A cancer diagnosis presents emotional and psychological challenges for patients and caregivers, and prostate cancer has some unique challenges, in part because management is not writ in stone. At several points along the trajectory of illness, men with prostate cancer face decisions that can be stressful, starting with biopsy and diagnosis, choice of primary treatment and what to do about a rising prostate-specific antigen (PSA) level. Recurrence after primary surgery or radiation therapy, treatment of metastatic prostate cancer, and finally end-of-life decisions also pose challenges.
The stress is partly related to the fact that there are several areas of controversy regarding management of prostate cancer among physicians who treat it. In fact, a recent report showed multiple areas of disagreement among an international group of prostate experts.1 (For more on the debate over the management of advanced prostate cancer, see page 10 of the August 25, 2017, issue of The ASCO Post.)
Because its indications [ie, PSA, Gleason score, doubling time] and outcomes are still being worked out, active surveillance remains an anxiety-provoking option for many men.— John Peteet, MD
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“Prostate cancer is the most common cancer in men and the second most common cause of cancer death. The incidence increases with age. There are controversies about treatment decisions, and disparities in the way it is treated,” explained John Peteet, MD, Associate Professor of Psychiatry, Harvard Medical School, and Psychosocial Oncology Fellowship Site Director at Dana-Farber Cancer Institute, Boston. Dr. Peteet recently hosted a webcast on the emotional and psychological impact of prostate cancer; the webcast was sponsored by the Prostate Health Education Network and can be accessed at www.rapcancer.org/.
The majority of prostate cancers have a long natural history and are usually silent until the cancer is more advanced, he explained. A rising PSA level is usually the first sign, yet many men avoid PSA screening. Primary care physicians are often reluctant to suggest screening in asymptomatic men based on the U.S. Preventive Services Task Force recommendations against routine PSA screening.2
“Men are fearful of diagnostic test results and fearful of treatments they know will impact their sexuality and continence,” Dr. Peteet explained.
Prostate cancer is not exactly like breast cancer; there is no single roadmap for choosing treatment. Once prostate cancer is diagnosed, patients are faced with a number of initial treatment choices that include surgery (open or robotic), radiation (external or brachytherapy), and active surveillance for those with Gleason 6 disease (ie, low risk).
“How to decide upon a course of action and who to trust in making these decisions are stressful for patients and caregivers,” Dr. Peteet said.
Surveys show there is no consensus on several areas of management among physicians who treat prostate cancer. Typically, for moderately differentiated clinically localized prostate cancer, urologists are more likely to recommend surgery, whereas radiation oncologists may recommend radiation. This becomes more confusing for patients because there are different types of surgery and radiation techniques.
Active surveillance is now recommended for men with a Gleason 6 and low-risk prostate cancer, but a study suggests this may not be the best approach for higher-risk groups. Patients with intermediate-risk disease (n = 237) managed on active surveillance were 3.75 times more likely to die of prostate cancer than low-risk patients managed on active surveillance.3
“Because its indications [ie, PSA, Gleason score, doubling time] and outcomes are still being worked out, active surveillance remains an anxiety-provoking option for many men,” Dr. Peteet commented.
Once primary treatment is selected, each choice has side effects that can be troublesome and even devastating. They include incontinence and erectile dysfunction with surgery; painful urinary frequency and bowel irritation with radiation therapy; and loss of libido, weight redistribution, hot flashes, and fatigue with androgen-deprivation therapy. Radiation therapy also is associated with late effects on erectile and bowel function. Patients who have more advanced prostate cancer treated with chemotherapy often suffer fatigue and other side effects.
These treatments and their side effects can be associated with anxiety and depression. In particular, androgen-deprivation therapy can lead to depression, especially if the patient has a history of depression, revealed Dr. Peteet. “Physical activity can protect against depression,” he told listeners. But it can be difficult to motivate patients to exercise when they feel fatigued.
Men are fearful of diagnostic test results and fearful of treatments they know will impact their sexuality and continence.— John Peteet, MD
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Recurrence is also stressful. At recurrence, patients lose hope for a cure and may regret earlier treatment choices, believing a different treatment might have had a better outcome. Also, they are afraid of the future.
Disease progression is associated with fatigue and pain. Patients with metastatic disease may no longer be able to work or to participate in activities they previously enjoyed. They become dependent on others as they become more debilitated, and they know the future is limited.
An older survey of 135 patients with prostate cancer of any stage found that distress was common in 47% of patients and 76% of partners. Severe distress was present in 11% and 30%, respectively. The most common concerns were treatment-related, pain, and physical limitations, and they were more frequent among partners than patients. Both patients and partners were equally concerned about urinary symptoms.4
“Interestingly, sexual concerns were the least prevalent and were more common among patients than partners,” Dr. Peteet said.
Styles and values dictate how men and their families adapt to the challenges of prostate cancer. Men who exhibit the most stress tend to have histories of trauma, anxiety, depression, or other problems such as alcohol abuse or unemployment.
“Men who are proactive rather than avoidant in coping with the challenges of prostate cancer tend to have more positive psychological and physical outcomes and are more likely to be able to return to the precancer activities they enjoyed,” Dr. Peteet noted. He advised men with prostate cancer to work with caregivers who they trust and to make a game plan for what they anticipate in the future.
“Hope for the best while preparing for the worst,” advised Dr. Peteet. This includes taking care of unfinished business in relationships, making sure you have a will and advance directives, and creating a “bucket list.”
Patients with prostate cancer should consider consulting an experienced mental health professional for emotional symptoms such as anxiety, depression, or insomnia, he added. Studies have shown that education and discussions with a health-care professional and other men with prostate cancer (eg, a support group) can improve quality of life. Therapy, including individual, couples, and cognitive behavioral, can be helpful. Also, antianxiety and antidepressants may be useful for some. Attending to spiritual concerns may also be advisable. ■
DISCLOSURE: Dr. Peteet reported no conflicts of interest.
1. Gillessen S, Attard G, Beer TM, et al: Management of patients with advanced prostate cancer: The Report of the Advanced Prostate Cancer Consensus Conference APCCC 2017. Eur Urol. June 24, 2017 (early release online).
2. Jemal A, Fedewa SA, Ma J, et al: Prostate cancer incidence and PSA testing patterns in relation to USPSTF screening recommendations. JAMA 314:2054-2061, 2015.
3. Segaran S, Jelski J, Burns-Cox N: Active surveillance: A cautionary tale. J Clin Urol 7:112-115, 2014.
4. Cliff AM, MacDonagh RP: Psychosocial morbidity in prostate cancer: II. A comparison of patients and partners. BJU Int 86:834-839, 2000.