Rehabilitation potential in patients with prostate cancer: psychological aspect

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Introduction

Modern Russian clinical guidelines for the treatment of patients with cancer currently contain the section “Rehabilitation”, which separately describes its stages. This includes pre-rehabilitation as well as the rehabilitation of the 1st, 2nd and 3rd stages. Psychological, including social, rehabilitation of patients with malignant neoplasms is a system of measures implemented in stages and aimed at psychological and social adaptation, starting from establishing the diagnosis, treatment and ending with the period of recovery [1]. The detection of cancer in a patient, the course of treatment, and the period of remission are usually accompanied by severe psychological issues and feeling of distress, which are closely related and affect all spheres of life. At the same time, various psychosocial needs of patients and their personal experience require a selective approach to identifying people, who need psychological assistance according to the level of adaptive potential.

In rehabilitation practice, aimed at restoring the biopsychosocial status, such a prognostic characteristic as rehabilitation potential is used [2]. Rehabilitation potential is defined as a complex of biological and psychological characteristics of a person, as well as socio-environmental factors that allow to realize their potential abilities to some extent [3]. The central principle of cancer rehabilitation is to help the patients recover and improve their physical, psychosocial, and professional functioning within the constraints imposed by the disease and its treatment. Due to the rising survival rate of oncological patients, issues related to the quality of life are becoming increasingly important [4]. Many consequences of antitumor treatment and complications of an oncological disease can be alleviated through the implementation of rehabilitation measures. [5].

Methods and technologies of providing care for oncological patients continue to develop [6]. New hormonal and chemotherapeutic agents, new surgical methods, and targeted radiotherapy protocols have improved the survival rate and reduced the likelihood of an unfavorable course of the disease. Such patients may need to be admitted to an inpatient rehabilitation facility before, during, or after treatment. The results of various studies indicate that the participation of multidisciplinary specialists in the rehabilitation of oncological patients improves the functional results and quality of life of such patients [7]. Thus, D. Razavi, and N. Delvaux divide the stages of psychosocial care for patients and their families into five stages: prevention, early detection, recovery, support, and palliative care [8].

Medical rehabilitation in Russia is a complex of medical and psychological measures aimed at full or partial restoration of impaired organ or body system and/or compensation for lost functions of the affected ones. Among the physiological and medical indicators, the psychophysiological features of oncological patients can act as factors influencing the choice of а rehabilitation strategy, the timing of the beginning of the early rehabilitation period, its duration in general, and the predicted result of recovery.

World-wide studies reveal the data indicating the connection between the prognostic outcome of cancer, the effective response of the body to antitumor treatment, and the psychological characteristics of oncological patients [9], and examine the attitude to the disease, the interconnection of anxiety, coping strategies, and defense mechanisms [10–12]. These mechanisms may also underlie rehabilitation processes, affecting the time of recovery of oncological patients after treatment and rehabilitation, as well as the duration of the period of remission.

The use of various methods of psychosocial rehabilitation can significantly reduce the anxiety of oncological patients at the stage of rehabilitation, improve self-confidence, and return to the previous (approximate) level of social role functioning, which can also lead to a return to professional activity after treatment [13]. Thus, the participation of oncological patients in psychological group training designed to address the emotional realm and mastering communication skills, increases the indicators of cognitive performance, changes the attitude to the consequences of cancer [14].

The objective of the study was to determine a list of psychological characteristics associated with the prognosis of prostate cancer outcome and rehabilitation potential in patients with cancer.

Materials and methods

In order to study the psychological markers of rehabilitation potential, the subjective and personal characteristics of the study participants were evaluated according to the following psychological methods:

1. Basic Beliefs Scale (World Assumptions Scale, R. Janoff-Bulman, adapted by M.A. Padun, A.V. Kotelnikova [15]). This questionnaire is based on the cognitive concept of a person’s basic beliefs, including five subscales: “Benevolence of the surrounding world”, “Justice”, “Self-image”, “Luck”, “Beliefs of control”. The questionnaire includes 37 items. Examinees need to express their agreement with each statement on a six-point scale, ranging from “Totally disagree” (1 point) to “Totally agree” (6 points). The main purpose of the method is clinical and psychological diagnostics of people who have experienced mental trauma and are presumably in a state of depression. The values of Cronbach’s alpha coefficient of internal consistency for the subscales range from 0.62 to 0.79.
2. The method “Questionnaire of ways to cope” by R. Lazarus (adapted by T.L. Kryukova, E.V. Kuftyak, M.S. Zаmyshlyaeva) [16]. The method is intended for determining the coping mechanisms (coping strategies) as ways to overcome difficulties in various areas of mental activity. It includes 50 statements for which it is necessary to choose one of four options: “never”, “rarely”, “sometimes” or “often”. The structure of the questionnaire consists of eight scales, each of which is aimed at measuring the manifestation of coping behavior strategies: “Confrontational coping”, “Distancing”, “Self-control”, “Seeking social support”, “Taking responsibility”, “Avoidance”, “Planning to solve problems”, “Positive revaluation”. The values of Cronbach’s alpha coefficient of internal consistency for the subscales range from 0.78 to 0.89.
3. Methodology of Subjective Control Level (E.F. Bazhin, E.A. Golynkina, L.M. Etkind) [17]. The methodology evaluates the degree of a person’s readiness to take responsibility for what is happening to them in various spheres of their life. It consists of 44 questions, forming seven scales: the scale of general internality, the scale of internality in the field of achievements, the scale of internality in the field of failures, the scale of internality in the family relations, the scale of internality in the field of industrial relations, the scale of internality in the field of interpersonal relations, the scale of internality in relation to health and disease. The values of Cronbach’s alpha coefficient of internal consistency for the subscales range from 0.74 to 0.86.
4. Test of vitality (S. Maddi, adapted by D.A. Leontiev, E.I. Rasskazova) is aimed at studying the factors contributing to successful coping with stress and reducing internal tension [18]. The full version of the questionnaire includes 45 questions related to the assessment of indicators on the scales of “Commitment”, “Control”, and “Risk-taking”. Examinees need to express the measure of agreement with the statements. The values of Cronbach’s alpha coefficient of internal consistency for the subscales range from 0.72 to 0.86.
5. Questionnaire SF-36 “Assessment of the quality of life” is a non-specific questionnaire for assessing the quality of life of patients, which is widely used in conducting quality of life studies in Europe and in the USA, Italy, France, and Australia [19]. The eight scales of the methodology are grouped into two indicators: “Physical component of health” and “Psychological component of health”, a total of 36 items. The questionnaire contains the following sub-scales: “Physical functioning”, “Role-functioning due to physical state”, “Bodily pain”, “General health”, “Mental health”, “Role-functioning due to emotional state”, “Social functioning”, “Vitality”. The questionnaire is presented in several blocks, which use 5-point or dichotomous scales of response. The values of Cronbach’s alpha coefficient of internal consistency for the subscales range from 0.76 to 0.84. Translation into Russian and interpretation of the methodology was carried out by the Institute of Clinical and Pharmacological Research, St. Petersburg.

The study involved men (n = 148) with a histologically confirmed diagnosis of malignant neoplasm of prostate gland. The sociological and statistical characteristics are presented in Table 1.

 

Table 1. Clinical characteristics of study participants (n = 148)

Characteristics	Abs Features. (%)
Histological structure of the tumor:
G1	26 (17.39)
G2	109 (73.92)
G3	13 (8.77)
Assessment of cancer differentiation
Gleason Score 7 (3+4)	109 (73.92)
Glisson Score 8 (4+4)	39 (26.08)
Age:
under 60 years	19 (12.8)
61–70 years	66 (44.6)
71–80 years	57 (38.5)
over 81 years	6 (4.1)
The size of the tumor and its invasion into neighboring tissues and organs.
T1	19 (13.04)
T2	99 (67.39)
T3	17 (10.88)
T4	13 (8.69)
Stages of the disease:
early stages of the disease (stages 1–2)	95 (64.2)
bone lesion (stages 3–4)	53 (35.8)

 

The study participants received a part of the radical course / full course of treatment for prostate cancer in accordance with the amount of therapy regulated by current Russian clinical guidelines, and went to the next stage of the treatment program or to an outpatient monitoring to control the disease. In the study group, 33 patients (22.2 %) showed stabilization of the process, progression was recorded in 36 patients (24.3 %), PSA-relapse (without other clinical signs) – in 32 (36.95 %), generalization was detected in 11 patients (7.4 %), the second cancer in 11 patients (7.4 %), remission – in 20 patients (13.5 %). Overall survival for one year in group was recorded in 148 patients (100 %), two years – in 143 patients (96.6 %). The cause of death in 5 (3.3 %) patients was disease progression.

The oncological patients (n = 148) were invited to participate in the study. The psychologist explained the goals and methods of the study, and received informed consent from the patients to participate. The survey of the patients was conducted after consultation with an oncologist and after confirming the course of the disease (remission, stabilization, generalization, relapse, progression).

The study participants were divided into groups according to the prognosis of the outcome of prostate cancer:

1.Group 1. Favorable course of the disease (stabilization, remission).

2.Group 2. Unfavorable course of the disease (generalization, relapse, progression, second cancer). In this group, subgroup 2A was singled out separately, where the fatal outcome was determined within 3–4 months after studying the subject and personal characteristics.

Statistical analysis: the significance level was set at 0.05. All statistical analyses were conducted using the IBM SPSS Statistics software version 26. Descriptive statistics and discriminant analysis were used.

All stages of the study comply with the legislation and regulatory documents of research organizations, as well as approved by the Bioethics Committee of the FSBEI HE (Federal State Budgetary Educational Institution of Higher Education) “National and Research “Tomsk State University” (Tomsk, Russia) (No. 5 dated February 11, 2021). Patients were informed about the goals and objectives and signed a written informed consent to conduct the study.

Results and discussion

The study participants’ subjective and personal characteristics were studied: cognitive beliefs, coping strategies, quality of life indicators, subjective control, personal helplessness/independence, and vitality. Tables 2–5 present the results of descriptive statistics (M, SD) of psychological characteristics in men with prostate cancer, as well as the reference values of diagnostic methods.

 

Table 2. Basic beliefs in men with prostate cancer

Basic beliefs	Mean values (standard deviation)
	Group 1. Men with a favorable course of prostate cancer, n = 53	Group 2. Men with an unfavorable course of prostate cancer, n = 95	Group 2A. Men with fatal outcome of prostate cancer, n = 5	Normative reference values
Benevolence of the surrounding world, points	33.1 (6.4)	34.9 (5.6)	41.0 (4.3)	31.9 (5.1)
Justice, points	21.2 (4.3)	21.5 (4.2)	20.3 (0.5)	22.6 (3.6)
Self-image, points	26.2 (3.8)	26.5 (5.2)	24.0 (1.0)	25.2 (3.2)
Luck, points	29.2 (6.5)	30.8 (4.6)	29.3 (6.0)	27.3 (3.3)
Beliefs of control	25.1 (4.9)	26.7 (4.0)	28.0 (1.0)	25.9 (3.6)

 

Table 3. Coping strategies for men with prostate cancer

Coping strategies	Average values (standard deviation)
	Group 1. Men with a favorable course of prostate cancer, n = 53	Group 2. Men with an unfavorable course of prostate cancer, n = 95	Group 2A. Men with fatal outcome of prostate cancer, n = 5	Normative reference values
Confrontational coping, points	8.6 (3)	8.2 (3.1)	10.00 (2.6)	8.9 (2.7)
Distancing, points	8.7 (3.5)	9.5 (3.1)	10.6 (1.5)	8.6 (3)
Self-control, points	12.6 (4.1)	11.8 (3.9)	14.0 (2.6)	13.6 (3)
Seeking social support, points	9.6 (3.9)	11.3 (5.4)	12.3 (2.5)	10.6 (3.1)
Taking responsibility, points	7.7 (2.3)	7.4 (2.6)	9.7 (2.5)	7.3 (2.1)
Avoidance, points	10.4 (3.7)	10.4 (4.2)	10.0 (2.0)	10.5 (3.5)
Planning to solve problems, points	12.1 (3.5)	11.6 (3.6)	13.3 (1.5)	12.7 (2.8)
Positive revaluation, points	l 12.0 (4.9)	11.0 (4.1)	15.0 (1.7)	12.3 (3.4)

 

Table 4. Average values of quality of life indicators in men with prostate cancer

Quality of life indicators	Average values
	Group 1. Men with a favorable course of prostate cancer, n = 53	Group 2. Men with an unfavorable course of prostate cancer, n = 95	Group 2A. Men with fatal outcome of prostate cancer, n = 5	Normative reference values
Physical functioning (PF), points	65.6	65.2	63.3	77
Role-functioning due to physical state (RP), points	43.6	28.2	8.3	53.8
Bodily pain (BP), points	60.9	59.1	52.3	61.3
General Health (GH), points	49.2	47.4	36.6	56.5
Vitality (VT), points	60.1	51.2	33.3	55.1
Social functioning (SF), points	69.2	71.8	54.2	69.6
Role-functioning due to emotional state (RE), points	54.3	41.9	11.1	57.2
Mental Health (MH), points	65.9	60.7	38.7	58.8

 

Table 5. Indicators of subjective control in men with prostate cancer

Indicators of subjective control	Mean values/walls (standard deviation)
	Group 1. Men with a favorable course of prostate cancer, n = 53	Group 2. Men with an unfavorable course of prostate cancer, n = 95	Group 2A. Men with fatal outcome of prostate cancer, n = 5
General internality, points/STEN scores	14.1 / 4 (6)	13.8 / 4 (6)	20.0 / 4 (8)
Internality in the field of achievements, points / STEN scores	4.2 / 5 (6)	4.6 / 5 (5)	2.7 / 5 (4)
Internality in the field of failures, points/ STEN scores	2.4 / 4 (7)	2.5 / 4 (5)	5.7 / 5 (7)
Internality in the field of family relations, points/ STEN scores	0.3 / 3 (5)	0.5 / 3 (5)	3.0 / 3 (8)
Internality in the field of industrial relations, points/ STEN scores	6.6 / 6 (6)	6.2 / 6 (5)	7.0 / 6 (5)
Internality in the field of interpersonal relations, points/ STEN scores	1.2/ 5 (3)	0.8/ 5 (3)	1.0/ 5 (2)
Internality in relation to health and disease, points/ STEN scores	0.5/ 3 (3)	–0.2/ 3 (1)	–2.0/ 2 (2)

 

Table 6. Vitality indicators for men with prostate cancer

Indicators	Mean values (standard deviation)
	Group 1. Men with a favorable course of prostate cancer, n = 53	Group 2. Men with an unfavorable course of prostate cancer, n = 95	Group 2A. Men with fatal outcome of prostate cancer, n = 5	Normative reference values
Commitment, points	29.2 (11.5)	24.4 (12.2)	19.0 (16.8)	37.6 (8)
Control, points	23.9 (8.1)	24.5 (7.3)	27.0 (6)	29.1 (8.4)
Risk-taking, points	12.8 (6.9)	13.9 (7.9)	16.7 (5.1)	13.9 (4.3)
Outcome indicator of vitality, points	65.9 (20.7)	62.9 (18.9)	62.7 (18.6)	80.7 (18.5)

 

Average values of indicators of cognitive beliefs included in the worldview indicate that men with prostate cancer with an unfavorable prognosis of the outcome are characterized by beliefs in the benevolence of the surrounding world, its relative justice, belief in their own value and significance, their own luck and ability to control what is happening. Moreover, the participants of the study who subsequently died of prostate cancer were also confident in their luck, justice of the world, had a positive image of themselves, they firmly believed in the possibility of controlling what was happening and the benevolence of the surrounding world. The obtained data on the features of the worldview of men who subsequently recorded a fatal outcome are consistent with the previously obtained results on the selection of women with breast cancer [20].

The results of evaluation of coping strategies in study participants with different prognosis and outcome of prostate cancer indicate that the preferred coping strategies are “Self-control”, “Planning to solve problems” and “Positive revaluation”. Overcoming negative experiences of oncological patients was carried out by suppressing and restraining emotions (“Self-control”), analyzing the situation and options for solving the problem (“Planning for solving problems”), as well as by positively rethinking a difficult situation, considering it as a stimulus for personal development (“Positive revaluation”). However, the values of these coping strategies in respondents with a favorable and unfavorable prognoses of the outcome do not exceed the reference values of the questionnaire, whereas in respondents with a fatal outcome, they are significantly higher than the reference (p < 0.001).

In study participants with an unfavorable prognosis and fatal outcome of prostate cancer, the indicators of quality of life were reduced relative to normative reference values, with the exception of “Social functioning” (SF) and “Mental Health” (MH). Reduced quality of life indicators are probably associated with the severity of cancer symptoms, yet cancer patients find the resources to feel active and experience positive emotions, which may also be related to the characteristics of coping behavior found in the study participants.

The indicators of the scales “Role-functioning due to the physical state” (RP) and “Role-functioning due to emotional state” (RE), which reflect the contribution of physical and emotional problems to role functioning of a person, were significantly reduced in the study participants with an unfavorable prognosis and fatal outcome of prostate cancer. These indicators of quality of life related to physical and emotional state, being indicators of the rehabilitation potential of an oncological patient, can be a point of application of the efforts of doctors in the process of complex rehabilitation, in particular, an ergotherapist and a psychologist [21].

Critically lower are all indicators of quality of life in study participants with a fatal outcome of the disease, which is due to severe symptoms of prostate cancer at stage 4 and with an unfavorable course.

According to the normative reference values of the questionnaire, when the indicator value is less than 5.5, the respondent is diagnosed with an external locus of subjective control. The results reveal that all participants in the study with prostate cancer have an external locus of control: men tend to explain the reasons for what is happening in their lives by external circumstances, other people, fate, luck or failure, while excluding their own contribution. However, internality is being diagnosed in the field of industrial relations. Men with prostate cancer with different prognosis and outcome recognize their own efforts and actions as the causes of success and failure related to their professional self-realization.

The obtained data on vitality in men with prostate cancer with different prognosis and outcome indicate its low rates, which reveals the unwillingness of men with prostate cancer to overcome life difficulties, control significant events, and get involved in life processes (due to externality). Speaking about individual indicators of vitality, it can be found that “Commitment” as involvement in the events of one’s own life is higher in men with a favorable course of the disease than in men with an unfavorable prognosis and outcome. The “Risk-taking” indicator reflects a person’s belief that life events contribute to the development and acquisition of new valuable experiences. The study participants with fatal outcome of prostate cancer demonstrated a high level of risk-taking compared to other indicators of vitality, which could be related to the life situation of the respondents, that is, the fight against a life-threatening disease.

The discriminant analysis was conducted in order to determine the discriminant variables, as well as to carry out the assessment of the role (contribution) of psychological characteristics in predicting the outcome.

In the course of discriminant analysis using a step-by-step method, a discriminant function was obtained, including: “Benevolence of the surrounding world” (ƛ = 0.828); “Distancing” (ƛ = 0.805); “Role-functioning due to emotional state” (ƛ = 0.780); “Social functioning” (ƛ = 0.782); “Beliefs of control” (ƛ = 0.785); “Commitment” (ƛ = 0.776); “Seeking social support” (ƛ = 0.770). The resulting discriminant function has a good predictive ability, as it explains 100 % of the variance (ƛ = 0.754; p = 0.001), 74.4 % of the initial grouped observations were classified correctly.

Thus, based on the data obtained, it can be suggested that a favorable prognosis for patients with prostate cancer may be related to their engagement in life events, active involvement in them, emotional investment, comprehension of the significance of the problem, partial independence from others, a slight restriction of role-functioning due to emotional state, optimal social functioning (social involvement) in combination with beliefs in the benevolence of the surrounding world and their ability to control events.

Furthermore, by evaluating the coefficients of the canonical discriminant function, we can say that the greatest contribution to the nature of the course of prostate cancer based on the psychological characteristics studied in this research are belief in the benevolence of the surrounding world (0.696), distancing (0.564), and social involvement (0.465). The least significant factor is seeking social support.

Thus, in the course of the study, a system of psychological predictors (the list) was obtained related to a favorable or unfavorable prognosis of the outcome of prostate cancer: basic beliefs – benevolence of the surrounding world, beliefs of control; coping behavior strategies – distancing, seeking social support; quality of life indicators – role-functioning due to emotional state, social functioning; an indicator of vitality – commitment. These psychological characteristics can help to determine the rehabilitation potential, being associated with the possibilities of recovery after antitumor treatment.

Conclusion

The basis of modern technologies for the rehabilitation of oncological patients is a biopsychosocial approach. The treatment and rehabilitation of an oncological patient also includes psychological support, since most patients experience fear, anxiety, distress, very often depression and other psychological issues [22]. This study presents an analysis of the psychological characteristics of men with prostate cancer with a different course of the disease, as well as the correlation of psychological characteristics with the normative reference values. The study identified the list of psychological characteristics among those studied that are associated with a favorable course of cancer and rehabilitation potential: 1. Benevolence of the surrounding world; 2. Distancing; 3. Role-functioning due to emotional state; 4. Social functioning; 5. The beliefs of control; 6. Commitment; 7. Seeking social support, social activity.

The psychological variables obtained during the analysis can form the basis of psychological rehabilitation as a direction of rehabilitation in general. The psychological characteristics studied in this research related to the course of the disease may become psychotherapeutic targets for psychologists from an interdisciplinary team whose goal is to support oncological patients, improve their quality of life, and enhance the effectiveness of therapy for this patient group. The perspective of the study is to provide a psychological intervention that can help optimize the psychological characteristics of patients diagnosed with prostate cancer.

About the authors

I. V. Ponomareva

Tomsk State University; Chelyabinsk State University

Email: ivp-csu@yandex.ru
ORCID iD: 0000-0001-8600-3533

Candidate of Psychological Sciences, Associate Professor, Senior Researcher of the Laboratory of Psychophysiology, Faculty of Psychology

Russian Federation, Tomsk; Chelyabinsk

A. I. Kuznetsova

Tomsk State University; South Ural State Medical University

Email: ann_rad@mail.ru
ORCID iD: 0000-0002-2496-8273

Candidate of Medical Sciences, Senior Researcher of the Laboratory of Psychophysiology, Faculty of Psychology

Tomsk; Chelyabinsk

A. V. Vazhenin

South Ural State Medical University

Email: vav222@mail.ru
ORCID iD: 0000-0002-7912-9039
SPIN-code: 1350-9411

MD, PhD, Professor, Academician of the Russian Academy of Sciences, Head of the Department of Oncology, Radiodiagnosis and Radiotherapy

Russian Federation, Chelyabinsk

D. A. Tsiring

Tomsk State University

Email: l-di@yandex.ru
ORCID iD: 0000-0001-7065-0234

Doctor of Psychology, Professor, Chief Researcher of the Laboratory of Psychophysiology, Faculty of Psychology

Russian Federation, Tomsk

Ya. N. Pakhomova

Tomsk State University

Email: sizova159@yandex.ru
ORCID iD: 0000-0001-9000-7238

Candidate of Psychological Sciences, Senior Researcher of the Laboratory of Psychophysiology, Faculty of Psychology

Russian Federation, Tomsk

M. N. Mironchenko

Tomsk State University; South Ural State Medical University

Author for correspondence.
Email: thoraxhir@mail.ru
ORCID iD: 0000-0002-3674-754X

Candidate of Medical Sciences, Associate Professor of the Department of Oncology, Radiodiagnosis and Radiotherapy, Chief Researcher, Deputy Chief Medical and Scientific Officer

Russian Federation, Tomsk; Chelyabinsk

References

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