1. March 11, 2016 – Society for Personality Assessment
Psychological state and trait correlates of illness-related stigma in prostate cancer
Sara Walker, PhD, Yiyi Chen, PhD, Kyungjeen Paik, BS, Brandy Mirly, RN, Alexis Fields, BS, Arthur Hung, MD, & Charles Thomas, Jr., MD
March 11, 2016 – Society for Personality Assessment

2. Charles Thomas, Jr., MD
Joel Nigg, PhD
Jeffrey Robinson, PhD
Arthur Hung, MD
Yiyi Chen, PhD
Kyungjeen Paik, BS
Alexis Fields, BA
Brandy Mirly, RN
Jo Price
Scott Madsen
Daphne Baracena
Feather Coates
Sole Avila
Carrie North
Jenn Lockhart, RN

3. OHSU – Another View
Note to reviewers: this is a joke geared toward this audience, i.e., a foggy picture that reminded me of an item on an old projective/behavior-based psychological test (in case you’re interested:

4. Prostate Cancer The prostate Prostate cancer Gland below the bladder
Secretes seminal fluid
Size changes w/age
Prostate cancer
Second most common type of cancer in men in U.S.
Second leading cause of cancer-related death
≈ 220,000 dx/year; ≈ 27,500 deaths/year
1 in 7 will be diagnosed in lifetime; ≈3 million living w/it
Average age at dx is 66
Second most common after skin
Second leading cause of death after lung
Secretes slightly alkaline fluid that makes up about 30% of semen volume; also contains smooth muscles that help expel semen during ejaculation.
Few types of cells (i.e., glandular, myoepithelial, subepithelial); glandular most often site of prostate cancer
Types of pathology: inflammation, benign prostatic hyperplasia, cancer
American Cancer Society

5. Prostate Cancer, Continued
Heterogeniety in disease characteristics/prognosis
Clinical, pathological staging
Multidisciplinary treatment
Active surveillance
Surgery, radiotherapy, adrogen-deprivation therapy
Quality of life (QOL) affected by many individual, disease, and treatment characteristics
Age at diagnosis, time from treatment, primary treatment
Active surveillance: regular monitoring with prostate-specific antigen (PSA), rectal exams, ultrasounds.
Huang, Sadetsky, & Penson, 2010

6. Well-being in Cancer Care
With advances in treatment effectiveness, there is the need and opportunity to focus on issues of QOL and survivorship
QOL during and after treatment is affected by several psychosocial factors at baseline
Demographic characteristics
Psychosocial support
General Medical Comorbidities
American Cancer Society, 2007; Zabora et al., 2001

7. Psychological State in Prostate Cancer
Depression and anxiety are common among individuals with cancer, in general
In prostate cancer, specifically:
Depression during treatment associated with:
Higher health resource utilization and healthcare costs
Functional impairment
Health-related quality of life
Mortality
Risk/protective factors
SES, comorbidities, self-efficacy, sexual functioning
Issues of intersection among older adults
In radiation therapy, specifically:
Fatigue is common
Anxiety and depression have been found to significantly increase the experience of fatigue during radiotherapy
Crystal et al., 2003; Jayadevappa et al., 2012; Pirl et al., 2008; Prasad et al., 2014; Weber,
Roberts et al., 2008

8. Psychological Trait in Prostate Cancer
Impact of personality traits on general health and well- being has been thoroughly investigated
In prostate cancer:
Low optimism, low resilience associated w/higher distress among newly diagnosed patients
Neuroticism associated with reduced post-treatment QOL, experience of side-effects
Neuroticism inversely associated w/intention for screening
Extraversion and Conscientiousness positively associated
Personality change post ADT?
E.g., high Conscientiousness has positive health outcomes
E.g., Neuroticism associated with clinically elevated levels of inflammatory cytokines
Treleaven et al., 2013, found suggestion of increased Agreeablness post ADT
Goodwin & Friedman, 2006; Kyrdalen et al., 2010; Sutin et al., 2010; Roberts, Walton, & Bogg, 2005
Neeme, 2012; Orom et al., 2015; Stensvold et al., 2010; Treleaven et al., 2013

9. Illness-Related Stigma in Cancer
Stigma: labeled by an aspect of one’s identity (e.g., a diagnosis)
An individual is seen as part of a stereotyped group
Negative attitudes toward a stereotyped group can lead to prejudice
Cancer stigma has significantly changed over time
Strong associations persist b/w lung cancer stigma and depression/QOL
Predictions can be significantly overestimated
Responsive to psychoeducational intervention
Negative affect significantly associated with
experienced social stigma
Stigma more associated with the implication of
mental health than health-related distress
Cancer stigma and self-blame in colorectal cancer
are independent predictors of depressive symptoms
Entire body of stigma-related literature
Crawford & Petrylak (2010), ASCO, re: stigma associated w/ CRPC term, e.g., implication of testicular removal; no stigma associated w/”hormone-refractory PC,” but not as accurate
Allensworth-Davies (2011), Boston U School of Public Health dissertation; gay men reported more stigma, lower masculine self-esteem, more treatment regret than straight men following treatment for prostate cancer
Cataldo et al., 2012; Holland et al., 2010; Koller et al., 1996; Phelan et al., 2013; Waljee et al., 2011

10. Current Study - Methods
Procedures
Participants consented following simulation visit in clinic
Prospective observational design
Department of Radiation Medicine
Questionnaires pre-treatment, halfway, final day
Measures
PHQ-9
GAD-7
NEO Five Factor Inventory (NEO-FFI-3)
Stigma Scale for Chronic Illness (SSCI)
Functional Assessment of Cancer Therapy, Prostate (FACT-P)
Cella et al., 1993; Costa & McCrae, 1992, 2011; Esper et al., 1997; Kroenke et al., 2001;
Lowe et al., 2008; Rao et al., 2009; Spitzer et al., 2006

11. Stigma Scale for Chronic Illness
24-items re: past week experience
Respondents endorse on 1-5 scale
Never, Rarely, Sometimes, Often, Always
Content validity determined via lit reviews, focus groups, interviews
Psychometric properties initially based on individuals with neurologic disorders
Unidimensional model indicated by CFA
Examples
Because of my illness, I have felt emotionally distant from other people.
I felt embarrassed because of my physical limitations.
I avoided making new friends to avoid telling others about my illness.
People with my illness lost their jobs when their employers found out.
I lost friends by telling them that I have this illness.

12. Participants N=47 Average age=67.1 (SD=6.3, range=52-79)
Average education=15.6 (SD=2.8, range=10-20)
78% (n=25) European-American
3 identified as Latino/a, 1 as African-American, and 6 declined to respond
53% (n=25) were employed
Of those, 28% (n=13) were employed full-time
70% (n=33) were living with a partner

13. Psych State, Trait, and Stigma
Psych State – low levels of state distress endorsed
PHQ-9: M=4.7 (SD=5.4, Range=0-22)
GAD-7: M=3.9 (SD=4.3, Range=0-20)
Psych Trait – clustered around normative mean/SD, w/wide range
Stigma – low levels endorsed (possible range=24-120)
SSCI: M=30.8 (SD=8.0, Range=24-59) M SD
Range
Neuroticism
45.7
12.1
26-75
Extraversion
50.0
12.3
25-73
Openness
55.5
11.7
30-75
Agreeableness
56.8
9.7
36-71
Conscientiousness
53.7
10.8
31-75
-A lot of focus on psychological risk factors, less on protective factors?
-Resilient group, on average, rather emotionally well

14. Correlations: Stait, Trait, Stigma, QOL
SSCI
PHQ-9
GAD-7 N E O A C
Stigma(SSCI) --
0.77***
0.72***
0.52***
-0.22
0.02
-0.04
-0.25
Physical WB
-0.72***
-0.68***
-0.53***
-0.45**
0.19
0.11
-0.09
0.13
Social WB
-0.33*
-0.38**
-0.28
-0.23
0.48***
0.22
0.25
0.40**
Emot’l WB
-0.58***
-0.62***
-0.76***
-0.48***
0.21
0.05
Funct’l WB
-0.66***
-0.55***
-0.50***
0.42**
0.03
0.14
0.36*
Meaning/Pc
-0.56***
-0.65***
-0.64***
-0.52***
0.53***
0.08
0.29
Faith
0.10
0.04
0.07
0.23
-0.18
0.09
Main findings re: relationships between these factors at baseline – spend a bit of time here
Themes
Strong correlations b/w stigma and depression, anxiety, neuroticism
No sig corrs b/w stigma and trait protective factors
Additional Info
Strong correlations b/w stigma and QOL/well-being across measured domains, as well as sense of meaning/peace
No sig corrs b/w stigma and religious faith, per se
Strong corrs b/w state and trait risk factors and QOL/well-being across domains
Corrs b/w Extraversion and Social WB, Functional WB, Meaning/peace
Corrs b/w Conscientiousness and Social WB, Functional WB
No sig corrs b/w trait protective factors of Agreeableness, Openness and QOL/well-being
* p< ** p< *** p< .001

15. Role of Stigma in Psych State Changes
Median split, pros and cons
N=22
PHQ-9
-Not significant main effect for time; not significant interaction effect.
-B/w group effect for depression: F (1, 19)=8.29, p =0.01
GAD-7
-B/w group effect for anxiety: F (1, 20)=9.96, p =0.005

16. Role of Stigma in QOL Changes
Other QOL Domains
No interaction effects
Main effects for time in:
Physical well-being (down)
Emotional well-being (up)
Prostate-related (down)
B/w group effects in:
Physical
Functional
Median split, pros and cons; Range of FACT-P total is
Approaching significance: effect of time for SWB (going up); b/w group effect for EWB and prostate
FACT-P Total
-Not significant main effect for time; not significant interaction effect.
-B/w group effect for QOL: F (1, 18)=5.56, p =0.03
PWB
-Not significant interaction effect.
-Main effect of time: F (2,38)=7.43, p =0.002; going down.
-B/w group effect for PWB: F (1, 19)=7.02, p =0.016
SWB
-Not significant interaction effect; no b/w group effect.
-Main effect of time approached significance: F (2,38)=2.43, p =0.102; going up.
EWB
-Main effect of time: F (2,38)=9.031, p =.001; going up.
-B/w group effect for EWB approached significance: F (1, 19)=3.95, p =0.06
FWB
-Not significant interaction effect; no main effect for time.
-B/w group effect for FWB: F (1, 19)=5.43, p =0.03
Prostate
-Not significant interaction effect
-Main effect for time: F (2,36)=5.43, p =0.009
-B/w group effect for prostate approaching significance: F (1, 18)=3.57, p =0.075

17. Conclusions
Perceived illness-related stigma is significantly positively associated with:
Psychological state distress
Psychological trait risk factor
Perceived illness-related stigma is significantly negatively associated with:
QOL/well-being across measured domains
Sense of meaning/peace
Perceived illness-related stigma is not significantly associated with trait protective factors, faith

18. Stigma-Related Interventions
-Self, social, structural
-Effect of psychoeducation
-Lung cancer vs. prostate; HIV, mental illness, etc.

19. Limitations and Future Directions
Correlation ≠ Causation
Relatively small sample size, particularly for repeated measures at this time
Self-selected group
Homogenous sample (e.g., racial/ethnic identity, region)
Future Directions
Complete prospective measurements
Determine if state, trait, or stigma relate to response to psycho-oncologic intervention