2025 Volume 266 Issue 4 Pages 343-351
Offline cognitive-behavioral stress caring program (CBSC) modifies maladaptive cognition and improves management stress skills, which relieves mental disorders in some cancer patients; however, it is limited by space and time. This study compared the effect of online and offline CBSC on mental health, spiritual well-being, fatigue, and patient satisfaction in prostate cancer survivors after prostatectomy. Totally, 147 prostate cancer survivors after prostatectomy were divided into offline (n = 89) and online (n = 58) CBSC groups. CBSC included stress management, relaxation, disease-relevant education, and weekly homework. Selection bias was adjusted by matching patients in both groups (1:1) using propensity scores (n = 58 in both groups after adjustment). Hospital Anxiety and Depression Scale (HADS)-anxiety, HADS-depression, Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale (FACIT-SP), the brief fatigue inventory-China (BFI-C), and patient satisfaction score (PSS) were evaluated. ‘Improvement’ was defined as positive improvement values in indexes after a 10-week CBSC. Before and after adjustment, HADS-anxiety, HADS-depression, FACIT-SP, BFI-severity, and BFI-interference scores were improved at week 10 vs. baseline in the online or offline CBSC group. However, these scores did not vary at baseline or week 10 between groups. The improvement of HADS-anxiety, HADS-depression, and FACIT-SP scores was smaller in online CBSC group than in offline CBSC group. The improvement of BFI-severity and BFI-interference scores were non-differential between groups. PSS scores were reduced in online CBSC group vs. offline CBSC group. Overall, online CBSC alleviates mental disorders, elevates satisfaction, and relieves fatigue in prostate cancer survivors after prostatectomy, but its overall effect is less than offline CBSC.
Prostate cancer is the second most frequent malignancy among men, with 1,414,259 new cases and 375,304 deaths in 2020 around the world (Sung et al. 2021; Bergengren et al. 2023). Prostatectomy is a common treatment option to prolong the survival of prostate cancer patients (Sekhoacha et al. 2022; Williams et al. 2022). However, due to some postoperative complications, such as urinary incontinence and erectile dysfunction, prostate cancer survivors after prostatectomy often suffer from anxiety and depression (Nelson et al. 2011; Oeffinger 2023; Tozzi et al. 2024). Moreover, these survivors also experience reduced spiritual well-being and increased fatigue (Luo et al. 2021; Xia et al. 2023). Notably, cognitive-behavioral stress caring program (CBSC) changes individuals’ maladaptive minds and increases individuals’ ability to deal with stress, whose traditional offline model shows a good effect on alleviating a series of mental disorders in postoperative prostate cancer patients (Traeger et al. 2013; Carlson et al. 2019; Curtiss et al. 2021; Nakao et al. 2021; Sui and Guo 2024). However, traditional offline CBSC may not reach some patients, such as those with stigma, unwillingness to communicate offline, geographical limitations, or physical disabilities (Cuijpers et al. 2008). Moreover, traditional offline CBSC consumes a great deal of time and energy of therapists (Cuijpers et al. 2008). Therefore, searching for a novel CBSC model may be further conducive to the management of prostate cancer survivors after prostatectomy.
With the progress of information technology, online CBSC shows the advantages of increased accessibility of populations, convenience, saving time, and high cost-effectiveness, which has become a burgeoning nursing method (Cuijpers et al. 2008; Andersson and Titov 2014; Andersson et al. 2019). In recent years, online CBSC is gradually applied in some cancer patients (Carpenter et al. 2014; Zhang et al. 2018; Liu and Sun 2023). For example, a previous study found that online CBSC was effective in helping breast cancer patients increase confidence in their ability to cope with stress (Carpenter et al. 2014). Another study illustrated that online CBSC reduced cancer-related fatigue, decreased depression, and elevated the quality of sleep in patients with ovarian cancer (Zhang et al. 2018). However, relevant studies exploring the effect of online CBSC in postoperative prostate cancer patients are lacking.
Thus, this study aimed to compare the effect of online and offline CBSC on anxiety, depression, spiritual well-being, fatigue, and patient satisfaction in prostate cancer survivors after prostatectomy.
From May 2021 to March 2023, this prospective cohort study consecutively included 147 prostate cancer survivors after prostatectomy who had symptoms of anxiety or depression. The inclusion criteria were: 1) diagnosed with prostate cancer by pathological methods; 2) aged more than 18 years old; 3) survivors of prior prostatectomy; 4) with symptoms of anxiety or depression currently (defined as Hospital Anxiety and Depression Scale (HADS)-anxiety score ≥ 8 or HADS-depression score ≥ 8, respectively) (Hauffman et al. 2020); 5) about to receive offline cognitive-behavioral stress caring program (CBSC) or online CBSC for stress relief. This study excluded those who: 1) with other solid tumors or hematological malignancies; 2) with recurrence of prostate cancer at enrollment; 3) with abnormal cognitive function that could not fill in the relevant questionnaires. This study was approved by the Ethics Committee of Harbin Medical University Cancer Hospital, and each participant signed the informed consent.
Data collection and group settingBaseline demographics, disease histories, and therapies were collected. Patients chose offline CBSC or online CBSC based on their anxiety or depressive symptoms and according to their preferences. According to the choice of patients, 89 cases were included in the offline CBSC group and 58 cases were included in the online CBSC group. The study did not interfere with any treatment of prostate cancer.
Brief of the CBSCCBSC was performed in a group-based format with 10-week sessions, and each session lasted for 90 minutes (60-minute stress management and 30-minute relaxation). The content of CBSC included stress management, relaxation, disease-relevant education, and weekly homework, which was identical to a previous study (Penedo et al. 2021). Offline CBSC was a conventional project implemented offline, while online CBSC was implemented based on WeChat (Tencent, China) or a network platform.
QuestionnairesAnxiety or depression symptoms, spiritual well-being, and fatigue state were evaluated at baseline and 10 weeks after CBSC initiation (week 10). More specifically, the HADS-anxiety or HADS-depression scores were used for evaluating anxiety or depression symptoms, respectively (Zigmond and Snaith 1983); the Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale (FACIT-SP) was used for evaluating spiritual well-being (Peterman et al. 2002); the brief fatigue inventory-China (BFI-C) was used for evaluating fatigue state, which contained BFI-severity and BFI-interference scores (Wang et al. 2004). The ‘Improvement’ was defined as positive improvement values observed in the above evaluation indexes after a 10-week CBSC (e.g., a decrease in HADS and BFI-C scores; and an increase in FACIT-SP). Besides, the satisfaction of patients was evaluated at week 10 using an 11-point scale (0-10) patient satisfaction score (PSS). A score of ‘0’ represented very dissatisfied, while ‘10’ represented very satisfied; the higher the more satisfied.
Data analysesSPSS version 26.0 (IBM, USA) was used for data analyses. Continuous variables were described as mean ± standard deviation (SD), and comparison analyses between groups or within each group were conducted using the student t-test or paired t-test, respectively. Counting variables were described as numbers (percentage), and comparison analyses between groups were conducted using the χ2 test or Fisher’s exact test. Patients who lost follow-up at 10 weeks were excluded from the study analysis. To adjust for selection bias, patients in both groups were matched in a 1:1 ratio using propensity scores [A statistical method that eliminates the imbalance between groups, which reduces selection bias caused by confounding variables and increases the reliability of the results (Liau et al. 2024)]. A P < 0.05 indicated significance.
There were 58 patients in the online CBSC group with a mean age of 63.5 ± 8.7 years and 89 patients in the offline CBSC group with a mean age of 66.0 ± 8.8 years. There was a certain difference in age between the 2 groups, but it was not statistically significant (P = 0.090). The proportion of local patients was lower in the online CBSC group than in the offline CBSC group (P = 0.016). No discrepancy was observed in other clinical features between the 2 groups (all P > 0.05). To eliminate the influence of confounding factors, age and residence were adjusted. Patients were matched in a 1:1 ratio in both groups. After adjustment, the number of patients in the 2 groups was both 58. There was no difference in the clinical features between the 2 groups, including demographics, disease histories, or therapies (all P > 0.05). More specific information on the 2 groups is shown in Table 1.
Clinical characteristics of prostate cancer survivors.
CBSC, cognitive-behavioral stress caring program; SD, standard deviation; EBRT, external beam radiotherapy; ADT, androgen deprivation therapy.
Before adjustment and after adjustment, the HADS-anxiety scores and HADS-anxiety scores were reduced, and FACIT-SP scores were elevated at week 10 compared to baseline, whether in the online group or in the offline CBSC group (all P < 0.001) (Table 2).
Comparison of anxiety, depression, and spiritual well-being between baseline and week 10 in each group.
CBSC, cognitive-behavioral stress caring program; HADS, Hospital Anxiety and Depression Scale; SD, standard deviation; FACIT-SP, Functional Assessment of Chronic Illness Therapy Spiritual Well-Being Scale.
Before adjustment, there was no discrepancy in HADS-anxiety scores at baseline (P = 0.459) or week 10 (P = 0.146) between the 2 groups, while the improvement of HADS-anxiety score was smaller in the online CBSC group than in the offline CBSC group (P = 0.002) (Fig. 1A). After adjustment, HADS-anxiety scores did not differ at baseline (P = 0.858) or week 10 (P = 0.054) between the 2 groups. However, the improvement of HADS-anxiety score was smaller in the online CBSC group vs. the offline CBSC group (P = 0.007) (Fig. 1B).
Before adjustment, HADS-depression scores at baseline (P = 0.320) or week 10 (P = 0.287) were not different between the 2 groups. HADS-depression scores showed a smaller improvement in the online CBSC group vs. the offline CBSC group (P = 0.020) (Fig. 1C). After adjustment, HADS-depression scores did not vary at baseline (P = 0.723) or week 10 (P = 0.166) between the 2 groups. The improvement of HADS-depression score was slighter in the online CBSC group than in the offline CBSC group (P = 0.044) (Fig. 1D).
Comparison of anxiety and depression between groups.
Comparison of HADS-anxiety scores before adjustment (A) and after adjustment (B) between groups; comparison of HADS-depression scores before adjustment (C) and after adjustment (D) between groups.
Before adjustment, there was no difference in FACIT-SP scores at baseline (P = 0.436) or week 10 (P = 0.290) between the 2 groups. The improvement of FACIT-SP score was smaller in the online CBSC group than in the offline CBSC group (P = 0.006) (Fig. 2A). After adjustment, there was no difference in FACIT-SP scores at baseline (P = 0.892) or week 10 (P = 0.149) between the 2 groups, but the improvement of FACIT-SP score was slighter in the online CBSC group than in the offline CBSC group (P = 0.016) (Fig. 2B).
Comparison of spiritual well-being between groups.
Comparison of FACIT-SP scores before adjustment (A) and after adjustment (B) between groups.
Before adjustment, the BFI-severity scores did not vary (P = 0.181), but BFI-interference scores were reduced at week 10 vs. baseline in the online CBSC group (P < 0.001). The BFI-severity and BFI-interference scores were reduced at week 10 vs. baseline in the offline CBSC group (all P < 0.001). After adjustment, the BFI-severity scores did not change (P = 0.181), while BFI-interference scores were decreased at week 10 vs. baseline in the online CBSC group (P < 0.001). The BFI-severity scores (P = 0.002) and BFI-interference (P < 0.001) scores were both reduced at week 10 vs. baseline in the offline CBSC group (Table 3).
In terms of comparison analyses between groups, whether the selection bias was adjusted or not, there was no discrepancy in BFI-severity scores at baseline or week 10 between the 2 groups (all P > 0.05). No difference was observed in the improvement of BFI-severity score between the 2 groups (both P > 0.05). In addition, whether adjusting the confounding factors or not, BFI-interference scores at baseline, BFI-interference scores at week 10, and the improvement of BFI-interference score did not vary between the 2 groups (all P > 0.05) (Table 3).
BFI-C score of prostate cancer survivors.
BFI-C, brief fatigue inventory-China; CBSC, cognitive-behavioral stress caring program; SD, standard deviation.
The superscript’#’ indicated that P value was conducted for the comparison within each group before (baseline) and after (Week 10) the program.
When the selection bias was not adjusted, PSS was reduced in the online CBSC group compared to the offline CBSC group (P = 0.045) (Fig. 3A). After adjusting for age and residence, PSS was also decreased in the online CBSC group compared with the offline CBSC group (P = 0.034) (Fig. 3B).
Comparison of the satisfaction of patients between groups.
Comparison of PSS before adjustment (A) and after adjustment (B) between groups.
The main findings of our study included: (1) Online CBSC achieved smaller improvements in anxiety, depression, and spiritual well-being vs. offline CBSC in prostate cancer survivors after prostatectomy. (2) Online CBSC showed a comparable effect on fatigue vs. offline CBSC in prostate cancer survivors after prostatectomy. (3) Online CBSC reduced satisfaction vs. offline CBSC in prostate cancer survivors after prostatectomy.
Anxiety and depression are common psychiatric symptoms that occur in prostate cancer survivors after prostatectomy (Meissner et al. 2023; Kim et al. 2024). Previous studies have reported that offline CBSC-involved management effectively ameliorated mental disorders in prostate cancer patients after prostatectomy (Traeger et al. 2013; Sui and Guo 2024). Online CBSC is timesaving, highly cost-effective, and convenient, which may reach populations who are limited by space, time, or physical disability (Cuijpers et al. 2008). Currently, online CBSC has gradually attracted extensive attention in the medical field (Cuijpers et al. 2008; Ruwaard et al. 2012; Carpenter et al. 2014; Shirotsuki et al. 2017; Zhang et al. 2018; Liu and Sun 2023). Herein, our study compared the influence of online and offline CBSC on anxiety and depression in prostate cancer survivors after prostatectomy. Notably, in our study, the proportion of local patients was lower in the online CBSC group than in the offline CBSC group. This was because: patients chose online CBSC or offline CBSC according to their preferences; due to the location advantage, local patients might be more willing to receive offline management than nonlocal patients. Our study adjusted this confounding factor (residence) by propensity scores and then found that the improvements in anxiety, depression, and spiritual well-being were smaller in the online CBSC group than in the offline CBSC group. The possible causes might be as follows: (1) CBSC involved theoretical education (Penedo et al. 2021). The learning atmosphere of online CBSC might not be as good as that of offline CBSC; thus, the effectiveness of online CBSC was relatively low (Jiao et al. 2022; Zhang et al. 2023). (2) Patients who received online CBSC were less convenient than those who received offline for communication and interaction with therapists, thus their improvement in mental health was smaller (Singh et al. 2022; Zhang et al. 2023).
In addition to mental disorders, fatigue is also a noteworthy issue that negatively affects the daily life of prostate cancer survivors for a long time (Ashton et al. 2019; Luo et al. 2021). Our study exhibited that the influences of online and offline CBSC on fatigue were not different. This might be because: the fatigue of prostate cancer survivors might be linked to a variety of factors, such as increased inflammation, abnormal hormone levels, the use of drugs, postoperative complications, and psychological factors (Thong et al. 2020). Simply changing the online or offline form of CBSC might have little impact on these factors. In terms of the satisfaction of patients, our study disclosed that online CBSC reduced PSS scores compared with offline CBSC in prostate cancer survivors after prostatectomy. It would be explained by several points: (1) Compared with offline CBSC, online CBSC may reduce the non-verbal communication between therapists and patients, such as smiling, physical touch, and eye contact, which weakens their intimate relationship, thus decreasing the satisfaction of patients. (2) Offline CBSC provides face-to-face communication and interaction, while online CBSC does not. When patients express their needs and seek help, online CBSC may solve problems less quickly and effectively than offline CBSC, thereby reducing the satisfaction of patients.
Notably, the CBSC contents in our study were basically consistent with those of previous studies, including stress management, relaxation, and weekly homework (Carpenter et al. 2014; Zhang et al. 2018). However, there were some differences: in previous studies, some additional parts, such as guided writing exercises and fatigue management training were included (Carpenter et al. 2014; Zhang et al. 2018). In our study, an education part about prostate cancer-relevant content was included, which was refer to a previous study (Penedo et al. 2021).
According to the results of our study, it was observed that online CBSC was less effective in alleviating mental health than offline CBSC in prostate cancer survivors after prostatectomy. This might be attributed to some advantages of offline interventions, such as providing a better intervention atmosphere and more interaction (Andersson and Titov 2014; Lieberman and Schroeder 2020). However, online CBSC also has some unique advantages, such as high cost-effectiveness, time freedom, convenience for patients with physical disabilities, reducing the stigma of patients going to a psychologist, and save the time of therapist (Cuijpers et al. 2008; Mohr et al. 2010; Andersson and Titov 2014). Taken together with our findings, offline CBSC could be recommended for most prostate cancer survivors after prostatectomy. However, for those patients who were limited by space, time, or physical conditions, online CBSC might be a more appropriate choice than offline CBSC. With the continuous development of online CBSC, it is likely to become a promising nursing intervention in medical use in future landscape. Recently, a blending concept of offline and online was proposed, which might be a novel model for the management of postoperative cancer survivors (Erbe et al. 2017). However, the application of this model in prostate cancer survivors after prostatectomy still needs further verification.
In our study, HADS, FACIT-SP, BFI-C, and PSS questionnaires had high reliability in Chinese population (Wang et al. 2004; Li et al. 2016; Liu et al. 2022; Luo et al. 2023). However, there still existed some limitations in our study: (1) our study only assessed short-term anxiety, depression, spiritual well-being, fatigue, and satisfaction of prostate cancer survivors after prostatectomy. The comparison of long-term effects between online and offline CBSC should be explored in future studies. (2) Our study only enrolled prostate cancer patients who received prostatectomy. Further studies should consider exploring the effect of online and offline CBSC in prostate cancer patients who are unable to receive surgery. (3) All questionnaires in our study were self-assessed, which might affect the results.
In conclusion, online CBSC may be a promising nursing intervention, while it is less effective in alleviating mental disorders and increasing satisfaction vs. offline CBSC in prostate cancer survivors after prostatectomy. Moreover, online and offline CBSC show a comparable influence on fatigue in these patients. However, more randomized controlled trials and large-sample studies are required to verify our results.
The authors declare no conflict of interest.
