This was a cross-sectional study with data collected from November 2016 to January 2017 at the Department of Urology of a tertiary care hospital in Zhejiang Province using convenience sampling. The study population included patients who met the following criteria: 1) PCa diagnosis through prostate puncture biopsy or surgical pathology results, 2) ability to communicate effectively in Mandarin, and 3) willingness to participate in the study after being informed about it and providing consent. Patients were excluded if they met any of the following criteria: 1) unknown condition, 2) concurrent presence of other types of tumors, 3) concurrent presence of other serious complications, and 4) combined psychiatric disorders. This study was approved by the Ethics Committee of the First Affiliated Hospital of Zhejiang University School of Medicine, and all participants provided informed consent.

Investigators in this study conducted training to standardize how they explained and reviewed the questionnaire items. After obtaining informed consent from eligible patients, the participants were given a packet of self-reported questionnaires on paper to complete. Questionnaires were collected and sent back on-site after quality review. For those with poor literacy or eyesight, two trained investigators conducted face to face interviews.

A self-designed questionnaire was used to collect demographic and clinical information, including age, marital status, occupational status, location of residence, education, recent PSA level, PCa family history, and treatment method.

The MAX-PC was developed by Roth et al. to identify and assess cancer-specific anxiety in men with PCa [6]. It comprises 18 items divided into three subscales: general PCa anxiety, anxiety related to PSA testing (PSA anxiety), and fear of recurrence. The scores range from 0 to 54 on the total scale, with higher scores indicating higher levels of anxiety [7, 9]. The Chinese version of MAX-PC had been translated by our team who had evaluated its psychometric properties in Chinese men, with Cronbach’s alpha coefficient for the total and the three subscales being 0.94, 0.93, 0.82, and 0.85, respectively [8].

The GAD-7 scale was originally developed by Spitzer et al. in 2006 and comprises seven items based on the seven diagnostic criteria of the DSM-IV [16]. The scale measures a single dimension with scores ranging from 0 to 3 for each item and 0–21 for the total score. The GAD-7 is a clinical tool used to screen for anxiety disorders and monitor treatment outcomes. The scale employs a scoring system of 0–4 indicating no anxiety, 5–9 indicating mild anxiety, 10–14 indicating moderate anxiety, and 15–21 indicating severe anxiety. The Cronbach’s alpha coefficient for Chinese version of GAD-7 was 0.859 [18]. In this study, the aforementioned scoring criteria were utilized, with cut-off values of 5, 10, and 15 for mild, moderate, and severe anxiety, respectively [17].

ROC curve analysis was used to test the ability of the MAX-PC to discriminate between patients with and without PCa-related anxiety. The following indicators were calculated: area under the curve (AUC), sensitivity, specificity, total consistency rate, diagnostic error rate, and diagnostic omission rate. The Youden index was also calculated in conjunction with the above results to select the optimal cutoff values for MAX-PC. The optimal cutoff values, located at the top-left point of the ROC curve, were derived in each curve from the point with the maximum Youden index, which represented the maximized sensitivity and specificity [14, 15]. Additionally, the Kappa consistency test was used to compare the degree of agreement between the two evaluation tools for the diagnosis of anxiety status in patients with PCa. The larger the Kappa score, the better the consistency. The specific evaluation criteria are as follows: Kappa ≤0.2, indicating poor consistency; 0.2 < Kappa ≤0.4, indicating average consistency; 0.4 < Kappa ≤0.6, indicating medium consistency level; 0.6 < Kappa ≤0.8, indicating good consistency level; Kappa > 0.8, indicating very good consistency [19]. In addition, the McNemar test, which is a chi-square test designed for paired count data, was employed to determine whether there was a statistically significant difference between the outcomes of the two assessment instruments, MAX-PC and GAD-7, in detecting anxiety among patients with PCa. All tests were two-tailed, and a p value < 0.05 was considered statistically significant. Statistical analyses were performed using the SPSS software (version 17.0).