Background
Prostate cancer (PCa) is the most common form of cancer amongst males in the UK and is the second most common cancer amongst men in the USA [
1,
2]. PCa tends to affect older men in that over 50% of those diagnosed are aged 70 and over [
1]. As with other forms of cancer, PCa is associated with a range of symptoms and treatment side-effects including sexual dysfunction, urinary incontinence, bowel changes, pain, and fatigue [
3]. These problems pose significant challenges to quality of life and well-being.
PCa is also associated with various adverse psychiatric, psychological, and quality of life outcomes. A meta-analysis by Watts and colleagues [
4] found rates of depression and anxiety to be higher (across several PCa treatment phases) than those found in the general population. PCa is also associated with sub-clinical distress and reduced quality of life [
5‐
7]. By contrast, some studies have reported relatively low rates of psychiatric disorder. Love et al. [
8] found no significant differences in the prevalence of depressive disorders, and only slightly elevated levels of anxiety disorders in men with PCa compared with community controls. Relatively low levels of anxiety and depressive symptoms were similarly found by Bisson et al. [
9]. Health outcomes for PCa are influenced by various physical and psychological factors, such as symptoms experienced [
10], treatment received [
11,
12], and extent of masculine identity threat [
13]. There is also support for different mental health-related quality of life trajectories [
14]. Combined with methodological differences, these factors may have contributed to variations in reported outcomes. Despite these variations, it is apparent that significant numbers of men do indeed experience psychological distress, and this is perhaps the key message from the literature. Research that attempts to inform and alleviate such distress should be encouraged.
Given the adverse outcomes associated with PCa, coping patterns amongst men with this disease are of great importance. Coping is broadly conceptualised as a person’s attempts to manage stressful circumstances, along with the ascribed meaning or interpretation given to such circumstances [
15]. Coping may be comprised of external (e.g. information seeking, engaging social support networks) and internal (e.g. humour, cognitive re-framing) strategies [
16]. Link and colleagues [
17] suggest that coping strategy selection in cancer is a multi-stage process incorporating a wide range of considerations, such as identification of potential coping strategies, goals of self and others, and illness severity.
There is an increasing body of qualitative research on the topic of coping in men with cancer. Wenger and Oliffe [
18] indicated that, across various types of cancer, men use multiple coping strategies that can be categorised as ‘fortifying resources’ (knowledge building and physical strengthening), ‘maintaining the familiar’ (e.g. shield others from distress), or ‘getting through’ (e.g. restricting emotion). The use of multiple coping strategies has also been reported with PCa specifically [
19] with Roesch et al. [
20] making links between coping strategies and outcomes. Specifically, these authors suggested that approach (e.g. seeking information, acceptance, positive reappraisal), problem and emotion-focused (e.g. seeking practical support, humour) coping strategies were associated with positive psychological outcomes. Conversely, avoidance was related to negative adjustment. Other reviews in this area have been published [
21,
22]. However, diffuse coping conceptual frameworks along with other methodological limitations (e.g. lack of detailed inclusion/exclusion criteria) have hindered such attempts to rigorously synthesise studies.
Various theoretical frameworks, including gender role socialisation, can be employed in understanding coping with a cancer context. This is because Courteney [
23] argued that men’s health behaviour can be influenced by a need to ‘do’ masculinity. Connell’s theory of hegemonic masculinity [
25] promoted the concept of pluralism in male gender socialisation (hence the term ‘masculinities’). Here, a particularly influential and idealised (hegemonic) form of masculinity is purported to exist that promotes a narrow, inflexible enactment of masculinity. Likely to be influenced by this are a set of masculine scripts in PCa that include ‘self-reliance’, ‘emotional control’, and ‘male sexual potency’ [
24].
Despite the potential dominance of hegemonic forms of masculinity, it is said to exist amongst non-hegemonic (subjugated) forms of masculinity [
25]. This raises the potential for more flexible interpretations of masculinity as documented in several recent studies. [
26‐
28]. With illnesses such as PCa, coronary heart disease, and depression, some men re-negotiate masculinity in an attempt to cope with the medical and psychological consequences of physical health problems [
29]. This research compliments work undertaken in the areas of psychological flexibility, positive masculinity, and coping flexibility, and the benefits such attributes confer on well-being [
30‐
32].
Matheson et al. [
33] proposed that adjustment in prostate cancer rests on the extent to which men can negotiate two key transitions labelled ‘gaining a sense of perspective over threats to testicular cancer’ and ‘striving to get on with life and restoring normality’. Successful adjustment in the first transition phase was said to involve strategies such as reflecting on positive meaning, positive reframing of cancer threat, active support seeking, and more flexible adherence to masculine values (amongst others). This last strategy reflects the practice of masculine role renegotiation as discussed above. The second transition was characterised by behaviours such as normalising bodily changes and resuming pre-illness occupational and social roles. There is some empirical evidence that these adjustment processes are adaptive. For example, acceptance and positive reframing have been associated with benefit finding in PCa [
34].
The current study
To summarise, PCa is serious disease with potentially wide-ranging implications for physical and psychological functioning. Coping and adjustment is a complex process, and research suggests that men’s strategies are wide-ranging and likely to be strongly influenced by masculinities. Empirical studies in this area have not been robustly summarised to date. However, in doing so, we may advance our understanding of how to support men affected by this illness.
The aim of the current review was to conduct a qualitative meta-summary [
35] to identify self-initiated coping strategies reported by men diagnosed with PCa. In line with the above discussion, coping in the current review was operationally defined as any internal or external psychological strategy intended to manage stress regarding a diagnosis of cancer, the interpretation or meaning associated with diagnosis, and difficulties directly related to this medical condition (e.g. symptoms, treatment side-effects). The current review focused on qualitative studies. One advantage, amongst others, of primary qualitative research is that coping data are not influenced by a pre-determined set of strategies as is found in various coping inventories. In advancing our understanding of coping in PCa and how to support men more effectively, it is important to systematically review and synthesise these studies. As this review involved the analysis of secondary data only, ethical approval was not sought.
Conclusions
The current review summarised a small but significant body of qualitative studies examining coping and adjustment of men diagnosed with PCa. A total of five meta-thematic categories were derived from this literature: avoidance, minimisation, and withdrawal; directing cognition and attention; reframing masculinity and seeking support; retain pre-illness identity and lifestyle; and symptom/side-effect management. While previous reviews of coping and adjustment have been conducted in this area [
21,
55], the current review differs in its scope, inclusion criteria, and approach to data synthesis. The current review provides important and novel insights into the nature of coping and adjustment of men diagnosed with this disease. This review adds to similar reviews and draws important parallels with men’s coping in other domains [
26,
27]. A gender socialisation framework was utilised to contextualise the selection and use of coping strategies. However, it is important to acknowledge that the coping strategies identified are not exclusive to males, and there are many other potential influences in the coping process. For example, avoidance and withdrawal may also result from underlying psychological issues such as anxiety and depression.
Avoidance, minimisation, and withdrawal relates to strategies aimed at the avoidance of engagement with PCa physically, psychologically, and interpersonally. Such strategies may reflect the dominant masculine scripts such as ‘self-reliance’ and ‘emotional control’ as detailed by Burns and Mahalik [
24]. These may represent efforts to minimise impact of side-effects as threats to masculinity [
47]. This approach to coping is likely to be undesirable given the potential link between restricted emotional expression and psychological adjustment [
20,
56]. This category is comparable to meta-themes reported elsewhere with men’s coping in depression (‘social concealment and minimisation’) and men functioning in a carer role (‘promoting masculinities and taking charge’) [
26,
27]. In other words, suppression and minimisation are coping approaches exhibited by some men across a diverse range of situations.
Directing cognition and attention was a meta-theme that involved men attempting to employ a positive focus and reframing of symptoms and treatment side-effects. Similar to men who ‘seek new perspectives’ as a way to cope with depression [
26], directing attention appears to be a coping strategy whereby men draw out aspects of their circumstances for which they can draw optimism and gratitude. Englar-Carlson and Kiselica [
31] have outlined a positive psychology/positive masculinity model in which they identify socialised male strengths in several areas. One such area is humour, which was a feature of this meta-thematic category. This suggests that, through gender socialisation, men may be able to utilise strategies such as humour more easily than other strategies. Directing cognition in a positive way may be an approach to be encouraged. According to Matheson et al.’s [
33] theory, positive reframing is also a process associated with adaptive adjustment to testicular cancer.
The current review indicated that some men engage in a process of reframing and seeking support. In line with theoretical work suggesting the pluralistic nature of masculinity [
25], along with masculine identity flexibility and re-negotiation [
27,
28], this meta-thematic category suggests that some men cope with PCa through actively re-positioning their identity in non-hegemonic terms. Men also adopt a more flexible interpretation and enactment of masculinity. Such strategies are again found elsewhere. This process has been labelled ‘creating new behaviours, roles, and identities’ amongst male carers [
27] and ‘promote flexible masculinity’ in men affected by depression [
26]. It appears that there may be different trajectories of resistance to masculine norms [
28], thereby explaining why some may adopt and others not adopt strategies within this meta-theme. This re-framing and flexibility may enable men to access greater levels of social support than that which was possible in those who strongly endorse hegemonic ideals. However, men are still highly selective around support seeking and generally limit this to partners, close family members, and others diagnosed with PCa. We could assume this meta-thematic category represents adaptive coping responses. For example, psychological flexibility is linked with positive adjustment [
32].
Retain pre-illness identity and lifestyle is a meta-theme that encapsulates men’s efforts to maintain ‘normality’ or a familiar, pre-illness lifestyle. This approach has again been noted in male carers and men affected by depression [
26,
27]. Men in the included studies appeared to approach this ‘status-quo’ objective largely through exhibiting traditional Western masculine characteristics. The diagnosis may be a context in which men attempt to ‘do masculinity’ [
23]. Additionally, because some men with PCa report diminished masculinity [
57], there may be an attempt by some to build masculine capital [
58] given the perceived threats to masculinity that some men report [
59]. The use of strategies within this meta-theme is of concern given the association of traditional masculine scripts with psychological maladjustment [
60,
61].
Strategies reported under the meta-theme symptom/side-effect management appeared to be in contrast with the first meta-theme (avoidance, minimisation, and withdrawal) in that there were several approach- and problem-solving-orientated strategies reported. This meta-theme also represents responses to physical issues (e.g. treatment side-effects) rather than psychological ones (e.g. adjustment). While the presence of symptoms and side-effects on their own necessitate a coping response, it could be argued that some men are more comfortable in engaging with practical coping strategies. A focus on practical tasks was reported by carers in Spendelow et al. [
27] where it was hypothesised that this might reflect a number of functions, such as using the body itself to fulfil social roles (e.g. a leader or initiator) as represented in Watson’s [
62] male body schema and to avoid negative affect.
The current findings apply to older men, given the age range of study participants. It, therefore, cannot be assumed that coping strategies discussed here are applicable to men at other developmental stages and/or with other illnesses (including other forms of cancer). There also might be various contextual and social variables that influenced these findings (e.g. cohort effects) that may have had a unique influence on the current review findings. Furthermore, issues of sexuality are relevant given the focus of included studies on heterosexual men. The coping experiences of sexual minorities may be different and require separate examination. Having said this, there is a general lack of research on masculinities and older men. This is significant because issues such as retirement, social relationships, and caregiving represent specific issues which may have a substantial effect on the health of older men [
63]. The current review has made a contribution to this lack of research with older male participants, in identifying that masculinities are likely to heavily influence coping in this age group.
Clinical implications
Men with PCa adopt numerous strategies to cope and adjust to the many challenged raised by this illness. The findings of the current review suggest the possibility that gender socialisation and masculinities may contribute to the selection and use of these strategies. There is a clear contrast to approaches where men either attempt to conform with or re-shape/interpret masculine identities. There is some evidence that the latter approach is associated with more positive health outcomes. Thus, knowing the types of strategies men employ is important in guiding health professional efforts to support adaptive coping in men with PCa. Refinement of psychological and psychoeducational interventions is needed because, while existing interventions may have a therapeutic effect over and above routine care, such gains may not be sustained [
64].
Because there is some evidence to suggest that flexibility in masculinities and coping is adaptive, it may be appropriate to focus on interventions that promote this skill. There are various ways in which this can be achieved. For instance, certain psychotherapeutic approaches incorporate psychological flexibility in the conceptualisation of mental health difficulties (e.g. Acceptance and Commitment Therapy (ACT) [
65]). Alternatively, Way et al. [
28] identified a number of social, cultural, and interpersonal factors that appear to facilitate resistance to masculine norms. One of these is having close relationships. Some men within studies included in the current review reported disclosure and social support seeking (reframing and seeking support). Helping men to strengthen and utilise social networks could be a way to increase flexibility provided these networks embody characteristics congruent with flexibility (e.g. empathy, interdependence). Support-seeking is further important because men and their partners have a reciprocal influence to the diagnosis of PCa [
66], the illness has an effect on partner well-being [
67], and married men with high partner support reported lower levels of distress than unmarried men or those married with low support [
68].
Future research
There are a number of important avenues for future research highlighted by the findings of this review. Firstly, the current body of studies represent a fairly homogenous group of men, and the literature would benefit from extending these findings to more diverse samples. For example, exploring the impact of sexuality, social class, and cultural and ethnic background might influence the selection of coping strategies chosen by men in response to PCa. This would assist us to understand whether the patterns of coping identified in this review are generally utilised across diverse groups of males with PCa, or represent styles of coping used by a specific group (and influenced by socio-cultural variables, etc.). Additionally, while the studies included in this review help us to better understand the types of coping strategies employed by some men, there is a need to further our understanding of variables that influence the choice and utilisation of these strategies. For example, a replication of the study conducted by Matheson and colleagues [
33] within a population of men with PCa would be helpful in this regard. As part of developing our understanding further about the role of masculine norms in the process of coping with PCa, an interesting research question might be the extent to which gender role conflict (GRC) might moderate the relationship between PCa variables and positive psychological well-being. For example, does GRC moderate the relationship between approach, problem, and emotion-focused coping strategies and psychological well-being? Finally, in thinking about how we might better support men during the treatment process for PCa, future research should seek to assess medical professionals’ awareness of psychological consequences of medical treatment and how to encourage adaptive self-initiated coping strategies men can employ to mitigate these impacts.
Study limitations
Limited attention was directed within included studies to considering dynamic aspects of coping, i.e. how the self-initiated coping strategies employed by men in response to PCa might change over the course of the illness. Focusing on characterisation of coping strategies rather than the more dynamic processes of how these might change over time and in response to contextual factors is not limited to studies looking at men’s coping responses to PCa. The more dynamic aspects of coping are rarely specifically addressed within qualitative research investigating male coping more broadly. Regarding the process of PCa diagnosis and treatment, it was not possible within this review to offer insight into how coping might change across the course of the illness (due to the nature of the included studies). Factors relating to disease progression and treatment, however, could be an important contributor in men’s psychological responses and self-initiated coping strategies. This would therefore be deserving of further investigation. Taking this into account, a further limitation of this review is the lack of consideration of how other contextual factors might influence coping strategy selection (e.g. investigating the influence of interpersonal relationships in choice of coping strategies).
In terms of methodological limitations of the current review, the extraction of coping strategies from included papers and the categorisation of these into the suggested meta-themes is a somwhat subjective process. In part, this is influenced by the variable conceptualisations of coping that were adopted by the included papers (which is an issue often highlighted within the coping literature more broadly). The use of clear inclusion/exclusion criteria and a clear operationalization/definition of coping adopted by this review helped to increase objectivity in this regard. However, the review studies included little in the way of reflexivity around how the world-views and personal characteristics of the researchers may have impacted upon the way in which they engaged with their own data and presented their findings. Again, this hindered the current review when thinking about the wider implications and the applicability of findings.
Finally, it is important to acknowledge the important impact of cohort/age effects that may have influenced these findings. The nature of, and adherence to, masculine norms positioned as ‘traditional’ or hegemonic may change over time. However, there was little focus in the current review around the impact of adherence to masculine norms and how norms might change as a result of contextual factors. Therefore, future reviews/research may like to compare findings between different age groups and cohorts to consider whether this impacts the meta-themes reported here.