A systematic review of tools used to assess body image, masculinity and self‐esteem in men with prostate cancer

Masculinity, body image and self‐esteem are important interlinked factors affecting prostate cancer (PCa) patients' quality of life. The aim of this systematic review was to identify and evaluate all tools measuring these domains in men with PCa.


| BACKGROUND
Prostate cancer (PCa) is one of the most common cancers in men, with 47 000 new cases per year in the UK. 1 With 10 year survival at over 80%, 1 PCa is an often-chronic disease, presenting a unique set of challenges to mental health and wellbeing. An estimated 60% of men with PCa experience psychological distress, 2 with many factors contributing to this, including the effects of treatment, anxiety about prostate specific antigen level, and the distress of a cancer diagnosis.
While the effect of PCa on generic outcomes such as quality of life (QoL), or diagnoses of depression and anxiety have been wellresearched, more peripheral concepts, also relating to QoL, have received less focus. PCa has been shown to have an impact on men's self-esteem, 3 body image 4 and sense of masculinity. 5 Furthermore, these concepts are connected and often are all mentioned as being affected by a diagnosis of PCa. Levy et al's qualitative study reported those who experienced bodily changes due to their PCa reported decreases in their sense of masculinity, as well as lowered selfesteem. 6 Furthermore, Langelier et al's qualitative review of exercise interventions in 105 men with PCa found exercise improved both masculinity and body image. 7 Similarly, a study of 230 American men with PCa found those who adhered more strongly to masculine scripts experienced poorer mental health, 8 suggesting the three domains may be linked as both moderators of QoL, as well as outcomes in their own right.
It has been suggested that the side effects of treatments and their impact on men's QoL are not assessed enough, or discussed, by some clinicians. 9 Masculinity, body image and self-esteem have all been measured by studies in PCa patients, either to assess the effect of the disease and its diagnosis on these outcomes, or to compare interventions to try and improve these outcomes. However, a wide range of tools currently exist for this measurement, with each containing different domains, response items, methods of distribution, and limited evidence for their use in men with PCa. Therefore, there is a need for identification of available tools, and those which are most suitable for both clinical and research purposes.
This systematic review therefore aims to (a) summarise all tools that have been used to measure masculinity, body image and selfesteem in studies of PCa patients to date and (b) establish the validity and suitability of these tools for use in men with PCa.

| METHODS
This systematic review was performed according to the PRISMA guidelines 10 and prospectively registered with PROSPERO (CRD42019157994).

| Study eligibility criteria
Studies were deemed eligible if their population was exclusively or mainly men with PCa, and were reporting on body image, self-esteem and masculinity outcomes, written or fully translated into English. Due to the paucity of literature in specific validation studies of tools to measure masculinity, body image and selfesteem, search criteria were widened to include experimental, observational and randomised controlled studies that used questionnaires as part of a predefined tool to measure the above outcomes.
Studies involving mixed cancer populations where results specific to the PCa cohort were not reported were excluded, as were systematic reviews. Studies that did not calculate any validity measures for their tool (such as internal consistency/reliability) in a PCa cohort were also excluded.

| Study selection
Two independent reviewers (J.B. + O.B.) screened titles, abstracts and subsequently full texts against eligibility criteria post de-duplication of results. Discrepancies after full text review were discussed until 100% agreement was reached. After study selection, the tools used in each study were summarised.

| Data collection and items
Data extraction was conducted by two independent authors (J.B. + O.B.). All data was extracted to a pre-defined extraction sheet detailing the number of patients the tool was used in, the country and language in which it was used, age and demographic data of the participants, primary outcomes of each study and method of collecting responses. Data extracted specific to the tools used were name of the tool used, author of the tool, whether the tool had been modified for the study, domains, response format, scoring method and whether the tool had been developed specifically for PCa patients, and if available, information on structural validity, internal consistency, discriminative validity and overall response rate from participants.
Measures were extracted to objectively assess validity of each tool used based on criteria set out by the COnsensus-based Standards for the selection of health status Measurement INstruments (COSMIN) checklist. 11 This checklist assesses the methodological quality of studies assessing the measurement properties of patient reported outcome measures (PROMs). It determines the extent to which aspects of a PROM have been assessed and reported on by studies, specifically if they have evaluated the reliability, validity, responsiveness and interpretability. Thereby, it provides an overall assessment of the quality of a PROM being assessed.
One author (Hoyt) was contacted personally for more information about the domains assessed and scoring method for the tool used in their studies. 12,13 We received the scale and scoring method which was used to complete Table 3.

| Study selection
A total of 2126 studies were identified, with a further eight added through reference review and conference abstract databases ( Figure 1). Initial screening resulted in 136 full-text articles assessed for eligibility. Of these, a final 46 studies were included in the review.
The final number of tools identified was 17. Of these, seven were modified versions of tools already identified, either using subscales, 4,8,[14][15][16] specific items, 17-20 removing specific items 21 or translating the tool to an alternative language. 22,23 There was one tool used to measure self-esteem, nine to measure masculinity, and seven to measure body image. Tools identified as well as validation articles in PCa patients are summarised in Table 1.
None of the body image tools were specifically developed for PCa The "Concern about Body Image" scale was used in one study of 1089 patients undergoing radical prostatectomy. 4   Concerns with body image "No change in appearance," "occasional concern," "often," "most of the time," or "constant" concern that appearance is worsening Either classified as "not frequent" or "frequent" Abbreviations: BIS, Body Image Scale; PROM, patient reported outcome measure.

| Masculinity
Masculinity was measured in 9021 patients using a total of nine different tools (Tables 1 and 3 The Bem Sex Role Inventory -Short Form was used in three studies of 280 patients total, with one study also adapting the tool to create an Importance of Sex Role Inventory by changing the response options to ranking the importance of each item instead of agreement. 46 The short form of the tool was shown to have higher levels of   The Masculinity in Chronic Disease Inventory (MCD-I) was used in two studies. 16,58 The original tool was developed specifically for use with PCa patients (Table 3) One study used the "I am able to feel like a man" item from the FACT-P tool, developed by Esper et al 66 as an adjunct to the Functional Assessment of Cancer Therapy (FACT), 67 which has been used to date in over 26 000 patients. 68 The PCa subscale, within which the "I am able to feel like a man" item is contained, showed acceptable internal consistency in initial evaluation (alpha = 0.65-0.69) within two cohorts of US men with localised and advanced PCa, 66 and was able to differentiate between patients at different disease stages.

| Self esteem
Self-esteem was measured in four studies totalling 624 US patients, 3,70-72 all using the Rosenberg Self-Esteem scale (RSE; Table 4). 73 The scale was developed in 1965 and validated in American students. 73 Internal consistency values were reported by two studies and were both acceptable (0.84 3  Some scales included in this review have been the subject of systematic reviews already, however no reviews have examined the use of these tools exclusively in PCa patients. The BIS has been reviewed in cancer patients, 76 confirming its validity but also highlighting the need for further research into its use in a more diverse group of cancer patients, due to the majority being breast cancer patients. The RSE has also been reviewed in cancer patients, 74 assessing 16 studies that used the tool, and finding it may be of limited use in cancer cohorts due to differences in the way studies score the scale, and that other aspects of self-esteem that may be important to patients are not recognised. and role in the community as an advocate or mentor affecting selfesteem. 79 These concepts are not included in current tools and would benefit from consideration in future tool generation. missed within this review considering the broad area of interest within in this review.

| Clinical implications
The reframing of PCa as a chronic disease has led to increased emphasis on treatment side effects, benefits and harms that men may experience, as these will have a lasting impact on their lives and mental wellbeing.  19 with a similar relationship between sexual functioning and self-esteem, 80 and depression. 50 The connection between physical functioning and QoL indicators, although difficult to ascertain casuality, highlights the fact that better tools to measure these factors could help clinicians recognise difficulties in physical and mental functioning their patients may be experiencing. This review also emphasises that tools to measure body image, masculinity and self-esteem in PCa patients should be used with caution, as many of these tools have undergone limited validation, and may not be measuring constructs which are relevant to men with PCa.
We highlight the current lack of tools specifically developed for PCa patients, showing how current studies and clinicians using these tools to measure the outcomes of body image, masculinity and selfesteem in PCa patients may not be measuring these constructs in a way that is sensitive to the unique position of these patients. Therefore, more qualitative research to help establish the domains of these outcomes that are important to men with PCa, followed by validation studies of current tools is needed. This will enable clinicians to use these tools in clinical practice to help understand how their patients' mental wellbeing can be best supported during their diagnosis and treatment.