Worry After Prostatectomy a Self-fulfilling Prophecy

Neil Osterweil

March 21, 2019

BARCELONA, Spain — Men who score high for the personality trait of neuroticism tend to have worse recovery and suffer from more adverse events following radical prostatectomy than men with more with a more serene outlook on life, investigators reported here at the European Association of Urology (EAU) 2019 Congress.

Neuroticism was identified by using the validated Eysenck Personality Questionnaire at a mean of 3 years after surgery.

Approximately one fifth (22%) of the 761 who answered scored high for neuroticism, and these men had 21% higher severity scores for symptoms such as erectile dysfunction, urinary leakage, and bowel problems than men with low neuroticism scores, said Karol Axcrona, MD, from Akershus University Hospital in Lørenskog, Norway.

"This is significant in our opinion, and it's very, very interesting since many men are offered radical treatment for their prostate cancer. In this instance, we analyzed patients operated on with radical prostatectomy; it would be very interesting to analyze also patients treated with radical radiation therapy," he told Medscape Medical News.

Axcrona emphasized that patients were asked to fill out the questionnaire only after having undergone surgery, and that the investigators did not have baseline data on the degree of neuroticism for each man in the study.

At the poster session where he presented his data, however, Axcrona noted that a psychiatrist at his institution informed him that "the personality trait is constant during life."

Neuroticism, Defined and Embodied

In an entry in the International Encyclopedia of the Social & Behavioral Sciences , David Watson, PhD, from the University of Iowa in Iowa City, described neuroticism as "a broad personality trait that reflects the extent to which a person experiences the world as stressful, threatening, and problematic. Neurotic individuals experience frequent and intense negative emotions; they report a wide variety of problems and are dissatisfied with themselves and the world around them."

The self-absorbed, nebbish character Alvy Singer, played by Woody Allen in his Academy Award-winning comedy Annie Hall — and in fact nearly every character he played in his early films — are among the best known avatars of neuroticism. For contemporary audiences, think of the persona of Larry David, creator and star of the TV show Curb Your Enthusiasm, or the entire cast of uber-nerds in The Big Bang Theory.

Axcrona and colleagues note as examples 6 of the 12 questions in the Eysenck Personality Questionnaire neuroticism domain:

  • "Are your feelings easily hurt?"

  • "Do you worry too long after an embarrassing experience?"

  • "Do you often feel 'fed up'?"

  • "Are you a worrier?"

  • "Do you worry about awful things that might happen?"

  • "Have you often felt listless and tired for no reason?"

Axcrona told Medscape Medical News that while the effects of surgical technique and age on post-prostatectomy outcomes are well known, the effects of personality on the ability to recover urinary function have been less well documented.

"People with neuroticism are more susceptible to stressors, and might be susceptible to developing somatic diseases and mental disorders such as depression in response to these stresses," he said.

For example, neuroticism is known to exacerbate conditions such as inflammatory bowel disease and ulcerative colitis in some patients, and to influence urinary symptoms and sexual function.

Study Details

Axcrona and colleagues sent surveys to 982 men who had radical prostatectomies at the Oslo University Hospital from 2005 through 2010, and based their study on responses from 761 men who reported adverse events and who responded to the neuroticism questionnaire.

Quality of life was measured by the self-reported EPIC-26 (Expanded Prostate Cancer Index Composite–Short Form) instrument.

At a mean of 3 years after surgery, 21% of the patients reported treatment failure, defined as salvage radiation treatment, hormonal treatment, or significant prostate-specific antigen (PSA) elevation, and 22% reported high neurotic tendencies.

Compared with men who reported low neuroticism, the men with high neurotic scores reported significantly more overall comorbidities (P = .006) and significantly worse scores in the EPIC-26 urinary domain (P < .001), including incontinence and irritation subscales (P < .001) for each.

Men who scored high on neuroticism also fared less well in bowel problems (rectal urgency, loose/liquid stools, fecal incontinence, bloody stools, rectal pain; P < .001 for overall bowel problems).

Similar results were seen in the sexual problems domain: men with high neurotic scores had more trouble with erections and had difficulty achieving orgasm (P < .001 for overall sexual problems). In the hormonal domain, men with high neurotic scores reported having significantly more hot flashes, breast problems, depression, lack of energy, and weight change (P < .001 for all).

Christopher Porter, MD, a urologic oncologist at the Virginia Mason Medical Center in Seattle, Washington, who was not involved in the study, told Medscape Medical News that "it's interesting in their study that one in five patients had some form of neuroticism. I think that's worth looking at. It's something that's unknown and maybe it's part of a whole host of other factors that need further investigation."

Porter's center takes a multidisciplinary approach to the care of patients with prostate cancer, including a psychologist and social workers who can intervene when there are concerns about the potential health effects of a patient's personality, he said,

Anne Sofie Friberg, MD, from the Rigshospitalet in Copenhagen, Denmark, lead author of another study showing that men who undergo radical prostatectomy have a significantly increased risk for depression, told Medscape Medical News that she sees a link between the study by Axcrona and colleagues and her group's findings.

"The neuroticism trait could be a vulnerability factor for depression, of course, so this would be a way to find some of those patients who are at most at risk," she said.

European Association of Urology (EAU) 2019 Congress: Abstract 1172. Presented March 18, 2019.

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