Distress and social dysfunction following prostate cancer treatment: a longitudinal cross-cultural comparison of Japanese and American men

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We assessed the impact of bother with urinary and bowel dysfunction on social activities among men in Japan and the United States following primary therapy for localized prostate cancer. In paired longitudinal outcomes studies, we measured general and disease-specific health-related quality of life in 400 Japanese and 427 American men who underwent radical prostatectomy or brachytherapy for localized prostate cancer. Outcomes included the social function domain of the Medical Outcomes Study Short Form-36 and the University of California, Los Angeles Prostate Cancer Index, all of which are scored 0–100. Participants completed the questionnaires before and 1, 12 and 24 months after treatment. Among men who reported any urinary bother, Japanese men had slightly better urinary function than American men (84 vs 77, P<0.01). Before brachytherapy, urinary bother was weakly correlated with social function in both the countries; after brachytherapy, urinary bother was strongly correlated with social function in American but not Japanese men. After brachytherapy, bowel dysfunction had a stronger correlation with social function in American than Japanese men (P<0.05). The bother associated with urinary and bowel dysfunction after surgery or brachytherapy for prostate cancer has a greater impact on social function in American men than in Japanese men.


Men diagnosed with localized prostate cancer are typically expected to live for many years with the sequelae of treatment; side effects may cause significant dysfunction, distress or disturbance in overall quality of life. Hence, the selection of primary therapy now includes consideration of health-related quality of life (HRQOL).1 Studies of the impact of symptoms following treatment may provide important information for those newly diagnosed with prostate cancer as they face decisions about therapy. Race and ethnicity can affect HRQOL because of their impact on satisfaction with care and other outcomes.2 Most ethnic comparisons of HRQOL after prostate cancer treatment have been limited to studies of non-Hispanic whites, African Americans and Hispanics in the United States.3 Interest is growing in HRQOL among Asian men with prostate cancer, however, as prostate cancer incidence rates are growing in both the United States and Asia.

We previously posited that cultural disparities in completing HRQOL surveys may explain differences in sexual activity profiles in Japanese and American men after prostate cancer treatment.4, 5 We also wondered to what extent the domains of urinary and bowel function and the associated bother (distress) affect social function. Comparatively, little is known about correlation between the urinary or bowel function and bother and social activities, although we have shown that that men undergoing surgery or radiation for prostate cancer receive strong benefit from social support systems.6 In this study, we assessed the extent to which bother with urinary and bowel dysfunction affected social activities among Japanese and American men following primary therapy for localized prostate cancer.

Materials and methods


Between June 2001 and December 2002, 400 Japanese men with localized prostate cancer (cT1-T3N0M0) who underwent radical prostatectomy (RP, n=324) or brachytherapy (BT, n=76) participated in a longitudinal outcomes study at Tohoku University Hospital, Kitasato University Hospital and Kurashiki Central Hospital, all of which are comparable in clinical and academic composition. Between 1999 and 2003, 427 American men with localized prostate cancer (cT1-T3N0M0) who underwent RP (n=325) or BT (n=102) at the University of California, Los Angeles (UCLA) also enrolled in a longitudinal outcomes study. In both studies, recruitment was consecutive. The respective institutions’ human subjects committees approved all recruitment and study protocols; all participants provided written informed consent.

Treatment protocols

All prostatectomies were performed by experienced staff urologists using the retropubic anatomic technique.7 In both countries, indications for treatment options depended on pretreatment factors, including the number and Gleason score of positive biopsies, serum prostate-specific antigen (PSA), clinical stage and patient preference. The use of nerve sparing also depended on intraoperative factors, such as anatomical variations and prioritizing cancer control.

In Japan, BT using iodine-125 was performed transperineally, as previously described,8 by a single radiation oncologist, accompanied by the referring urologist. The maximum prostate volume allowed was 45 cc, and men were excluded if they had undergone prior transurethral resection of prostate. The delivered implant dose was 145 Gy. Postimplantation radiation doses were determined by computed tomography 1 month after the treatment. American men who undertook BT received either it alone or in combination with external beam radiation therapy depending on the risk stratification of their prostate cancer. After preoperative volumetric analysis as a separate outpatient procedure, BT was performed through a transperineal approach with transrectal ultrasound guidance. According to preoperative dosimetric planning, a mean of 89±34 radioactive seeds was implanted. Plan radiography in the supine position confirmed seed placement. In subjects who received combination BT and external beam radiation therapy, BT was preceded by an attenuated external beam radiation therapy total dose of 45 Gy to low pelvis, centered on the prostate. Computed tomography imaging of the pelvis verified postimplant dosimetry 2–4 weeks after treatment.


General HRQOL was measured with SF-36.9 The survey covers four physical domains and four emotional domains, including social function. The eight scales are scored separately from 0 to 100, a higher score representing a better outcome. The social function domain of SF-36 includes two items that assess with a high level of validity and precision the impact of physical or emotional health problems on social activities.10 Prostate cancer-specific HRQOL was assessed with the UCLA Prostate Cancer Index (PCI), in which 20 items quantify six domains that include urinary and bowel function and bother.11 Its scales are scored separately from 0 to 100, a higher score representing a better outcome. Both instruments had already been translated into Japanese, and their validity and reliability has been established.12, 13 All subjects were aware of their cancer diagnosis prior to completing the baseline questionnaire. Baseline demographic items and a comorbidity index were collected at enrollment. Follow-up questionnaires were completed 1, 12 and 24 months after treatment. Questionnaires were returned in postage-prepaid envelopes to a third party. Clinical variables were abstracted from medical records.

Statistical analysis

Demographic and clinical variables were compared with χ2-analyses. We present PCI urinary and bowel bother scores as the proportion of subjects reporting any (score<100) vs no (score=100) bother. At each assessment point, we used χ2-analysis to compare function scores between countries. We also calculated Spearman's correlation coefficients to compare urinary and bowel function and bother with each other and with social function. We defined strong correlations as those with coefficients of at least 0.30. To minimize the influence of other factors, we adjusted for age (<70 vs 70), PSA at diagnosis (<10 vs 10), biopsy Gleason score (<6 vs 6), clinical T stage (T1/T2 vs T3) and comorbidity count (0 vs 1). To avoid the confounding impact of hormone therapy and nerve sparing, we confined our analysis to the urinary and bowel domains in men who did not receive androgen ablation. All statistical analyses were performed in SAS 9.1 (SAS Institute, Cary, NC, USA).


Table 1 presents demographic and clinical characteristics of our study sample. We analyzed 395 Japanese (99%) and 421 US men (99%) after excluding 5 Japanese and 6 American men because of missing demographic data or baseline outcomes. More participants underwent RP (n=646; 79%) than BT; a smaller percentage of American than Japanese men chose RP (76 vs 82%, P=0.05). In the RP groups, American participants were younger, had a lower mean pre-biopsy PSA value, earlier clinical stage tumors, lower biopsy Gleason scores and were more likely to undergo nerve-sparing surgery (all P<0.001). The BT groups were comparable in most demographic and clinical variables.

Table 1 Characteristics of the study sample

Table 2 presents mean urinary and bowel function scores, stratified by the presence or absence of bother among the 816 men before treatment. Comparing across bother categories, those with any bother reported significantly worse function scores than those with no bother in both countries. Among men reporting any urinary bother, Japanese men had somewhat better urinary function than did American men in both the RP (84 vs 76, P=0.03) and BT (86 vs 78, P=0.07) groups. In men reporting any bowel bother, Japanese and American subjects did not differ meaningfully in bowel function, either collectively or stratified by treatment.

Table 2 Mean baseline urinary and bowel function, by any or no bother

Table 3 summarizes the correlation coefficients for the associations among the four PCI scales. Urinary and bowel function scores were strongly correlated with their respective bother score (r>0.30). Urinary function and bother were more weakly correlated with each other in Japanese than in American men (r=0.42 vs 0.65). In both countries bowel function and bother were similarly highly correlated. In both countries, correlations between urinary bother and bowel bother were also strong.

Table 3 Correlations between baseline urinary and bowel function and bother (by country)

Table 4 presents the correlations of urinary and bowel function and bother with the SF-36 social function domain at each time point. Bowel function was more strongly correlated with social function in American than in Japanese men. Although a weak relationship between urinary bother and social function in both countries at baseline, subgroup analyses demonstrated that after BT urinary bother was more strongly correlated with social function (r=0.41, 0.47 and 0.32 at 1, 12, 24 months, respectively) in American than in Japanese men, especially at 12 months (P<0.05). Urinary function was not highly correlated with social function in either country. Bowel bother was more strongly correlated with social function in American than Japanese men at baseline and 1 month after RP; however, at 12 months after RP, bowel bother and social function were more strongly correlated in the Japanese men.

Table 4 Correlations of urinary and bowel function and bother with SF-36 social function domain over time, adjusted for age, clinical T stage, baseline PSA, biopsy Gleason sum and comorbidity


Our analysis supports several findings. First, urinary function and bother do not vary consistently with each other across both countries. Of men with any urinary bother, the Americans reported more urinary dysfunction than did the Japanese. This cross-national difference is consistent with prior work showing that 63% of Japanese prostatectomy subjects who used no pads consistently reported not leaking urine at all,14 while only 42% of American prostatectomy subjects demonstrated concordance between not leaking urine at all and using no pads.15 Japanese men may be less likely than American men to acknowledge or consult their physicians about urological symptoms.5

Second, bowel function and bother were strongly and more consistently correlated in both countries. Japanese and American men experiencing no bowel bother both reported excellent bowel function, while those with any bowel bother reported significantly worse bowel function. It is not clear whether the national variations we found in association between function and bother are attributable to intrinsic differences or the relative disease severity in our two samples. The two cultural groups may simply have different concepts of health, well-being and illness or disease with regard to urinary function. Even though we used validated survey instruments, we remain cognizant that cross-cultural issues still significantly affect symptom reporting and thus clinical assessment.

Third, men with more urinary and bowel bother reported more limited social activities after treatment for prostate cancer. This underscores the importance of considering cancer-specific bother after treatment for localized prostate cancer. Like fatigue,16 degree of bother due to urinary or bowel dysfunction is one of the factors, diminishing HRQOL such as social activities. However, our results surprisingly showed no meaningful associations between social function and urinary function. It is likely that urinary bother and social function are driven more by irritative and obstructive urinary symptoms, which are not measured by the PCI.17 This is consistent with previous reports that the irritative urinary symptoms often seen after BT cause more distress than does urinary leakage.18

Men in the two countries experienced different effects on their social activities from prostate cancer-specific HRQOL impairments. Specifically, American men were more socially limited by their bowel dysfunction and urinary and bowel bother than were Japanese men. Prior studies have been mixed with regard to whether prostate-specific dysfunction is associated with general HRQOL.19, 20 Our findings suggest that Japanese men may be better prepared for the complications that may ensue from RP or BT. That is, their anticipation of long-term problems may ameliorate any negative psychological consequences by allowing coping strategies that are more culturally consonant.21 Conversely, American men may seek help from the partner, family members or other sources of social support after prostate cancer treatment.22 Although no empirical investigations have reported on the specific role of culture between Japanese and American men, there may be cultural differences in perceiving and reporting HRQOL problems.

Fourth, the correlations between urinary bother and social function were more pronounced after than before treatment. This suggests that HRQOL might take on greater importance to individuals living with disease or the sequelae of the treatment as time passes. Men might be more sensitive to side effects if they can attribute such symptoms to the immediate aftermath of treatment. The longitudinal nature of data collection in this study, however, indicates that over time something in the process of recovery provides emotional and physical buffers against the impact of treatment side effects.

Our study has several important limitations. First, the groups were not random samples and as such may not be representative of all men treated for localized prostate cancer in either country. Selection bias may have been introduced by including individuals who either were more interested in the topic or had more time to answer the questionnaires. Second, the groups were imbalanced in several clinical variables, although we attempted to correct this in our multivariate models. Third, we did not account for the impact of disease progression on HRQOL. Although we did not control for this factor, our intent was to describe HRQOL outcomes for early stage prostate cancer. Fourth, we did not assess the sociodemographic variables of marital status, education or income, any of which could have affected our results.21 Fifth, we did not study men who had undergone external beam radiation therapy, who may experience entirely different HRQOL outcomes following treatment. Finally, in 2001–2002 permanent seed implantation was not covered by Japan's national health insurance system. Hence, Japanese patients in this study who underwent BT during that period paid for it out of pocket and as such may not be socioeconomically representative of the general population.

Despite these limitations, this cross-cultural comparison may aid in the counseling of patients regarding therapy decisions for newly diagnosed, localized prostate cancer. These differences highlight the need for pretreatment discussions with patients and families about quality-of-life expectations after treatment.23


We found significant cross-national variations between Japanese and American men in associations between urinary function and bother and the impact of urinary and bowel impairment on social activities following treatment.


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Dr Tatsuo Tochigi and Dr Sadafumi Kawamura, Miyagi Cancer Center; Dr Naomasa Ioritani and Dr Masataka Aizawa, Sendai Shakaihoken Hospital; Emiko Izutu, Tohoku University Hospital and Griselda Lopez, University of California, Los Angeles, assisted with data collection and management.

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Correspondence to M S Litwin.

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Namiki, S., Kwan, L., Kagawa-Singer, M. et al. Distress and social dysfunction following prostate cancer treatment: a longitudinal cross-cultural comparison of Japanese and American men. Prostate Cancer Prostatic Dis 12, 67–71 (2009) doi:10.1038/pcan.2008.20

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  • prostatic neoplasms
  • quality of life
  • social activity
  • cross-cultural comparative study

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