Bidirectional Longitudinal Associations Among Health-Related Quality of Life, Emotional Expressivity, and Readiness to Return to Work in Patients with Non–Muscle-Invasive Bladder Cancer Receiving Intravesical Therapy: A Three-Wave Cohort Study

Purpose: We aimed to elucidate the temporal relationship among health-related quality of life(HRQoL), emotional expressivity, and readiness for return to work(RRTW) in patients with non–muscle-invasive bladder cancer receiving intravesical therapy. Design: A three-wave cohort study. Methods: In this prospective observational study, we recruited 425 patients from two tertiary hospitals between August 2022 and January 2024. Three waves of self-reported questionnaires were administered at the start of at the start of intravesical therapy (T1, N=412), at six months (T2, N=309), and at twelve months (T3, N=227). The main analysis was based on data from patients who completed all three waves of the assessment. We constructed cross-lagged panel models to examine the temporal associations among HRQoL, emotional expressivity, and RRTW. Results: A total of 227 patients completed all three waves of assessment. Controlling for covariates such as intravesical therapy medication, age, gender, economic income, and marital status, the results indicated a longitudinal relationship between HRQoL at T1 and T2 and emotional expressivity and RRTW at T2 and T3. Emotional expressivity at T1 and T2 was positively associated with HRQoL and RRTW at T2 and T3. HRQoL and emotional expressivity were mutually reinforcing relationships. RRTW at T1 and T2 was positively associated with HRQoL at T2 and T3; however, this positive association disappeared after emotional expressivity was added. Mediation analyses revealed that HRQoL at T1 was positively associated with RRTW at T3 through emotional expressivity at T2 (standardized indirect effect=0.020, 95% bootstrap CI 0.005, 0.035). Conclusion: These results demonstrated that HRQoL and emotional expressivity mutually reinforced effect relationships, and both could facilitate RRTW among non–muscle-invasive bladder cancer receiving intravesical therapy. As an observational study, these findings identify potential targets for intervention but require confirmation in experimental designs. Keywords: non-muscle-invasive bladder cancer, receiving intravesical therapy, readiness for return to work, health-related quality of life, emotional expressivity