Factors associated with feelings of loss of masculinity in men with prostate cancer in the RADAR trial Christopher F. Sharpley 1 *, Vicki Bitsika 2 and James W. Denham 3,4† 1 Brain-Behaviour Research Group, University of New England, Armidale, Australia 2 Brain-Behaviour Research Group, Bond University, Gold Coast, Australia 3 Department of Radiation Oncology, Calvary Mater Newcastle Hospital, Newcastle, Australia 4 School of Medicine & Public Health, University of Newcastle, Newcastle, Australia *Correspondence to: PO Box 378, Coolangatta, Qld 4225, Australia. E-mail: csharpley@onthenet.com.au † Director, TROG 03.04 RADAR Trial. Received: 25 July 2013 Revised: 20 October 2013 Accepted: 21 October 2013 Abstract Objectives: To identify the factors underlying prostate cancer (PCa) patients’ depression–anxiety, sexual problems, urinary dysfunction and androgen deprivation therapy (ADT)-linked breast changes and hot flushes, and test these as predictors of loss of masculinity (LoM) over 36 months following diagnosis. Methods: One thousand seventy patients from the TROG 03.04 (RADAR) trial the EORTC QLQ C-30 and PR 25 questionnaires, and the International Prostate Cancer Symptom Score of the American Urological Association at baseline, 3, 7, 12, 18, 24 and 36 months. Selected items from these scales were factor-analysed to identify a four-component solution for responses at 18 and 36 months, and these components were regressed against a single-item measuring LoM. Results: Depression–anxiety factor was the most powerful predictor of LoM at both time points, followed by sexual problems of ADT side effects (breast changes and hot flushes). Urinary dysfunction was not a consistent predictor of LoM. Depression–anxiety was also the most significant factor distinguishing between those men who reported LoM and those who did not. Conclusions: Although LoM is often reported as arising from ADT, the relative power of depres- sion–anxiety in predicting LoM, both at the selected time points and using a time-lagged analysis, plus the finding that depression–anxiety was the most consistent difference between men who reported LoM and those who did not, argues for the presence of adverse mood states as being the key ingredient in deciding if PCa patients experience loss of their feelings of masculinity. Copyright © 2013 John Wiley & Sons, Ltd. Introduction Many prostate cancer (PCa) patients report a loss of masculinity (LoM) [1,2], sometimes attributed to the effects of androgen deprivation therapy (ADT) [3,4]. However, quality of life (QoL) data from the randomised controlled RADAR trial for men with locally advanced PCa suggested that the duration of ADT was not a driving issue in overall patient QoL [5]. Further, despite LoM being a component of the ADT-related symptoms domain of the EORTC PR25 organ-specific QoL instrument used in the RADAR trial, the interval change profile of LoM differed substantially from the ADT profile of those patients (shown in Appendix A), suggesting that LoM might be influenced by additional factors to those that lead to other ADT symptoms. Masculinity is a multi-faceted construct that may un- dergo significant reframing by men when they experience the challenge of PCa [6], even to the point where the central characteristics that men have held as indicators of their masculinity are altered [7]. Although it is sometimes considered to be an outcome of decreased sexual activity and performance, urinary dysfunction and ADT side effects [8,9], LoM in PCa patients is a multi-faceted construct that may also be influenced by decreases in men’s perceptions of their self-reliance, competitiveness, control and ability to provide for others [10], plus mental resilience and vulnerability to stress, emotional control and rationality [11], and ability to cognitively process emotions [12]. These contributors to LoM are likely to increase anxiety and depression [13], and it may be that anxiety and depression are involved in LoM as well as the more traditionally iden- tified sexuality, urinary and ADT factors. Therefore, because feelings of LoM are significantly aversive for PCa patients, and because there are few reports investigating the possible antecedents that might contribute to LoM, this study aimed to define and then com- pare the LoM-predictive power of symptoms of depression and anxiety, sexual problems, urinary dysfunction and direct physiological outcomes of ADT that were related to lowered testosterone, using standardised instruments designed to assess QoL in PCa patients. In order to identify any variation over time in the ways that these four aspects of ADT related to LoM, separate analyses were conducted for 18-month and 36-month values collected at those points in time, and for the ‘time-lagged’ effects of the former upon the latter, as an indication of possible ‘causality’. Copyright © 2013 John Wiley & Sons, Ltd. Psycho-Oncology Psycho-Oncology 23: 524–530 (2014) Published online 28 November 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/pon.3448