Predictors of well-being and quality of life in men who underwent radical prostatectomy: longitudinal study

ABSTRACT Objective: to identify socio-demographic, clinical and psychological predictors of well-being and quality of life in men who underwent radical prostatectomy, in a 360-day follow-up. Method: longitudinal study with 120 men who underwent radical prostatectomy. Questionnaires were used for characterization and clinical evaluation of the participant, as well as the instruments Visual Analog Scale for Pain, The Ways of Coping Questionnaire, Hospital Depression and Anxiety Scale, Satisfaction with Social Support Scale, Marital Satisfaction Scale, Subjective Well-Being Scale and Expanded Prostate Cancer Index. For data analysis, the linear mixed-effects model was used. Results: the socio-demographic factors age and race were not predictors of the dependent variables; time of surgery, problem-focused coping, and anxiety were predictors of subjective well-being; pain, anxiety and depression were negative predictors of quality of life; emotion-focused coping was a positive predictor. Marital dissatisfaction was a predictor of both variables. Conclusion: predictor variables found were different from the literature: desire for changes in marital relationship presented a positive association with quality of life and well-being; emotion-focused coping was a predictor of quality of life; and anxiety was a predictor of subjective well-being.

important as prostate cancer control itself, since changes in quality of life have been shown to affect satisfaction with the treatment outcome (12) . This concept is characterized as a feeling of satisfaction and prosperity in the context of the needs and capacities of the human being. However, the role of health-related quality of life for the selection of the systemic therapy for patients with prostate cancer remains uncertain (13) .
Studies indicate that factors related to the health of the individual and to the surgery (14)(15)(16)(17) , in addition to socio-cultural, emotional and physical aspects (9,13) and the conditions for the performance of daily life activities (18) , determine well-being and quality of life prospects for the surgical recovery of patients submitted to radical prostatectomy. The parameter considered is conditions superior or equivalent to those of the preoperative period.
Factors such as increased age (19)(20) , longer time of surgery and prolonged exposure to the anesthetic procedure and anesthetic agents (21) , complications in the patient recovery process (22)(23) pain after radical prostatectomy (24)(25)(26) , and unfavorable results regarding sexual function (27) affected the patients' perceptions of well-being and quality of life.
Regarding the psychological factors, high capacity to cope with stress resulted in a lower intensity of the postoperative symptoms. Patients with lower capacity to cope with stress presented greater problems during surgery recovery (28) . Problem-focused coping was a positive predictor for psychological well-being and quality of life, while emotion-focused coping was negative (29)(30) .
Social support had positive effects on human life during difficult times, on recovery activities, well-being, health and adjustment to stress, which resulted in a better quality of life (31)(32)(33) . Psychological symptoms such as anxiety and depression were related to lower quality of life and well-being, with increased pain and sensitivity to symptoms. These symptoms may negatively influence patients' motivation, energy, their coping with the disease, adherence to treatment and the recovery process (34)(35)(36) . Likewise, marital support was related to higher levels of quality of life, physical and mental health and recovery after radical prostatectomy (37)(38)(39) .
Understanding the surgical recovery of men after prostatectomy may favor the use of approaches directed to their characteristics. In this sense, the objective of this study was to identify socio-demographic, clinical and psychological predictive factors for the well-being and quality of life of men submitted to radical prostatectomy, in a 360-days follow-up.

Method
This is a longitudinal descriptive observational study (40) , conducted in the Urology Division of a public teaching hospital in the state of São Paulo, a reference in urologic oncology. Participants were men undergoing prostatectomy. After the medical indication for surgery, they were invited to the study by the main investigator.
Those who agreed to participate in the study by signing the Informed Consent Term, had their data collected, Regarding the collection process, there was a 6.5% to 12.2% loss to follow-up in the different periods.
The data collection in T0 occurred in the hospitalization unit and, in the other periods, it occurred in the outpatient sector. The presence or not of companions or caregivers in the room was at the discretion of the participant.
The researcher assessed the participant's ability to understand and respond to items of the instruments. For this, questions such as "What is the current date? What is the reason for hospitalization? What is the date and time of the surgery?" were asked. Then, the participants analyzed the instruments for their ability to respond to the items presented.
Men with prostate cancer (stage T1-T3), selected for surgical treatment (RP) by the medical team, who did not present clinical signs of metastases, aged 18 years or older and who reported they were able to read and write in Portuguese were included in the research.
Patients with a previous history of bladder or prostate surgery, diagnosis of neurological disease with probable repercussion on urinary control (for example, Parkinson's disease, psychiatric disease, Alzheimer's disease and spinal cord diseases) and those previously submitted to chemotherapy or radiotherapy were excluded.
The researcher approached 125 men who had clinical indication for prostate surgery. Of these, two did not meet the criteria (one had undergone chemotherapy and another had a prior surgery) and another three had the indication of surgery suspended. Data from 120 men undergoing prostatectomy were observed.
In this research, there was no interference of the researcher in the treatment and no assistance provided to the patient. If necessary, the patient would be directed to the responsible multidisciplinary team, but there was no need for this procedure.
The data collection instruments were completed with the researcher reading the instructions and the items. with "no pain" and "worst pain imaginable" at the extremities and "moderate pain" in the middle" (41)(42) ; • The Ways of Coping Questionnaire (43) -instrument adapted to the Brazilian culture (44) , with 66 items divided in 8 factors, answered on a Likert scale, with four possibilities: 0) Not at all, 1) A little, 2) pretty much, 3) a lot. In the factorial analysis carried out in the adaptation to Brazilian culture (44) , eight factors were identified (confrontation, distancing, self-controlling, social support, accepting responsibility, escape/ avoidance, problem solving and positive reappraisal), and most items found in each factor presented a factorial load similar to those obtained by the authors of the instrument (43) . In the present study, all the items of the original scale were included, as in other studies (45)(46) , and the eight classification factors initially proposed by the authors of the instrument were adopted (43) , but composed of the items indicated by the authors who adapted the instrument for Brazilian culture (44) . The ways of coping were classified into two categories: problem-focused coping and emotion-focused coping. The first is a combination of four-factors (confrontation, seeking social support, problem solving, and positive reappraisal), and the second is a combination of three-factors: distancing, accepting responsibility, and escape/avoidance. The factor self-controlling is considered independent, since it scores equally in both categories (47)(48) . Higher scores in the instrument indicate greater coping capacity (43,49) . In this research, problem-focused suggest the possibility of abnomarlity and more than 11 indicate probable abnormality. Score 8 is considered the cut-off point between the presence or absence of symptomatology (50)(51) .
In this study, the HADS score obtained a total Cronbach score of 0.71; • Satisfaction with Social Support Scale (SSSS) (52) -this scale consists of 15 statements regarding the perception of support received from friends, family and community. They are distributed in four Rev. Latino-Am. Enfermagem 2018;26:e3031.
factors, and 6 items must be reverted for analysis.
It is a 5-point Likert scale (5 -Totally agree, 4 -Partially agree, 3 -Neither agree nor disagree, 2 -Partially disagree and 1 -Strongly disagree), and the higher the score obtained, the greater the satisfaction with social support (52) . In this study, the scale presented Cronbach's alpha of 0.77; • Marital Satisfaction Scale -the instrument was validated for the Brazilian population (53) . There are three options for answering each item, which allow to qualify the level of satisfaction of the individual with respect to the conjugal aspects:  (54)(55) .
Regarding the data analysis, the results obtained in the continuous or discrete quantitative variables were Mixed Models) was used (56) . This method allows to describe the temporal trend taking into account the correlation between successive means and to estimate the variation in basal measurement and rate of change over time.
The dependent variables in the study were the total scores of the SWB and EPIC scales, the total scores of

Results
The initial number of participants (T0) in the study was 120 (Figure 1). The mean scores of the other variables, in the T0-T4 periods, are listed below (Table 1).

Regarding the socio-demographic
In the initial regression model, age, race, duration of anesthesia, pain, emotion-focused coping, depression and satisfaction with social support were not predictors of subjective well-being (p>0.05). In the final model of regression analysis, the variables time of surgery (p≅0.000), problem-focused coping (p≅0.000), anxiety (p=0.007) and marital satisfaction (p=0.010) were predictors of subjective well-being (Table 2).
It is expected that, for each one-point increase in problem-focused coping, there will be a relative increase of 5.9% in the mean of subjective well-being. For each one-point increase in the anxiety score, a relative increase of 0.6% in the mean well-being is expected.
For each one-point increase in the marital satisfaction score, a relative increase of 3.8% in the mean well-being is expected, suggesting that the more dissatisfied one is  (Table 3).     Romanzini AE, Pereira MG, Guilherme C, Cologna AJ, Carvalho EC.

Discussion
The literature reports frequent occurrence of imbalance or inequality in the number of participants in longitudinal studies (56) . In the present research, there was variation in the number of participants in the evaluation periods. Loss to follow-up may impair the internal validity and completion of the study (57) , but a participant's withdrawal may be reversible.
Thus, considering a single episode of non-response as non-participation may be premature (58) . This means that the analyzes may include temporary losses in previous moments, as occurred in this research in T2 and T3 (Figure 1). In order to adjust the data to the characteristics of the study design, analyzes were performed through mixed-effects models, which accept that the measurements of individuals do not need to be equal at all times (56) .
Regarding socio-demographic variables, age and race/color were not predictors, which was also found in other studies (55,59) . However, studies indicate that age greater than 60 years had greater impacts on quality of life (60) and that white individuals had better survival rates when compared to blacks (61)(62) .
Regarding the conditions of the surgical procedure, in the present study, time of surgery was a predictor of subjective well-being. There are reports in the literature that longer surgeries of radical prostatectomy are associated with more complications, longer periods of hospitalization and higher costs, which undermines the patient's well-being (21,63) . The mechanism by which hospital discharge is delayed and the recovery process is affected can be explained by the complexity of the pathology that required surgical intervention and by prolonged exposure to the anesthetic and surgical procedure and anesthetic agents (22) . A study showed that an increase in the radical prostatectomy operative time of 30 or 60 minutes was associated with 1.6 and 2.8 times increased risks of symptomatic venous thromboembolic events (21) . The association between time of surgery and well-being in the present study can be explained by the participant's (positive) cognitive evaluation of having successfully undergone the surgical and anesthetic procedure, with an expectation of cure for prostate cancer.
Surgical treatment for prostate cancer involves potential benefits and risks (3,(64)(65) . Factors inherent to the patient and to the surgical process may influence the development of problems related to cancer treatment and its duration. Many problems persist for years, affecting the patient's quality of life and wellbeing (66)(67)(68) .
Regarding the clinical variables, pain was a predictor of quality of life in the present study. This symptom was pointed out as a common factor associated with radical prostatectomy and related to the reduction of patients' quality of life, particularly regarding social function, Rev. Latino-Am. Enfermagem 2018;26:e3031.
walking and work activities, but the impact on these activities decreased with time (24)(25) .
In the present study, regarding the emotional variables, anxiety was a predictor of subjective wellbeing, as well as of quality of life. On the other hand, depression was only a predictor of quality of life.
However, in the prediction of anxiety in relation to wellbeing, as well as depression in relation to quality of life, the results indicated a direct relation, that is, the increase in the first predictive variable was associated with an increase in the outcome variable.
According to the literature, psychological symptoms such as anxiety and depression were related to worse postoperative outcomes and quality of life, as well as sensitivity to post surgery symptoms such as pain.
These symptoms may negatively influence motivation, level of energy, coping with the disease and adherence to treatment (34) . regarding the treatment (69) . Anxiety and depression can negatively influence motivation, energy, coping with the disease, adherence to treatment and, consequently, the patients' well-being (34) .
Regarding the type of coping, in the present study, problem-focused coping was a predictor of subjective well-being, whereas emotion-focused coping was a predictor of quality of life. One study pointed out that the intensity of the postoperative symptoms was inversely related to the capacity to deal with stressful situations (28) .
Other study has shown that patients have tendencies to deal with situations by focusing on problems rather than focusing on emotions (30) . In this sense, problem-focused coping was a positive predictor of psychological wellbeing, whereas emotion-focused coping was negatively associated with well-being (29) . Patients undergoing radical prostatectomy who used problem-focused coping experienced less anxiety and depression compared to those who used emotion-focused coping (70) . Problemfocused coping was a predictor of quality of life in the six and twelve-month postoperative period of radical prostatectomy (68) .
However, in our research, emotion-focused coping was a predictor of quality of life. These results generate new points of view on ways of coping, since they are in opposition to those pointed out in the literature (30,68) .
Regarding the variable satisfaction with social support, despite its relevance in situations of chronic diseases in which social support is present, in this study, it was not a predictor of well-being or quality of life.
In the treatment of prostate cancer, spouses take on the role of maintaining emotional balance, internalizing their feelings to try to keep a positive outlook for their partners. The responses of spouses to the results of the treatment can affect their own quality of life and the patients' (38,71) . A study pointed out that marital support was associated with higher levels of quality of life and it was essential for marital adjustment (72)(73) .
Regarding the outcome variables of the present study, it is important to highlight that subjective wellbeing is associated with mental health aspects and, to a lesser degree, with physical variables (74) . Subjective well-being can be affected by a number of factors, such as personality characteristics, health conditions, ability to manage economic life, presence of supportive relationships, place of living, freedom to make life choices, and enjoying work activities (7)(8) . In the present study (Table 2), the predictors of well-being were time of surgery, anxiety, problem-focused coping, and the desire for changes in marital satisfaction.
The distribution of means of well-being from T1 to T4 did not show differences in relation to T0. This result may be related to the observation period (360 days), which may have been insufficient to recover from the psychological effects related to frustrations and non-acceptance of changes required by the disease and treatment. Therefore, the level of well-being remained stable, unlike a study that reported that this factor remained stable in the first months after radical prostatectomy, but it increased after three months (6) .
In the present study, as discussed above, the increase in well-being was related to greater desire to change the marital relationship. Thus, these results can be considered unusual, since the literature reports that increased well-being is related to increased marital satisfaction (38,71) . Increased anxiety also had a positive relationship with increased quality of life. On the other hand, the literature highlights that anxiety is a predictor of several undesirable outcomes after surgery. However, it was also considered a predictor of quality of life in a study of prostatectomized men (70) .
The relevance of assessing the level of well-being is supported by evidence from studies that pointed out that a high level of subjective well-being contributed to the surgical recovery process, since it increased the patient's energy level and favored the performance of activities of daily living (6)(7)(8) . Subjective well-being was also considered a protective factor against mental illness, psychopathological symptoms and biomarkers of physical health (75) . On the other hand, low well-being negatively influenced the functional and emotional outcomes of patients in the postoperative period (76) .
Negative impacts on psychological well-being and general health after radical prostatectomy were related to physiological problems derived from the surgical treatment, such as urinary incontinence and/or erectile dysfunction (77)(78) .
Regarding quality of life, the other outcome of this study, it should be pointed out that in all postoperative periods the mean scores obtained were lower than those of T0, suggesting that in T4 the participants had not yet recovered the baseline condition. However, one study found that about 90% of patients reached the baseline quality of life after a mean period of five months (27) .
Another study identified that quality of life three and six months after treatment was lower than the baseline, especially the results related to urinary function (79) .
Authors report that the persistence of adverse effects such as sexual impotence and urinary incontinence may last for two (4) to four years (80) , which reinforces the findings of the present study.
Regarding the factors that may influence quality of life found in this study, pain, anxiety and depression were negative predictors of quality of life, whereas emotion-focused coping strategies and high scores on the marital satisfaction scale were positive predictors (Table 3).
The challenges posed by prostate cancer affect not only the quality of life of the individual, but also the quality of the relationship between the patients and their spouses. Studies indicate that the general stress associated with care and concerns generated sleep disturbances and impaired well-being and quality of life of the spouse (71) . In addition, couples who used strategies to avoid or defend themselves from cancer concerns and sexual changes have dealt better with prostatectomy-related losses and transformations (39) .
In this sense, the results of this research are unusual, since the desire to change the conjugal relationship, that is, conjugal dissatisfaction, had a positive association with quality of life and well-being. In addition, emotion-