Among men who have received similar treatments for prostate cancer, those with less education ---- particularly those who did not graduate from high school ---- experience a significant drop in their quality of life after treatment compared with men who have more education, according to a study led by researchers at the San Francisco VA Medical Center (SFVAMC).
"These men did not start out with a lower quality of life before cancer," says lead author Sara J. Knight, PhD, a staff psychologist at SFVAMC. "What's surprising is that after treatment, they have clinically significant problems across the board ---- mental and emotional as well as physical ---- in managing their lives."
The authors acknowledge that low educational level is often associated with lower income, which can lead to lower quality of life, but stress that for the men in their study, low education alone was associated with lower quality of life, irrespective of income. "In our analysis, it's their lower educational level that has made them more vulnerable to the effects of prostate cancer and its treatment," says Knight, who is also an assistant professor of psychiatry and urology at the University of California, San Francisco (UCSF).
The researchers analyzed the results of a self-reported quality-of-life survey completed by 248 patients who were diagnosed with prostate cancer between 1989 and 2002 and treated at three Veterans Affairs medical centers. Treatments included surgery, radiation therapy, hormone therapy, and observation or "watchful waiting."
After adjusting for a host of factors including severity and stage of cancer, treatment, age, education, income, marital status, and other diseases, the researchers found that men without high school diplomas "experienced greater decline and less recovery" during the first year after prostate cancer treatment across a wide variety of domains, including physical, emotional, and social functioning, vitality, mental health, general health, urinary function, and sexual function.
"More generally, the lower your educational level, the greater the likelihood that you would have a lower quality of life after diagnosis and treatment," says Knight. She points out a key aspect of the study: The subjects, as VA patients, all had equal access to the same quality of health care. "Since health care access is a key factor in predicting health outcomes, it's significant that we were able to control for this variable," she says.
The good news, she says, is that clinicians across the country can immediately begin to identify and help prostate cancer patients who are at greater risk for poor quality of life. "We can identify these men by their educational levels, ask them what difficulties they're having in managing their day-to-day lives, and try to provide them with the appropriate resources." She notes that VA medical centers offer a broad range of counseling and referral services to help veterans with mental, emotional, career, and other problems.
Knight says that the study is "as far as we know, the first to emphasize the impact of educational level on quality of life after prostate cancer treatment, as opposed to health literacy, a much more narrow measure which we've known for some time has an effect on health outcomes."
The study authors indicate they do not know why education plays such a large role in determining quality of life after prostate cancer treatment. One reason, they say, might be that "even in an equal-access health care system" such as the VA, men with less education have more trouble understanding educational materials about prostate cancer, its treatment, and post-treatment management, which in turn may lead to poorer disease management, greater worry, and greater difficulty adjusting to life as a cancer survivor.
"If that's the case, then we can begin to address the problem by creating educational materials that are better targeted to men with less education," says Knight.
She says another possible explanation is economic: "Men with less education might, indeed, have fewer financial resources, so prostate cancer is going to have a greater negative impact on their lives. For example, if you're driving a cab or working on a delivery truck, urinary dysfunction can become extremely disabling. It's hard to manage your symptoms, take breaks, and get enough rest when you're worried about keeping your job."
Knight stresses that, thanks to today's effective treatments, "men with prostate cancer can live a long time. If these problems go unaddressed, these men will have a much worse time over the course of their lives."
The researchers caution that because their study is based on results from only three VA medical centers, additional research will be needed to determine if the results can be generalized to all VA patients or to men in general.
Co-authors of the study are David M. Latini, PhD, of Baylor University and the Houston VA Medical Center; Stacey L. Hart, PhD, of SFVAMC and UCSF; Natalia Sadetsky, MD, MPH, of UCSF; Christopher J. Kane, MD, of SFVAMC and UCSF; Janeen DuChane, PhD, of Baxter International, Inc.; and Peter R. Carrol, MD, of UCSF. Patients in the study were enrolled in Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE), a nationwide longitudinal observational study of prostate cancer patients. Carroll is principal investigator of CaPSURE and Sadetsky is a CaPSURE investigator.
The paper is available in the on-line Early View section of the journal Cancer. The study was funded by the National Institutes of Health and UCSF. CaPSURE is supported by TAP Pharmaceutical Products Inc.
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