In our study, we showed that men with prostate cancer on AS, 5 years after their diagnosis of cancer, didn’t present an increased risk of anxiety or depression compared to patients treated by RP or RT, which is also reflected by the absence of overconsumption of anxiolytics. These results are consistent with those of the previously published ProtecT study, which assessed anxiety and depression using the Hospital Anxiety and Depression Scale (HADS)17. In the current literature regarding AS patients, the majority of the studies found low levels of anxiety, prostate cancer-specific anxiety, and depression17,18,19,20,21. Punnen et al. longitudinally studied anxiety and depression in 679 men who underwent RP or AS within 1 year, and between 1 and 3 years from baseline. Anxiety symptoms were measured using the General Anxiety Disorder scale 7 (GAD-7), distress was ascertained using the Distress Thermometer and Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). No difference in prevalence rates of depression, anxiety, and distress over time was noted , with < 5% of patients exhibiting moderate or high levels of depression or anxiety in both groups18. Van den Bergh et al. reported that patients with low-risk PC who chose AS showed low anxiety and distress from the time of diagnosis up to 9 months. Significant decreases were seen between 2.4 and 9.2 months after diagnosis in mean scores of general anxiety (STAI-6) (p = 0.016), prostate cancer-specific anxiety (MAX-PC), fear of progression subscale (p = 0.005), and self-estimated disease progression risk (p = 0.049)19. Men with prostate cancer on AS exhibit low general and illness-specific anxieties, relayed by Jake Anderson et al. A high percentage of men had low levels of general state anxiety as measured by the HADS-A (86%) and trait anxiety as measured by the STAI-T (77%). For illness-specific anxieties, 87% of men reported low levels of prostate cancer-related anxiety and 92% reported low levels of fear of recurrence20. In a study conducted by Marzouk et al., men undergoing active surveillance did present a moderate risk of cancer specific anxiety, which was 29% risk of reporting cancer specific anxiety within the first year. Moreover, anxiety significantly decreased with time21.

In the patients on AS, some risk factors of anxiety and depression have been identified in the literature. Greater intolerance of uncertainty and moderate/severe urinary symptoms have been described as risk factors in patients on AS, as shown by Tan et al.22. Other risk factors as neurotic personality score seemed to be an important determinant of anxiety and distress in men on AS23. In our study, we identified new factors significantly associated with anxiety and depression in patients with localized prostate cancer, in particular a financial situation perceived as critical or difficult. Less surprisingly, the other parameters of HR-QOL, namely mental or physical HR-QOL and reported fatigue, were also associated with anxiety and depression.

Strengths of our study are the prospective, population-based and nationwide design, which facilitates generalizability. Moreover, we ensure long-term follow-up with a larger sample at 5 years, and a high questionnaire response rate which increased the precision and internal validity. Finally, the evaluation of the consumption of anxiolytics is an interesting parameter that has not been usually evaluated previously.

Several limitations of the present study require discussion. First, the active surveillance protocol was not standardized, as it was left to the discretion of the urologist, assuming regular PSA monitoring and repeat biopsies according to national guidelines. Similarly, the criteria for treatment choice were not detailed. These limitations are inherent in the design of the VICAN observational survey. A second limitation is that this research used self-report measures by phone, which may limit the objectivity of participant responses and induce a risk of information bias. In the end, the distribution of patients in each group is unequal, without randomization, which can induce a patient selection bias. Although the overall response rate is quite high in this survey (43% of patients with prostate cancer at diagnosis), we do not know if the response rate was similar across the different treatment groups (AS versus other), especially for patients presenting with symptoms of depression or anxiety, and this could induce a nonresponse bias.

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