Introduction
Understanding the psychological factors influencing disease-related lifestyle in elderly patients with prostate cancer can lead to evidence-based nursing care. While some studies have examined the impact of lifestyle changes post-diagnosis on disease recurrence and survival [20, 21], less attention has been paid to the relationship between psychological aspects, such as anxiety and depression and disease-related lifestyle in this population. Given that the psychological factors affecting lifestyle post-diagnosis differ based on cultural and social structures, identifying these factors can contribute to strategies for improving adaptability and mitigating the psychological influences on lifestyle. Accordingly, this study determines the relationship between anxiety and depression and disease-related lifestyle in elderly Iranian patients with prostate cancer.

Methods
This descriptive-correlational study was conducted between 2021 and 2022 using a convenience sampling method. A total of 250 elderly patients attending oncology and urology clinics and private practices in the western Mazandaran Region, Iran (Noor, Nowshahr, Chalous, Tonekabon, and Ramsar) participated in the study. The data were collected using the self-assessment anxiety and depression scales and the prostate cancer-related lifestyle questionnaire. The inclusion criteria were a confirmed diagnosis of prostate cancer by a specialist, absence of metastasis, age between 60 and 74 years, a minimum score of 7 on the short cognitive test, no known psychological disorders, and awareness of their diagnosis. Withdrawal from the study was considered the sole exclusion criterion. Given that the prostate cancer-related lifestyle questionnaire had not been used in Iran, it was translated and localized into Persian in two stages. First, the questionnaire was translated from English to Persian and back-translated by two English-proficient translators. Second, the psychometric properties of the Persian version were evaluated, resulting in a reduction from the original 36 items to 32 items. The intraclass correlation coefficient for the disease-related lifestyle construct was 0.93, indicating excellent reliability in this population [26]. Data analysis was performed using the SPSS software, version 18 along with statistical tests, including analysis of variance, independent t-test, the Pearson correlation coefficient, and multiple regression analysis. A significance level of P<0.05 was considered.

Results
The study included 250 elderly patients with prostate cancer, with a mean age of 69.33±3.69 years. The majority (216[86.4%]) were married, 28% (n=70) had three children, 156(62.4%) had a moderate income, 84(33.6%) held a high school diploma, 100(40%) were retired, and 122(48.8%) lived with their spouse. The Mean±SD of the disease-related lifestyle score was 70.09±18.21, reflecting a moderate level overall. Lifestyle scores were categorized as good (n=114 [45.6%]), moderate (n=114 [45.6%]), and poor (n=22 [8.8%]). Mean scores for anxiety (44.69±12.7) and depression (42.22±5.43) also indicated moderate levels. Anxiety severity was mild in 98 individuals (39.2%), moderate in 124(49.6%), and severe in 28(11.2%). Depression severity was mild in 4 participants (1.6%), moderate in 232(92.8%), and severe in 14(5.6%) (Table 1).


The Pearson correlation analysis revealed significant relationships between disease-related lifestyle and both anxiety (P<0.001) and depression (P=0.003). Higher anxiety and depression levels were associated with a poorer disease-related lifestyle. Additionally, lifestyle was significantly associated with economic status (P<0.001) and educational level (P<0.001), with poorer lifestyles observed in individuals with low economic status and lower educational levels. No significant associations were found between other demographic variables and lifestyle. Furthermore, lifestyle was significantly associated with treatment type (P=0.006) and disease status (P=0.005), with lower lifestyle quality observed in patients undergoing chemotherapy and those with recurrent disease.

Conclusion
The results indicated significant relationships between anxiety and depression and disease-related lifestyle in elderly patients with prostate cancer. Increased anxiety and depression were associated with poorer lifestyle quality. Regression analysis showed that anxiety had the strongest impact on lifestyle; for each one-unit standard deviation increase in anxiety, lifestyle quality decreased by 0.884 units. Similar findings were reported in Sharpley et al.’s study, which demonstrated a negative correlation between anxiety, depression, and disease-related lifestyle in prostate cancer patients [6]. Additionally, lifestyle quality was lower in patients with recurrent disease, consistent with Sharpley’s findings [6].

Ethical Considerations
Compliance with ethical guidelines
This study was approved by the Ethics Committee of Babol University of Medical Sciences, Babol, Iran (Code: IR.MUBABOL.REC.1399.445).

Funding
This article is derived from the master’s thesis of Reyhaneh Karager Niyavol, approved by the Department of Nursing, Ramsar Fatemeh Zahra School of Nursing and Midwifery, Babol University of Medical Sciences, Babol, Iran (Code: IR.MUBABOL.REC.1399.445). 

Authors' contributions
All authors equally contribute to preparing all parts of the research.

Conflicts of interest
The authors declared no conflict of interest.


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