Psychological Distress, Decision-Making, and Health Behaviors Among Prostate Cancer Survivors with Urinary Incontinence: A Multilevel Network Analysis

Objective This study aimed to investigate the interrelations among depressive symptoms, anxiety symptoms, decision-related factors, and health behaviors in prostate cancer survivors using a symptom network approach. Methods A cross-sectional study was conducted among 251 prostate cancer survivors experiencing urinary incontinence at a tertiary hospital in China between October 2025 and February 2026. Participants completed interviewer-administered questionnaires assessing depression, anxiety, shared decision making, decisional conflict, loneliness, urinary incontinence, and exercise adherence. Scale-level and symptom-level networks were estimated using Gaussian graphical models with graphical LASSO regularization and EBIC model selection. Centrality, predictability, and network stability were examined using bootstrap procedures. Results At the scale level, anxiety and depression emerged as the most central nodes, forming a tightly connected psychological cluster with loneliness. Shared decision making was strongly associated with decisional conflict (partial r = 0.68); and urinary incontinence was moderately associated with exercise adherence (partial r = 0.43) and weakly associated with anxiety and depression. At the symptom level, suicidal ideation and low energy were the most central depressive symptoms, while difficulty controlling worry occupied a central position in the anxiety network. Conclusions Depression and anxiety occupy central positions within integrated psychosocial and clinical networks in patients with prostate cancer. Identifying these core nodes underscores their importance for clinical monitoring and comprehensive symptom assessment. Longitudinal investigations are required to clarify their potential role in managing broader psychological distress, treatment-related symptoms, and health behaviors.