al ime and
disease- ee ime
HR haza d a ios in Cox models: impac o each p edic o analyzed indi idually and adjus ed o age, bio-
logical p ognos ic ac o s and adju an ho monal he apies
a Physical symp oms scale (RSCL) low = sco e < 7 (18.5%) e sus he emaining sco es. When he scale
was di ided in o wo le els based on he median, he highe le el was associa ed wi h a longe o e all su -
i al wi h HR 0.43, p = 0.1
b In he RSCL quali y-o -li e index (1–7) he highes sco e 7 ‘excellen ’ (18.2%) e sus he emaining sco es
c A scale in he EORTC QLQ-C30
d By he LES
Indi idual p edic o s Uni a ia e analyses
Associa ion wi h o e all su -
i al ime
Associa ion wi h PSA-
elapse- ee ime
HR (95% CI) pHR (95% CI) p
No oca ional educa ion 2.78 (1.02–7.59) 0.046 2.40 (0.89–6.46) 0.083
Family income low (< 17,000) 4.85 (1.69–13.90) 0.003 n.s
Le el o physical symp oms low, no/yesa5.99 (2.02–17.77) 0.001 3.21 (0.96–10.72) 0.058
Sel - epo ed QOL ‘excellen ’, no/yesbn.s 5.21 (1.81–14.95) 0.002
Painc0.20 (0.05–0.83) 0.026 n.s
No. o non-cance li e e en sd0.71 (0.51–1.00) 0.048 n.s
Table 3 Psychosocial and QOL measu es a he ime o cu a i e adi-
o he apy p edic ing o e all su i al
HR haza d a ios in he Cox model; all a iables we e adjus ed o
each o he
a Based on he RSCL Physical symp oms scale: he lowes 18.5% e -
sus he emaining sco es
b A scale in he EORTC QLQ-C30
c The LENT-SOMA scale. When he RSCL o e all quali y-o -li e
index (1–7) was es ed ins ead o he LENT-SOMA p os a e-a ea
symp oms, i s ela i e HR was 0.51 (95% CI 0.27–0.95, p = 0.033)
P edic o Mul i a ia e analysis
HR (95% CI) p
Age, yea s 0.98 (0. 89–1.07) 0.599
Biological isk
Mode a e isk in Tumo 1–2 0.15 (0.02–0.97) 0.047
High isk in Tumo 1–2 0.52 (0.06–4.64) 0.562
T3 Tumo 4.98 (0.63–39.29) 0.127
Neo-adju an ho monal he apy, no/yes 0.17 (0.02–1.21) 0.076
Adju an ho monal he apy, no/yes 1.54 (0.24–9.77) 0.649
Socioeconomic s a us
Mode a e 0.20 (0.04–0.91) 0.037
High 0.04 (0.01–0.34) 0.003
Le el o physical symp oms low, no/yesa9.90 (1.48–66.30) 0.018
Painb0.05 (0.01–0.32) 0.002
U ina y, bowel, and sexual symp oms c1.18 (1.03–1.36) 0.017
Fa igueb7.08 (1.77–28.32) 0.006
683Quali y o Li e Resea ch (2019) 28:677–686
1 3
The p opo ional haza d assump ion was success ully
es ed o he inal models locally and globally using Sch-
oen eld esiduals [51], indica ing ha hese impac s emain
s able o e he ollow-up pe iod.
Discussion
O e all su i al and disease- ee ime in pa ien s wi h local-
ized p os a e cance we e p edic ed by socioeconomic s a-
us, psychological ac o s, and pa ien - epo ed QOL. Di -
e en QOL measu es demons a ed con adic o y esul s as
ei he a a o able o an un a o able impac . Su p isingly,
we ound ha he pa ien s’ epo s o no o ew physical
complain s p edic ed sho e su i al, whe eas epo ed
pain was p ognos ic o longe su i al. In addi ion, a longe
PSA- elapse- ee ime was p edic ed by esponding o he
cance diagnosis wi h a Cogni i e A oidance/Denial coping
pa e n, whe eas p oblems in social unc ioning, hopeless-
ness, and—con adic o ily— epo ing an excellen QOL,
p edic ed a sho e PSA- elapse- ee ime. We sugges
an explana ion o hese su p ising indings, i.e., ha he
obse ed su i al dec easing e ec o high sco es in ce ain
simple QOL measu es may e lec a ai o non-exp ession
o nega i e emo ions (a endency no o exp ess nega i e
eelings and o keep ‘ acade o con en men ’), ha has been
ound po en ially associa e wi h cance p og ession. We p o-
pose ha he pa ien s who sco ed excep ionally low/high in
simple wellbeing/QOL measu es may ha e been hose wi h
high non-exp ession o nega i e emo ions and ha hey hus
o e - epo ed hei wellbeing.
Few ea lie s udies on psychosocial ac o s and cance
su i al ha e add essed p os a e cance [8, 52, 53] o male
pa ien samples ha also include he oldes age-g oups.
We we e able o collec a ela i ely small bu egionally
ep esen a i e sample o newly diagnosed p os a e cance
pa ien s. A he ime o he da a collec ion, he p os a e
cance he apy was di e en han oday (e.g., ac i e su -
eillance was ha dly used) and he ac i e ea men modes
ha e imp o ed e e since. The e we e no popula ion PSA-
sc eening p og ams going on in Finland. The s udy sample
was limi ed o pa ien s who unde wen cu a i e adio he apy,
and he o he majo de ini e he apy mode, adical p os a ec-
omy, was no ep esen ed. Howe e , younge and heal hie
pa ien s mo e o en unde go ope a ion, whe eas ex e nal
adia ion is ecei ed by a wide pa ien coho [54]. Fo p ac-
ical easons, he iming o he measu emen since diagnosis
a ied (2–9mon hs); he onse o he adio he apy di e ed,
and he pa ien s we e willing o ake pa o he in e iew a
di e en ime poin s du ing hei adio he apy.
We in es iga ed bo h o e all su i al and disease- ee
imes because hey a e e y di e en ou comes in cance
ypes wi h good p ognoses, such as p os a e cance , and may
hus be p edic ed by di e en mechanisms; we ound ha
hey we e indeed p edic ed by di e en ac o s. The po en ial
p edic o s we e simul aneously in es iga ed o accoun o
hei ela i e impac , and we e ei he de i ed om a heo e i-
cal model [35] o we e p e iously demons a ed o exhibi
an associa ion wi h cance su i al [4, 20, 33]. Mos o he
p edic o a iables we e subscales o es ablished alida ed
ques ionnai es. The adio he apy was cu en ly going on in
all pa ien s. The analyses we e ca e ully adjus ed o age,
known biological p ognos ic ac o s, and ea men .3
We ound ha a highe socioeconomic s a us p edic ed a
longe su i al bo h independen ly and when e alua ed wi h
he psychological and QOL ac o s. The su i al p olonging
e ec o socioeconomic s a us in cance is well known [15,
16, 55], and has been p e iously epo ed in p os a e cance
pa ien s ecei ing cu a i e ea men [53]. Howe e , p e i-
ous s udies o en conside ed i s e ec alone wi hou o he
po en ial p edic o s [52, 53, 56]. We concu wi h p e ious
s udies sugges ing ha socioeconomic s a us should be aken
in o accoun o ob ain alid in o ma ion on he impac o
QOL on su i al in p os a e cance [57].
The measu es associa ed wi h poo e ou comes appea ed
o be he simple indica o s o sel - epo ed wellbeing, i.e.,
low sco es in pe cei ed physical symp oms and an excel-
len sco e in an o e all QOL index. We did no ind nega-
i e associa ion be ween es ablished QOL measu es and
Table 4 Psychosocial and QOL measu es a he ime o cu a i e adi-
o he apy p edic ing PSA- elapse- ee ime
HR haza d a ios in he Cox model; all a iables we e adjus ed o
age, biological isk, ho monal he apies, and SES (which we e all s a-
is ically non-signi ican ), and we e adjus ed o each o he
a Cogni i e a oidance coping was s a is ically signi ican only when
all he o he a iables we e included in he model
b Based on he RSCL quali y-o -li e index (1–7): he sco e ‘excellen ’
(= 7) e sus he emaining sco es
c The EORTC QLQ-C30. When Ange -in pe sonali y ai was es ed
ins ead o he social unc ioning, i showed HR o 1.15 (95% CI 0.98–
1.37, p = 0.1)
Mul i a ia e analysis
HR (95% CI) p
Cogni i e a oidance/denial copinga0.76 (0.59–0.97) 0.031
Sel - epo ed QOL ‘excellen ’, no/
yesb
47.31 (6.35–352.33) < 0.001
Hopelessness, no/yes 8.90 (1.62–48.87) 0.012
P oblems in social unc ioningc3.32 (1.45–7.56) 0.004
3 As expec ed, ha ing a locally in asi e umo (T3) p edic ed a
sho e su i al when compa ed wi h ully localized disease, and neo-
adju an ho monal he apy was e ec i e.
684 Quali y o Li e Resea ch (2019) 28:677–686
1 3
he su i al ou comes, o i he e was an associa ion, i was
posi i e. We sugges ha hese esul s may e lec he ha m-
ul e ec o non-exp ession o nega i e emo ions, which
has been de ined o e e a endency no o exp ess nega i e
eelings and o keep ‘ acade o con en men ’[17]. Acco d-
ing o his heo y, indi iduals wi h high non-exp ession o
nega i e emo ions po en ially unde - epo hei symp oms
as hey a e p one o a ep essi e coping s yle, i.e., end o
a oid a nega i e a ec , and consequen ly answe wellbeing
measu es o e ly posi i ely [17, 32]. This idea was suppo ed
by he inding ha he Ange con ol pe sonali y ai was
associa ed wi h less epo ed symp oms and a be e QOL.
One suppo ing ac o o ou a gumen is ha sco ing
low in symp om measu es and e y high in o e all QOL
a he ime o ecen cance diagnosis and ongoing adia-
ion ea men may no e lec he ue objec i e si ua ion.
Ins ead, hese sco es may e lec a pe sonali y ai o coping
beha io a a s ess ul si ua ion ( ecen cance diagnosis,
ongoing adio he apy). Fu he mo e, when e.g., he quali y-
o -li e index was es ed as a o al scale ( e y poo –excellen )
i p edic ed a longe su i al. So, ou esul s did no indica e
ha epo ing a good QOL was haza dous, bu ha epo -
ing an ‘excellen ’ QOL was. Indi iduals wi h a ep essi e
coping s yle ha e also p e iously been ound o sco e low
in sel - epo ed physical symp om scales [58]. Up o 20% o
he popula ion has been ound o answe sel - epo scales in
an o e ly posi i e ashion [32], which co esponds wi h ou
inding ha he haza dous e ec on su i al was iden i ied
when he sco es we e di ided in o wo ca ego ies: no/ e y
ew symp oms o an ‛excellen ’ QOL e sus o he (bo h we e
p esen in app oxima ely 18% o he pa ien s).
The esul s ob ained on simple wellbeing/QOL indica-
o s suppo he conclusions we ha e made in ou p e ious
s udies [6, 7], i.e., ha simple global- a ing me hods a e
no sui able o elici ing in o ma ion on QOL o all cance
pa ien s. Ce ain subg oups (“ ep esso s”) seem o unde -
s a e hei condi ion and o e - epo hei wellbeing. The e is
a isk ha he simple global- a ing measu es ac ually p o ide
mo e in o ma ion on non-exp ession o nega i e emo ions
beha io han QOL. I has been sugges ed [32] ha o elici
in o ma ion om ep esso s measu es equi ing speci ic
answe s should be used ins ead o single-i em indexes o
symp om lis s.
P os a e-a ea symp oms (u ina y, sexual, bowel) and
a igue—as e alua ed wi h well-es ablished alida ed meas-
u es comp ising speci ic ques ions—we e p ognos ic o
sho e su i al, as expec ed. These a e common ad e se
e ec s in ex e nal adia ion and a e likely o be well eco ded
a he oncology clinic, and pa ien s may be less likely o
unde - epo hem. This measu emen was, howe e , no
cong uen because he iming o he in e iew du ing he
adio he apy a ied, which po en ially a ec s he le el o
side e ec s. Howe e , he su i al model also held when
he o e all QOL index ( o al sco e 1–7) was es ed ins ead o
he p os a e-a ea symp oms. These ac o s bo h indica ed he
wellbeing/ill-being o he pa ien du ing he p ima y ea -
men . Sel -e alua ion o he wellbeing s a us is con inuously
p esen ed o be a eliable indica o o an indi idual’s cu en
and u u e heal h.
The ob ained esul s on p oblems in social unc ioning
and hopelessness, and a sho e elapse- ee ime may also
ela e o concep s close o non-exp ession o nega i e emo-
ions, such as an iemo ionali y (“emo ional de ensi eness”)
[17] and Type C esponse s yle [18, 19]. An iemo ionali y
(supp ession and con ol o emo ions) is mani es ed in sel -
sac i icing beha io , which may e en ually lead o p oblems
in social unc ioning. Helplessness/hopelessness in s ess ul
si ua ions is a componen o he Type C s yle. We p e iously
ound ha an iemo ionali y p edic ed sho e su i al in
b eas cance [6] and hopelessness in melanoma [7]. Hope a
cance diagnosis is essen ial [59] and i may p edic su i al
[1, 11]. Hopelessness has been ound o a ec cance mo al-
i y a he popula ion le el [60], especially in olde popula-
ions [61], o which mos p os a e cance pa ien s belong.
Mo eo e , he obse ed a o able e ec s o pain and num-
be o s ess ul li e e en s may be ela ed o non-exis ence
o non-exp ession o nega i e emo ions: hose wi hou may
ha e epo ed mo e symp oms and e en s.
In acco dance wi h ou p e ious s udies [6, 7, 12], we
iden i ied only one p o ec i e psychological ac o : he Cog-
ni i e A oidance/Denial coping pa e n, and i p edic ed
only he disease- ee ime. As no ed abo e, o e all su i al
and PSA- elapse- ee ime a e e y di e en ou comes in
p os a e cance ; he o me is less a ec ed by he cance
because o he good p ognosis, whe eas he la e is cance -
speci ic. This esul is in line wi h cumula ing esea ch sug-
ges ing ha a a o able p ognosis in cance is p edic ed by
esponding o he cance diagnosis by a coping pa e n o
denying [21] o , nowadays mo e o en called, ‘minimizing’
he ac o ha ing cance [1, 2, 4–7, 17, 20, 29]. This concep
e e s, acco ding o de ini ion o coping, he pa ien s’ e o s
o manage demands caused by he cance by minimizing
impac o he disease, no he consequen nega i e a ec .
Howe e , denying/minimizing may a a la e poin o ime
ha e a di e en e ec [59].
Ou esul s p o ide an explana ion o why good sel -
epo ed QOL in some p e ious s udies appea ed o ha e
had an un a o able impac on cance su i al ou comes.
Pa ien epo s o a good wellbeing in simple measu es may
e lec non-exp ession o nega i e emo ions. Thus, e y high
epo s o wellbeing in newly diagnosed cance pa ien s may
indica e a psychological isk ac o o educed su i al ou -
comes. I may be good o he pa ien s o ha e complain s
a he ime o p ima y ea men . This inding may ha e
clinical ele ance gi en ha pa ien s who epo no o ew
p oblems (no symp oms, excellen QOL) may ac ually be
685Quali y o Li e Resea ch (2019) 28:677–686
1 3
ulne able and in need o ex a a en ion and ca e. How-
e e , mo e esea ch is needed, e.g., o in es iga e he issue
in pa ien s wi h di e en cance ypes/di e en diseases, in
bo h gende s, in di e en phases o ca e and ehabili a ion,
and in p ospec i e designs.
Clinicians a e o in e p e sco es o alida ed ques ion-
nai es on wellbeing and QOL as usual. A clinician who
in e p e s he sco es should know he pa ien ’s si ua ion, e.g.,
phase o ea men and ime since diagnosis. Conclusions
o he pa ien s’ wellbeing should no be based on a single
measu emen . Valida ed ques ionnai es a e good ools o
sc eening o s a e o QOL, which may equi e u he clini-
cal examina ion. Ou c i icism is a ge ed o simple QOL
indica o s which a e easily in luenced by o he ac o s, e.g.,
non-exp ession o nega i e emo ions.
Acknowledgemen s Open access unding p o ided by Na ional Ins i-
u e o Heal h and Wel a e (THL). This wo k was suppo ed by he
Medical Resea ch Fund o Tampe e Uni e si y Hospi al, he Compe i-
i e S a e Resea ch Financing o he Expe Responsibili y a ea o Tam-
pe e Uni e si y Hospi al, 9U020; he Finnish Cance Founda ion; and
he Signe and Ane Gyllenbe g Founda ion. We hank P o esso Teu o
Tammela, he head o Depa men o U ology o Tampe e Uni e si y
Hospi al, o his help in p epa ing he da a o he su i al analyses.
Funding This s udy was unded by he Medical Resea ch Fund o
Tampe e Uni e si y Hospi al, he Compe i i e S a e Resea ch Financ-
ing o he Expe Responsibili y a ea o Tampe e Uni e si y Hospi al,
he Finnish Cance Founda ion, and he Signe and Ane Gyllenbe g
Founda ion.
Compliance wi h e hical s anda ds
Con lic o in e es The au ho s decla e ha hey ha e no con lic o
in e es .
E hical app o al All p ocedu es pe o med in s udies in ol ing human
pa icipan s we e in acco dance wi h he e hical s anda ds o he ins i-
u ional and/o na ional esea ch commi ee and wi h he 1964 Helsinki
decla a ion and i s la e amendmen s o compa able e hical s anda ds.
In o med consen In o med consen was ob ained om all indi idual
pa icipan s included in he s udy.
Open Access This a icle is dis ibu ed unde he e ms o he C ea-
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