Coping and adjustment in men with prostate cancer: a systematic review of qualitative studies

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.

Studies investigating men’s self-initiated coping strategies for PCa were eligible for inclusion in the current review. Coping strategies via formal interventions (e.g. support groups, individual psychological therapy) were not eligible for inclusion. Strategies that were not primarily psychological were also not eligible (e.g. symptom management via dietary changes). Studies needed to be primary empirical papers that used a qualitative research design and data-analytic strategy that yielded thematic categories. No other restrictions in study design were imposed. Study samples had to be comprised of adult males over the age of 18 who had a diagnosis of PCa (even though final participants were most likely to be much older than this). Studies needed to specifically report at least one coping strategy, based on the definition of coping provided above. Strategies that involved direct attempts to treat cancer were not eligible. Studies exclusively recruiting sexual minority men were excluded in order to facilitate analysis with a relatively homogenous group.

Searches of the electronic databases PsychINFO and MEDLINE were conducted in April 2016 for English-language, published peer-review studies undertaken with adult male participants. No date restrictions were imposed. Search terms were developed from a preliminary search of existing studies in the area of coping and adjustment in informal male carers. Keywords were selected in the three concept areas of coping (“coping” OR “adaptation” OR “resilience” OR “self-help” OR “adjustment” OR “management” OR “strategies”), gender (“men(s)” OR “male(s)” OR “masculin*”) and cancer (“cancer” OR “neoplasms” OR “oncology” OR “tumour” OR “malignancy”). In addition, a hand search of reference sections within included studies was conducted to identify additional potentially relevant articles. A manual search of key journals was also conducted to identify additional articles. All publications returned from this search strategy underwent initial screening, followed by full-text review where eligible. See Fig. 1 for a summary of the study selection process.

The approach to data extraction and analysis was the same as that adopted in previous research conducted in the area of men’s coping [26, 27]. Rationale and detailed description of this process have been previously provided so is not reproduced here. To briefly summarise, extraction and analysis took place in three stages:

Methodological quality assessment was undertaken for each included study. The Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields [36] was used for this purpose. This tool was used to assess each individual study in the domains of question/objective description, design identification and appropriateness, specification of study context, association with theoretical framework/body of knowledge, sampling strategy, data collection, data analysis, use of study credibility verification procedures, results–conclusions coherence, and reflexivity of potential impacts upon study data and findings. Individual studies were evaluated and assigned a score of zero, one or two for each of these 10 domains. A total quality score was then derived as listed in Table 1. Screening was conducted separately by two researchers (EJ and BF). Scoring results were compared and discrepancies resolved through discussion and use of a third scorer (JS) where necessary. The major methodological issue amongst the included studies was a lack of researcher reflexivity. There was no reflective account in seven of the included studies (four studies obtained a maximum score of two in this domain). Other issues involved inadequate/insufficiently detailed sampling strategies, theoretical frameworks, and study contexts.

An initial list of six meta-thematic categories were generated, then reduced to five following refinement of category definitions. Each study was then reviewed by two independent coders (JS and HL) and relevant thematic content assigned under the applicable meta-thematic category. An individual study theme could be categorised within more than one meta-thematic category where appropriate. The categorisation of individual study themes was then compared between the two coders, and discrepancies resolved. The final categorisation of thematic content from the included studies can be found in Table 2.

In total, 18 studies meet inclusion criteria for the qualitative synthesis. See Fig. 1 for a flow chart of the study screening protocol. Details for the included studies can also be found in Table 3. There was an overall sample size of 389 taken from studies published between 2003 and 2015. Data were drawn from several countries, most notably the UK (7). Many of the remaining studies originated from continental Europe and North America. The sample comprised mainly of middle and older-aged men with an age range of 45 to 85 (three studies did not provide age data). Other sociodemographic data were reported with little consistency. Nine studies indicated that proportion of their samples identifying as retired. This group comprised at least 50% of participants in six of these studies (range 33–100%). In the seven studies that reported relationship status data, the label of ‘married’ was used most frequently. Participants in this category comprised the majority of participants in all of these studies (range 66–90%). Overall, limited sociodemographic data were presented in these studies. This limited the extent to which the overall sample could be characterised.

Study design information is summarised in Table 1. Semi-structured interview was the most frequently used data collection method. Focus groups were used in only one study [37]. A range of data analytic procedures were employed across included studies, notably thematic analysis (or some variation). Aims of individual studies broadly corresponded with topics related to coping and adjustment. Most studies focused on adjustment to PCa symptoms and treatment side-effects, along with implication of PCa for identity and masculinities.

Following analysis of data from the individual included studies, a total of five meta-themes were derived under which study-level thematic domains could be classified. Meta-thematic categories were ‘avoidance, minimisation, and withdrawal’, ‘directing cognition and attention’, ‘reframing and seeking support’, ‘retain pre-illness identity and lifestyle’, and ‘symptom management’.

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].

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.

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.