Psychosomatics 41:85-94, April 2000
© 2000 The Academy of Psychosomatic Medicine
Biopsychosocial Aspects of Prostate Cancer
Elisabeth J.S. Kunkel, M.D., ,
Jennifer R. Bakker,
Ronald E. Myers, Ph.D., ,
Olu Oyesanmi, M.D., and
Leonard G. Gomella, M.D.
Received May 21, 1999; accepted September 14, 1999. From Departments of Consultation-Liaison Psychiatry, Internal Medicine, and Psychiatry and Human Behavior, Jefferson Medical College; and the Department of Urologic Oncology, Kimmel Cancer Center, Jefferson Medical College. Address reprint requests to Dr. Kunkel, Department of Psychiatry and Human Behavior, Thompson Building, Suite 1652, 1020 Sansom Street, Philadelphia, PA 19107–5000.
|
ABSTRACT
|
Prostate cancer early detection choices and treatment options are fraught with controversy. To update the consultation-liaison psychiatrist who works with at-risk men, the authors reviewed all pertinent citations in the medicine database from 1966 to 1998 and in other relevant publications. Though watchful waiting for early-stage prostate cancer has no side effects, men must cope psychologically with issues of long-term cancer survivorship. Men can choose between different treatment options (e.g., radiation vs. radical prostatectomy) with early detection. Urinary incontinence, sexual dysfunction, and fatigue are major emotional and physical stressors for this population. Consultation-liaison psychiatrists and physicians need to be aware of the psychosocial sequelae of both prostate cancer and treatment-related side effects.
Key Words: Prostate Cancer • Syndromes Secondary to General Medical Disorders
|
BIOPSYCHOSOCIAL ASPECTS OF PROSTATE CANCER
|
Although fear, anger, confusion, and depression are common reactions to all cancers, treatment for prostate cancer means dealing with impotence and incontinence. The biopsychosocial model1 is reviewed as it applies to prostate cancer.
Epidemiology
In the United States, prostate cancer is the most frequently diagnosed non–skin cancer and the second leading cause of cancer death in men. The American Cancer Society estimates 184,500 newly diagnosed cases of prostate cancer for 1998, with 39,000 deaths. The lifetime risk of prostate cancer is about 10%. White men survive longer than African American, Hispanic, and American Indian men, but survival rates for different races are similar when corrected for grade and stage. The stage at diagnosis predicts 5-year disease-specific survival rates: local stage disease, 100%; regional stage, 94%; and metastatic disease, 31%.2
Although African American men are twice as likely as white men to get prostate cancer, African American men in Philadelphia do not perceive their personal risk of prostate cancer to be high.3 Only some studies reveal differences in the frequency of digital rectal exam (DRE) screening between African American men and white men.4 African American men are more likely to be diagnosed at later stages, and men 65–69 years old, with localized disease, are less likely to be treated via radical prostatectomy (RP).5
In one study, non–private patients were less likely to receive prostate-specific antigen (PSA) screening.4 Lower socioeconomic groups are less willing than middle socioeconomic groups to participate in clinical trials because of distrust of the medical community.6,7 RP is used more commonly in younger men (<60 years), and radiotherapy (RT) or watchful waiting is mostly used in older men (>70 years). Married men tend to be diagnosed earlier. Not surprisingly, survival rates are higher in married men from higher socioeconomic strata.8
Perceived discomfort of prostate screening, embarrassment, and financial cost have been identified as barriers to screening and need to be addressed by sensitive counselors.9 Churches consisting of predominantly African American members, and work sites may be effective sites for prostate cancer screening and education.10 Patients, particularly poorer African Americans, may opt to forgo needed care in the absence of available and affordable means of transportation to treatment facilities. Healthcare providers need to work with patients, families, and volunteer agencies in the community to enhance transportation to cancer treatment.11 Although racially and culturally sensitive educational outreach programs need to provide education about prostate cancer and reduce barriers to early detection of prostate cancer among African American men, the relationship between access to care and prostate cancer outcome remains unclear.12
|
BIOLOGICAL ASPECTS
|
Anatomy and Physiology
The prostate gland surrounds the urethra, and prostatic secretions make up part of the seminal fluid.13 The hypothalamus secretes luteinizing hormone-releasing hormone (LHRH), which stimulates luteinizing hormone (LH) release from the pituitary. LH stimulates the testicular production of testosterone, which is turned into dihydrotestosterone, which stimulates prostatic cell growth and intracellular protein synthesis. PSA is produced both by benign and cancerous prostatic cells and released into the circulation. Prostate cancer metastasizes through blood or lymph to the pelvic nodes and then to distant sites.14
Staging and Grading
The TNM (Tumor, Node, Metastasis) system of the American Joint Committee on Cancer is identical to the classification system of the Union Internationale Contre le Cancer and is widely accepted. Most prostate cancers are adenocarcinomas; grade determination is based on the histopathological degree of cell differentiation and is often reported as a Gleason score (2=very well differentiated to 10=poorly differentiated). Lower Gleason scores are better.
Risk Factors
The cause of prostate cancer is unknown. Possible risk factors include African American race, increased age, family history of prostate cancer, a diet high in animal fat, and high plasma testosterone.15 Occupations associated with increased risk include printers, painters, rubber workers, textile workers, mechanics, loggers, ship fitters, farmers, and drug and chemical workers.16 Vasectomy and benign prostatic hyperplasia (BPH) do not appear to increase one's risk.17
Nutritional factors appear to play a role in the progression rate of prostate cancer.18 Vitamin D deficiency, polyunsaturated fats, and saturated fats may increase the risk of prostatic cancer; monounsaturated fats may be protective. Selenium supplements and lycopene, an antioxidant found in tomatoes,19 may lower the risk of prostate cancer. Vitamin E may reduce the incidence of prostate cancer in men who smoke.20
In rare instances, prostate cancer is inherited by autosomal dominant allele with high penetrance; 88% of carriers and 5% of noncarriers develop prostate cancer by age 85.21 Men with HPC1 (hereditary prostate cancer 1) have a 90% risk of developing prostate cancer in their 90s.22 Male carriers of the BRCA1 (breast cancer 1) mutation are at three times greater risk than the general population. Receiving BRCA1 results impacts on quality of life, insurance, employment, and psychosocial well-being, but the health benefits of BRCA1 testing are unknown. Currently, there are no prostate cancer screening recommendations for men who are BRCA1 carriers.23
Clinical Diagnosis
Many patients with prostate cancer are asymptomatic at diagnosis; others report dysuria, urinary frequency, hematuria, dribbling, decreased force of the urinary stream, incomplete bladder emptying, and/or nocturia. Metastatic disease may present with pain in the back, hips, or perineal area; bowel or urethral obstruction; or weight loss and fatigue.16
Screening
PSA is the most sensitive marker for prostate cancer. Uncommonly, it is possible to have a normal PSA level (<4.0 ng/ml) and still have prostate cancer. A rise of PSA >0.75 ng/ml per year or a total PSA >4 ng/ml is associated with increased likelihood of cancer. Many men with BPH have PSA concentrations ranging from 4.1 to 10 ng/dl. Higher PSA concentrations (>10 ng/ml) have been associated with cancer as well as BPH, prostatitis, prostate infections, DRE, cystoscopy, transrectal ultrasonography, indwelling urinary catheters, transurethral resection of the prostate (TURP), and biopsy of the prostate. The clinician should aggressively investigate a PSA >10 ng/ml to rule out malignancy.24
A rising PSA level after treatment indicates recurrent disease. Lower levels of free PSA and higher levels of circulating PSA (i.e., bound plus free PSA) are more likely to be associated with prostate cancer.19 Reverse transcriptase polymerase chain reaction is a highly specific research assay, which may be used in the future for staging, prognosis, and management.25 The newest tests include prostate-specific membrane antigen, telomerase, and prostate markers.26
The American Cancer Society recommends annual screening with PSA and DRE for asymptomatic men over 50 who are expected to live at least 10 years longer and for men over 40 who are at higher risk. Combined abnormal PSA and DRE has a greater positive predictive value than abnormal DRE alone. Screening of asymptomatic men remains controversial (see Table 1), and the U.S. Prevention Services Task Force, National Cancer Institute, and Canadian Task Force on the Periodic Health Examination do not recommend screening.2,23,24 If further testing is required after combined PSA and DRE, transrectal ultrasonography with transrectal biopsy typically follows; yet the true sensitivity of transrectal biopsy is not known. The combined use of PSA, DRE, and ultrasound-guided biopsy may result in earlier detection, but there is no evidence from randomized trials that it reduces morbidity or disease-specific mortality. Biopsy may be associated with infection (20%), bleeding (20%), and hospitalization (<1%).15
Modifications in PSA measurement have included PSA density (serum PSA/volume of prostate gland), age-specific reference ranges, and PSA velocity (serial measurements of PSA).24 Exercise and sexual activity may reduce the reliability of PSA-velocity in prostate cancer patients.27 It is unclear if PSA velocity, PSA density, and age-specific reference ranges for PSA are better or not, compared to using standard PSA levels; in certain cases, however, they may provide additional information regarding early detection and treatment.
There is no way to distinguish between slow-growing tumors and clinically significant tumors.26 Treatment may not reduce disease-specific mortality for tumors discovered incidentally. Although 30% of men over age 50 get prostate cancer, only 3% die from the disease. Aggressive treatment confers both morbidity and mortality.15 The downside of screening is increased psychological stress with repeated testing and/or diagnosis, treatment complications, reduced quality of life, and increased costs.15
Treatment
Treatment of prostate cancer depends on the patient's age, health, DRE, tumor stage, PSA levels, prostate biopsies, Gleason scores, and response to prior treatments for prostate cancer.28 Accepted therapies include watchful waiting, RP, RT, hormonal therapy, orchiectomy, and antineoplastic drug therapy. There is no consensus regarding the relative survival benefits of different treatment modalities (see Table 2).
Localized prostate cancer may be managed by watchful waiting or may be treated with RP or RT. There are few published data on mortality in prospective, population-based studies for patients treated via RP or RT.29 Watchful waiting may be most appropriate for older patients with low-grade tumors, who have other serious medical problems that make them poor surgical candidates. In an asymptomatic patient, whose life expectancy is under 10 years, prostate cancer is unlikely to cause death. Disease progression is detected with periodic screening during watchful waiting, and treatment-related complications are avoided.30 Patients may experience helplessness while not pursuing active treatment. They describe being "in limbo", waiting for their cancer to grow so that definitive treatment can begin.
RT may be used successfully for localized tumors. After treatment, a PSA level that falls below 0.5 ng/ml is associated with a better prognosis. External-beam irradiation requires visits (5 days/week for 8 weeks).31 Transperineal placement of radioactive seeds under ultrasound guidance is a relatively newer treatment; the seeds are left in place and emit local radiation for a short period of time.16,29,32 RT also may control pain from metastatic disease.
RP involves complete surgical removal of the prostate, seminal vesicles, ampullae of the vas deferens, the vas deferens, and the bladder cuff. One cannot compare the relative benefits of RP (which includes lymph node biopsy) vs. RT, where the extent of disease is not known.29,33 Because prostate cancer progresses slowly, more than 10 years may be needed to fully compare the effectiveness of RP vs. RT.29
Both RP and RT confer similar risks: mortality (0.2%–0.3%), incontinence (0.8%–0.9%), and impotence (30%–70%) are the most common sequelae.32 Urinary leakage may be more common after RP than RT. Reports of pad usage after RP vary in the literature with the majority of men having minor or no urinary leakage by 6 months. Despite the newer "nerve sparing" techniques, many men may become impotent immediately after surgery.34 Postoperative potency may be related to the number of spared neurovascular bundles, frequency of intercourse preoperatively, absence of seminal vesicle or lymph node involvement with cancer, absence of postoperative incontinence or stricture, age, and cancer volume.35,36 With RT, men may have a progressive loss over time in erectile function, suggesting that with time, posttreatment impotence may not differ significantly between men treated with RT vs. those treated with RP.34 Gastrointestinal problems are more likely to be seen after RT.31
Locally advanced disease is treated with combinations of RP, RT, and hormonal therapy.16,29 Before surgery or RT, hormones may be used to reduce tumor size or to downstage the cancer. RT may be used with local tumor recurrence. If PSA is elevated post-RP, therapeutic irradiation can achieve a complete response (PSA <0.1 ng/ml) in up to 80% of patients.37
In advanced prostate cancer, therapy is aimed at disease control rather than cure. Asymptomatic patients may choose watchful waiting. Although hormonal treatment is preferred in symptomatic patients, it may not increase survival. Hormonal therapies include orchiectomy, estrogen use, or chemical castration via LHRH agonists. Bilateral orchiectomy removes 95% of serum testosterone and is a minor, low-cost procedure that eliminates the need for daily medication. Metastatic pain may be relieved within hours or days. Side effects include loss of libido and impotence. The psychological impact of orchiectomy may preclude the choice of this treatment option.16,32
Orchiectomy may cause feminization, gynecomastia, redistribution of fat, loss of facial hair, sterility, and/or reduced libido.38 Montgomery and Santi39 noted significant differences in physical self-concept and identity before and after orchiectomy. Postoperatively, patients felt greater negativity in physical appearance, state of health, and sexuality. Patients expressed identity concerns and feared that a reduction in masculinity might lead to personality changes. Profound symbolic loss (as well as physical loss) after orchiectomy is experienced if the man associates his testicles with male strength, virility, and power.39 The psychological effects of orchiectomy may be reduced with insertion of testicular prostheses.40
Diethylstilbestrol (DES) reduces testosterone by negative feedback on LH. Daily therapy is required, and side effects include nausea, vomiting, fluid retention, headache, impotence, reduced libido, gynecomastia, and increased cardiovascular risk, including thromboembolic complications. Recently, LHRH analogues are replacing DES.16
LHRH analogues (e.g., leuprolide, goserelin) are taken daily or via long-acting injections and cause constant pituitary stimulation by occupying the LHRH receptors. Initially, they increase testosterone release, inducing tumor growth; if the tumor is located in the spinal cord, this growth can cause spinal cord compression. Side effects include impotence, loss of libido, and hot flashes.16,32 Concomitant use of an antiandrogen for the first 2 weeks of treatment may prevent the testosterone surge. Antiandrogens block androgen receptors and are either steroidal (progestin) or nonsteroidal (flutamide, nilutamide, bicalutimide). Total androgen blockade may be achieved using a combination of orchiectomy and/or antiandrogens. Androgen deprivation causes hot flashes, loss of libido, impotence, and decreased muscle mass.16,32 In hormone-refractory cancers, various therapies including antineoplastic agents are used, with most agents showing poor response. Combination therapy may slow disease progression and increases survival compared to monotherapy, but this is controversial.
Hormonal castration usually tends to improve depression in patients with prostate cancer. As there is no threatened loss of body parts, patients describe feeling whole again and "embodied."41 However, increased depression also has been observed in some patients on hormonal therapy, perhaps linking depression to decreased testosterone. As one study has described depression secondary to leuprolide treatment in patients who had metastatic prostatic cancer, screening for depression may be warranted.42
In advanced cancers, pain control should be assessed. Methods to control pain include wraps, pressure stockings, and heat in addition to opioids, steroids, nonsteroidal anti-inflammatory agents, antidepressants, and psychological support.16,32 Treatment, side effects, and quality-of-life (QOL) concerns often influence patients' decision-making regarding early detection and treatment.
|
PSYCHOLOGICAL ASPECTS
|
Patient education regarding screening is needed, since screening results in a high probability that further testing, treatment, and treatment-related decision-making will be necessary, particularly in high-risk groups.26 If the patient has male relatives with prostate cancer, he may want a genetic test to determine his risk for prostate cancer.43 Although African American men in Philadelphia are receptive to annual screening,4 there are still misconceptions about DRE (e.g., is something being inserted that will compromise their masculinity?). In one study, patients of low socioeconomic status showed less interest in PSA screening after informed consent. Videotaped educational interventions enhance patient knowledge and allow physicians to discuss more sophisticated patient concerns.44 Faced with the diagnosis of a deadly disease, men simultaneously must confront threats to their sexuality and masculinity. Building rapport and trust during initial visits allows men to share their concerns. Survivors of prostate cancer must deal with treatment-related complications in the context of other age-related losses: health, energy, retirement, and deaths of peers and family members.
Patients with prostate cancer face several barriers to receiving appropriate psychiatric intervention. Cancers with sexual associations carry greater social stigma. North American men generally do not seek psychiatric help and tend to use mental health services less than women. Older men may be less likely to agree to psychiatric evaluation or treatment and are unlikely to report emotional distress. Physicians tend to underestimate the psychological comorbidity of prostate cancer patients, and patients with subsyndromal psychiatric symptoms may remain untreated, even after identification. A paper thermometer scale to screen for psychological distress in prostate cancer patients, who might need psychiatric referral, detected a high degree of distress (32.6% anxiety and 15.2% depression). However, 40% of the distressed men missed or refused their psychiatric interview. Over half the men identified failed to meet the criteria for a psychiatric diagnosis.45,46
Although there is increasing emphasis for men to assume a more active role in treatment decision-making, not all men may be comfortable with this role. Davison and Degner47 studied whether improved information acquisition and assuming a more active role in treatment decision-making would lead to decreased anxiety and depression in men with newly diagnosed prostate cancer. Sixty newly diagnosed men with prostate cancer were randomized to receive either an intervention that consisted of written information with discussion, a list of questions to ask their physician, and an audiotape of the medical consult, or written information alone. At 6 weeks postintervention, lower state anxiety scores on the Spielberger State-Trait Anxiety Inventory were observed for the intervention group. The Center for Epidemiologic Studies Depression Scale (CES-D) did not reveal significant differences between the two groups.47
Anxiety
Between 25% and 47% of cancer patients suffer from psychiatric syndromes. Reactive anxiety is the most common reason for psychiatric referral of cancer patients. Prostate cancer patients may react to the PSA test with anxiety, either before obtaining the test or while awaiting test results.48 The degree of anxiety and depression experienced by cancer patients (prostate included) was not measurably different between different cancer sites (i.e., prostate, gynecologic, breast, lung, brain, colon, head and neck, hepatoma, and lymphoma) on the Brief Symptom Inventory.49
Screening for prostate cancer is marked by increases in psychological stress and serum cortisol levels. The highest cortisol levels are detected 2 weeks after biopsy, just prior to being informed of the biopsy results. Even patients who were told that their biopsies were benign had elevated cortisol levels. Cortisol levels subsequently decreased to normal baseline values. Prostate cancer patients noted a lag in sleep disturbance, correlating with increased anxiety, 2 weeks after they were given their results.50,51
Posttraumatic stress disorder (PTSD)-related symptoms also have been reported in prostate cancer patients.52 Patients may reexperience the traumatic events in dreams, disturbing recollections, and flashbacks.53 Risk factors such as poor social support, a history of traumatization/victimization, or previous psychiatric disorder may predispose certain patients to PTSD. Cancer treatments are frequently intrusive and painful. Patients may feel a loss of control or experience helplessness in the face of life-threatening disease. In long-term cancer survivors, repeated treatments and/or recurrences may act as a series of stressors. While 25%–33% of all people who experience traumatic events develop PTSD, in one study, 4% of female cancer survivors had PTSD.54 Although no specific PTSD treatment has been proposed for cancer patients with PTSD, cognitive-behavioral therapies and support groups may be beneficial.
Kornblith and colleagues52 studied 173 men with prostate cancer and 83 spouses/partners, using the Intrusion Subscale of the Impact of Event Scale and Selby's Quality of Life Uniscale. Both patients and spouses reported frequent intrusive thoughts and images. Spouses reported greater psychological distress than the patients. Prostate cancer patients exhibited no relationship between treatment severity or intensity and intrusive or avoidant symptoms.
Clark and colleagues55 studied quality-of-life issues in men with metastatic prostate cancer and identified three key domains: self-perceptions; anxiety about the effects of treatment; and concerns about treatment decision-making. Many of the men reported anxious preoccupation or developing a fighting spirit in the face of their disease. Relationships with wives were altered. Though issues of intimacy and affection were troublesome for some men, impotence was emotionally distressing for most men. It was both difficult and comforting for spouses to emphasize emotional companionship. Body image, sexual problems, spouse affection, spouse worry, masculine image, cancer-related self-image, cancer distress, cancer acceptance, and regret over previously made decisions were areas of concern, particularly in men who had experienced many side effects.55
Depression
Some sadness is not unusual when patients are diagnosed with prostate cancer. Physicians must distinguish between "normal" sadness in response to the cancer diagnosis and clinically significant depression.56,57 Issues such as cancer stage, clinical course, type of treatment, and presence of pain must be considered in evaluating depression.58 Although 20%–25% of all patients with cancer may have a depressive disorder, depression often goes unrecognized. Neurovegetative symptoms may be due to the cancer or to the depression. Symptoms that differentiate the depressive illness from cancer include a sense of failure, social withdrawal, feelings of being punished, suicidal ideation, dissatisfaction, and indecision. Loss of interest and crying may present with more severe depression. Risk factors for depressive disorders include social isolation, recent losses, a tendency to pessimism, socioeconomic pressures, previous mood disorder, alcohol or substance abuse, previous suicide attempt, poorly controlled pain, depressive side effects of medication, and metastatic cancer. Psychotherapy, psychopharmacology, psychoeducation, and electroconvulsive therapy are all effective treatments for cancer patients with depression. Antidepressants with significant anticholinergic side effects should be avoided in patients with urinary retention or reduced intestinal motility.56,57,59,60
Most individuals associate cancer with a slow, painful death.61 Patients with pain are more likely to suffer depression and anxiety, and Heim and Oei62 found that 55% of patients with prostate cancer reported pain. Analgesic drugs with lower side-effect profiles should be combined with adjuvant pharmacologic (e.g., antidepressants) and nonpharmacologic strategies, particularly in older patients.63,64
Adjustment to Treatment-Related Side Effects
Physicians may underestimate the degree of emotional distress related to reduced libido, feeling unattractive, impotence, and incontinence. Although most impotence is treatment-related, for some men, psychogenic factors may be partly responsible, and psychiatric intervention may be important.65 In the past, as most older adult men passed the traditional age associated with raising a family, less attention was paid to erectile function and the psychological consequence of impotence. However, older men are as likely to be disturbed by postsurgical impotence as younger men.66 Etiology of erectile dysfunction after prostate cancer therapy is probably multifactorial. Arteriogenic impotence predominates among men undergoing RT. Veno-occlusive/cavernosal pathology predominates among men undergoing RP. Although most patients report problems in sexual/urinary function, global quality of life does not appear to be compromised after RP.67
Despite complaints of difficulty with erections, 60% of impotent patients did not use erectile aids (e.g., injections, vacuum devices) for 12 months or longer post-RP. Although impotency was a principal concern, most stated they would undergo surgery again for their peace of mind.66 Sildenafil citrate (Viagra) can reduce erectile dysfunction. It is administered orally, once daily, and is less invasive compared to cavernosal injection and implantation of penile prostheses. According to the manufacturer, 43% of men who had erectile dysfunction after RP achieved adequate sexual function with sildenafil citrate.68 Men have to be sexually aroused for the drug to be effective. Side effects of sildenafil citrate include headache, flushing, dyspepsia, and visual disturbances. The use of organic nitrates is absolutely contraindicated in patients taking sildenafil citrate. Sixty-nine deaths have been associated with sildenafil citrate: 46 had cardiovascular events; 21, unknown; and 3 had strokes.69
Men suffering from prostate cancer report impotence, fatigue, and incontinence as their primary concerns. Fatigue may be worsened by the increased demands of going for office visits and to the pharmacy. Incontinence (i.e., urine leakage, smelling of urine, and having to wear pads) leads to related demands to do more laundry and increased planning to be able to participate in social activities. After RP, some men may occasionally lose a few drops of urine when lifting heavy objects or coughing (i.e., stress incontinence). Other men are left with very little control over urine flow. Social isolation and embarrassment are understandable consequences.
|
SOCIAL ASPECTS
|
Until recently, prostate cancer had not received the same attention as other cancers in the popular press. Despite increasing numbers of published personal accounts of prostate cancer, the stigma of having cancer and potentially impaired sexuality may prevent patients from seeking adequate social and psychological support. Furthermore, there may be confusion between BPH and prostate cancer, leading men to underestimate the seriousness of the disease.
Men with prostate cancer receive assistance with household matters, emotional support, and encouragement from their spouses. However, spouses (and partners) show greater psychological distress than their husbands do, and this distress increases as the patient's condition worsens. It is unclear if this reflects gender differences in reporting or truly greater stress induced by repeatedly witnessing intrusive, invasive, and painful treatments of a loved one while dealing with anticipatory bereavement.52 One study suggests that wives prefer early detection strategies for their spouses that offer increased survival at the expense of quality of life. Decision-making strategies clearly vary among couples.8,70
Social support is positively correlated with psychological well-being, and low levels of social support correlate with increased mortality from all causes. Emotional support enhances self-esteem; informational support may provide advice or cognitive guidance. Social companionship provides contact with others and may provide a needed distraction from the stress of having cancer. Instrumental support can meet concrete needs by providing financial aid or material resources. Involvement in a social network can contribute to well-being by helping to develop feelings of predictability and stability. Social support buffering mechanisms for men are met through friendship, reassurance of worth, and reliable alliances. Companionship and task accomplishment adds to satisfaction. These social supports may translate into health benefits by positive influences on the functioning of neuroendocrine or immune systems, thereby acting as a buffer against disease. Other positive health-related effects include positive influences on behavior patterns (e.g., smoking and alcohol use).8,59,70,71
Although it seems obvious that families caring for patients with prostate cancer are under emotional, physical, and financial strain, literature on prostate cancer caregivers is not available. Difficulties in communication and delays in care may result from inadequate knowledge or reluctance to ask about urologic needs or sexual symptoms. Dysfunctional and difficult families may find caregiving particularly overwhelming. Competent psychosocial intervention may help.47
National support groups, such as "Us Too" and "Man to Man," can help meet the emotional and educational needs of prostate cancer patients.71 Interviews of some group members of Us Too and their primary care physicians revealed that although a high percentage of physicians recall discussing treatment options, side effects, and costs, a very low percentage of patients recall having had the same discussions. However, over 90% of both physicians and patients felt that the patient's own primary physician was a good source of cancer-related information. Both patients and physicians felt that physicians are less likely to provide emotional support. Support groups can address unmet emotional and educational needs of prostate cancer patients and minimize suffering.72–74
Unfortunately, most survey instruments used to measure quality of life have not been standardized in this population, and complete data relating to QOL are absent in the literature. Reliable questionnaires that are prostate cancer–specific are being developed; however, physical function, pain, social activity, and sexual function are the most important areas of concern.75 Most QOL studies include physical functioning, activities of daily living, and patient-reported sense of well-being. There have been some reports of physician resistance to measuring QOL. There is no consistency between which factors were measured by different instruments. QOL researchers suggest that problems in adaptation are seen most often in late-stage patients, who report greater pain, fatigue, and urinary difficulties.
Physicians often overestimate the level of physical functioning of a patient. Decreased sexual functioning, urinary incontinence, and bowel symptoms need to be considered in evaluating QOL. Some men trade long-term survival for potency; others avoid decreased sexual potency at all costs. Personality, motivation, a strong support system of family and friends, favorable environmental factors such as living in a first-floor apartment, having access to a pharmacy and other stores, and appropriate medical care are all important determinants of QOL.52,76–79 Some indicators that are used to measure QOL are body image, sexual problems, spousal affections, spousal worry, masculinity, cancer-related self-image, cancer distress, cancer acceptance, and regret of treatment decisions.80 Self-perceptions, anxiety regarding treatment effects, and decision-making are equally important domains. Preservation of QOL at the expense of survival requires a clear understanding of what this trade-off entails.81 Quality-adjusted survival rates may not be appropriate to use in determination of treatment plans because of variations in individual values. It may be unreasonable to base treatment expectations on a return to the patient's premorbid level of functioning.
Because there is no therapy that is clearly superior for all patients and because all treatments carry risks of side effects, QOL considerations become increasingly important in decision-making models. Often patients are faced with complex decisions that need to be made within a moderate time frame and for which patients are ill-prepared. Recent studies have attempted to incorporate educational programs into standard office visits. Determination of patient treatment preferences, using various decision-making aids, may facilitate decisions regarding early detection and treatment.82 Development of screening and treatment programs is hindered by lack of consensus regarding optimal methods of detection and treatment for prostate cancer. Even Medicare does not reimburse PSA screening. One study of 21 large managed care organizations indicated that they felt PSA testing was not mandatory; no treatment policy was in place for any of the managed care companies surveyed.83
|
CONCLUSION
|
Men undergoing early detection for prostate cancer experience uncertainty related to the time course of cancer and often fear treatment and treatment-related side effects. It is still unclear whether early detection can reduce disease-specific mortality, and therein lies the controversy about early detection. Healthcare providers need to consider patient and family beliefs in the context of ethnocentric values. Although most patients are able to adapt to the cancer diagnosis and its management, QOL and treatment complications should be discussed by physicians who can counsel patients in the selection of preferred courses of treatments. Treatment choices are made more difficult by the lack of information on the long-term relative effectiveness of RP vs. RT.
Ideally, the management of anxiety and depression requires a multidisciplinary and multimodal approach. Psychiatrists can assist as diagnostic consultants in monitoring adjuvant psychotropic medications and in providing appropriate psychotherapy for treatment for men with prostate cancer and their families. An understanding of the current controversies in early detection and treatment can assist the C-L psychiatrist in working through difficult medical decisions with their patients.
|
REFERENCES
|
- Engel GL: The clinical application of the biopsychosocial model. Am J Psychiatry 1980; 137:535–544[Abstract/Free Full Text]
- Rosenthal DS: Changing Trends: Cancer statistics, 1998. CA Cancer J Clin 1998; 48:3–4[Abstract]
- Myers RE, Wolf TA, McKee L, et al: Factors associated with intention to undergo annual prostate cancer screening among African American men in Philadelphia. Cancer 1996; 78:471–479[CrossRef][Medline]
- Perez N, Tsou HH: Prostate cancer screening practices: differences between clinic and private patients. Mt Sinai J Med 1995; 62:316–321[Medline]
- Imperato PJ, Nenner RP, Will TO: Radical prostatectomy: lower rates among African American men. J Natl Med Assoc 1979; 88:589–594
- Wolf AM, Nasser JF, Wolf AM, et al: The impact of informed consent on patient interest in prostate-specific antigen screening. Arch Intern Med 1996; 156:1333–1336
- Robinson SB, Ashley M, Haynes MA: Attitude of African-Americans regarding prostate cancer clinical trials. J Community Health 1996; 21:77–87[CrossRef][Medline]
- Nayeri K, Pitaro G, Feldman JG: Marital status and stage at diagnosis in cancer. NY State J Med 1992; 92:8–11[Medline]
- Myers RE, Wolf TA, Balshem AM, et al: Receptivity of African-American men to prostate cancer screening. Urology 1994; 43:480–487[CrossRef][Medline]
- Boehm S, Coleman-Burns P, Schlenk EA, et al: Prostate cancer in African American men: increasing knowledge and self-efficacy. J Community Health Nurs 1995; 12:161–169[CrossRef][Medline]
- Guidry JJ, Aday LA, Zhang D, et al: Transportation as a barrier to cancer treatment. Cancer Practice 1997; 5:361–366[Medline]
- Powell IJ, Schwartz K, Hussain M: Removal of the financial barrier to health care: does it impact on prostate cancer at presentation and survival? A comparative study between black and white men in a Veterans Affairs system. Urology 1995; 46:825–830[CrossRef][Medline]
- Pansky B: Vas deferens, seminal vesicles, and prostate, in Review of Gross Anatomy, 4th Edition. New York, Macmillan, 1979, pp 370–371
- Sagalowsky AI, Wilson JD: Hyperplasia and carcinoma of the prostate, in Harrison's Principles of Internal Medicine, 14th Edition. Edited by Fauci AS, Braunwald E, Isselbacher KJ, et al. New York, McGraw Hill, 1998
- Coley CM, Barry MJ, Fleming C, et al: Early detection of prostate cancer. Part I: Prior probability and effectiveness of tests. Ann Intern Med 1977; 126:394–406
- Cersosimo RJ, Carr D: Prostate cancer: current and evolving strategies. Am J Health Syst Pharm 1996; 53:381–396
- Pollack AE: Vasectomy and prostate cancer. Adv Contracept 1993; 9:181–186[CrossRef][Medline]
- Flair WR, Fleshner NE, Heston W: Cancer of the prostate: a nutritional disease? Urology 1997; 50:840–848[CrossRef][Medline]
- Gunby P: Prostate cancer's complexities of causation, detection, and treatment challenge researchers. JAMA 1997; 277:1580–1582
- Bonn D: Vitamin E may reduce prostate-cancer incidence. Lancet 1998; 351:961
- Keeley FX, Gomella LG: Epidemiology of prostate cancer, in Prostate Cancer. Edited by Ernstoff MS, Heaney JA, Peschel RE, et al. Malden, MA, Blackwell, 1998
- Smith JR, Freije D, Darpten JD, et al: Major susceptibility locus for prostate cancer on chromosome 1 suggested by a genome-wide search. Science 1996; 274:1371–1374
- Burke W, Daly M, Garber J, et al: Recommendations for follow-up care of individuals with an inherited predisposition to cancer, II: BRCA1 and BRCA2. JAMA 1997; 277:997–1003
- Presti JC, Stoller ML, Carroll PR: Urology, in Current Medical Diagnosis and Treatment, 38th Edition. Edited by Tierney LM, McPhee SJ, Papadakis MA. Stamford, CT, Appleton & Lange, 1999
- Gomella LG, Raj GV, Moreno JG: Reverse transcriptase polymerase chain reaction for prostate specific antigen in the management of prostate cancer. J Urol 1997; 158:326–337[CrossRef][Medline]
- Von Eschenbach A, Ho R, Murphy GP, et al: American Cancer Society guidelines for early detection of prostate cancer. Cancer 1997; 80:1805–1807
- Catalona WJ, Beiser JA, Smith DS: Serum free PSA and PSA density measurements for predicting cancer in men with prior negative biopsies. J Urol 1997; 158:2162–2167
- American Joint Committee on Cancer: Prostate, in American Joint Committee on Cancer Staging Manual, 5th Edition. Edited by Fleming ID. Philadelphia, Lippincott-Raven, 1997
- Lu-Yao GL, Yao S: Population-based study of long-term survival in patients with clinically localized prostate cancer. Lancet 1997; 349:906–910[CrossRef][Medline]
- Thompson IM: Observation alone in the management of localized prostate cancer: the natural history of untreated disease. Urology 1994; 43(suppl 2):41–46
- Wallner K: External radiation: how much radiation is given, in Prostate Cancer: A Non-Surgical Perspective. Canaan, NY, Smartmedicine Press, 1997
- Frydenberg M, Stricker PD, Kaye KW: Prostate cancer diagnosis and management. Lancet 1997; 349:1681–1687
- Cadeddu JA, Partin AW, Epstein JI, et al: Stage D1 (T1–3, MO) prostate cancer: a case-controlled comparison of conservative treatment versus radical prostatectomy. Urology 1997; 50:251–255[CrossRef][Medline]
- Talcott JA, Rieker P, Clark JA, et al: Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study. J Clin Oncol 1998; 16:275–283[Abstract/Free Full Text]
- Perez MA, Meyerowitz BE, Leeskovsky G, et al: Quality of life and sexuality following radical prostatectomy in patients with prostate cancer who use or do not use erectile aids. Urology 1997; 50:740–746[CrossRef][Medline]
- Geary ES, Dendinger TE, Freiha FS, et al: Nerve sparing radical prostatectomy: a different view. J Urol 1995; 154:145–149[CrossRef][Medline]
- Forman JD, Velasco J: Therapeutic radiation in patients with a rising post-prostatectomy PSA level. Oncology 1998; 12:33–39[Medline]
- Smith JA Jr: Hormonal therapy of prostate cancer: current concepts and future prospects. Clin Ther 1988; 10:281–286[Medline]
- Montgomery P, Santi G: The influence of bilateral orchiectomy on self-concept: a pilot study. J Adv Nurs 1996; 24:1249–1256
- Augbert JL, Vautherin R: Radical orchiectomy. Ann Urol (Paris) 1992; 26:80–82
- Maguire P, Parkes CM: Surgery and loss of body parts. BMJ 1998; 316:1086–1088
- Rosenblatt DE, Mellow A: Depression during hormonal treatment of prostate cancer. J Am Board Fam Pract 1995; 8:317–320
- Bratt O, Kristofferson U, Lundgren R, et al: Sons of men with prostate cancer: their attitudes regarding possible inheritance of prostate cancer and screening among African American men in Philadelphia. Cancer 1996; 78:471–479
- Schapira MM, Meade C, Nattinger AB: Enhanced decision-making: the use of a videotape decision-aid for patients with prostate cancer. Patient Education & Counseling 1997; 30:119–127
- Roth AJ, Kornblith AB, Batel-Copel L, et al: Rapid screening for psychological distress in men with prostate carcinoma. Cancer 1998; 82:1904–1908
- Rafuse J: Men's attitude about seeking health care may put them at risk, conference told. Can Med Assoc J 1993; 149:329–330[Medline]
- Davison BJ, Degner LF: Empowerment of men newly diagnosed with prostate cancer. Cancer Nurs 1997; 20:187–196[CrossRef][Medline]
- Roth AJ, Scher HI: Genitourinary malignancies, in Psycho-Oncology. Edited by Holland JC. New York, Oxford University Press, 1998
- Zabora JR, Brintzenhofeszoc KM, Smith ED: Prevalence of psychological distress by cancer site (abstract). Proc Annu Meet Am Soc Clin Oncol 1996; 15:A1627
- Gustafsson O, Theorell T, Norming U, et al: Psychological reactions in men screened for prostate cancer. Br J Urol 1995; 75:631–636[Medline]
- Whelan P: Are we promoting stress and anxiety? BMJ 1997; 315:1549–1550
- Kornblith A, Herr HW, Ofman US, et al: Quality of life of patients with prostate cancer and their spouses. Cancer 1994; 73:2791–2802
- Kunkel EJS: The assessment and management of anxiety in patients with cancer, in Medical-Surgical Psychiatry: Treating Psychiatric Aspects of Physical Disorders. Edited by Thompson TL. San Fransisco, Jossey-Bass, 1993
- Alter CL, Pelcovitz D, Axelrod A, et al: Identification of PTSD in cancer survivors. Psychosomatics 1996; 37:137–143[Abstract/Free Full Text]
- Clark JA, Wray N, Brody B, et al: Dimensions of quality of life expressed by men treated for metastatic prostate cancer. Soc Sci Med 1997; 45:1299–1309
- Massie MJ, Shakin EJ: Management of anxiety and depression, in the cancer patient, in Psychiatric Aspects of Symptoms Management in Cancer Patients. Edited by Breitbart W, Holland JC. Washington, DC, American Psychiatric Press, 1993
- Bukberg J, Penman D, Holland JC: Depression in hospitalized cancer patients. Psychosom Med 1984; 46:199–211[Abstract/Free Full Text]
- McDaniel JS, Musselman DL, Porter RM, et al: Depression in patients with cancer. Arch Gen Psychiatry 1995; 52:89–99[Abstract/Free Full Text]
- Cohen MJM, Kunkel ES, Levenson JL: Associations between psychosocial stress and malignancy, in Handbook of Stress Medicine: An Organ System Approach. Edited by Hubbard JR, Workman EA. New York, CRC, 1998
- Massie MJ, Holland JC: Assessment and management of cancer patient with depression. Adv Psychosom Med 1988; 18:1–12
- Holland JC: Anxiety and cancer: The patient and family. J Clin Psychiatry 1989; 50(suppl 11):20–25
- Heim HM, Oei TPS: Comparison of prostate cancer patients with and without pain. Pain 1993; 53:159–162[CrossRef][Medline]
- Monti DM, Kunkel EJS: Management of chronic pain in the elderly. Psychiatr Serv 1998; 49:1537–1539
- Breitbart W: Psychotropic adjuvant analgesics for cancer pain. Psychology 1992; 1:133–145
- Van Heeringen C, De Schyver A, Verbeek E: Sexual function disorders after local radiotherapy for carcinoma of the prostate. Radiother Oncol 1988; 13:47–52[CrossRef][Medline]
- Brasilis KG, Santa-Cruz C, Brickman AL, et al: Quality of life 12 months after radical prostatectomy. Br J Urol 1995; 75:48–53[Medline]
- Zelefsky MJ, Eid JF: Elucidating the etiology of erectile dysfunction after definitive therapy for prostate cancer. Int J Radiat Oncol Biol Phys 1998; 40:129–133[CrossRef][Medline]
- Goldstein I, Lue TF, Padma-Nathan H, et al: Oral sildenafil in the treatment of erectile dysfunction: Sildenafil Study Group. N Engl J Med 1998; 338:1397–1404
- Kloner RA, Jarow JP: Erectile dysfunction and sildenafil citrate and cardiologists. Am J Cardiol 1999; 83:576–582[CrossRef][Medline]
- Volk RJ, Cantor SB, Spam SJ, et al: Preferences of husbands and wives for prostate cancer screening. Arch Fam Med 1997; 6:72–76[Abstract/Free Full Text]
- Jakobsson L, Hallberg IR, Loven L: Experiences of daily life and life quality in men with prostate cancer: an explorative study. Part I. Eur J Cancer Care (English Language Edition) 1997; 6:108–116
- Kaps EC: The role of the support group, "Us Too." Cancer 1994; 74:2188–2189
- Gregoire I, Kalogeropoulos D, Corcos J: The effectiveness of a professionally led support group for men with prostate cancer. Urol Nurs 1997; 17:58–66[Medline]
- Gray RE, Fitch M, Davis C, et al: Interviews with men with prostate cancer about their self-help group experience. J Palliat Care 1997; 13:15–21[Medline]
- Borghede G, Karlson J, Sullivan M: Quality of life in patients with prostate cancer: results from a Swedish population study. J Urol 1997; 158:1477–1485
- Helgason AR, Adolfsson J, Dickman P, et al: Waning sexual function—the most important disease-specific distress for patients with prostate cancer. Br J Cancer 1996; 73:1417–1421
- Helgason AR, Fredrikson M, Adolfsson J, et al: Decreased sexual capacity after radiation therapy for prostate cancer impairs quality of life. Int J Radiat Oncol Biol Phys 1995; 32:33–39[CrossRef][Medline]
- Lucas MD, Strijdom SC, Berk M, et al: Quality of life, sexual functioning and sex role identity after surgical orchidectomy in patients with prostatic cancer. Scand J Urol Nephrol 1995; 29:497–500[Medline]
- Fossa SD, Aaronson N, Calais da Silva F, et al: Quality of life in patients with muscle-infiltrating bladder cancer and hormone-resistant prostatic cancer. Eur Urol 1989; 16:335–339[Medline]
- Roth AJ, Wray N, Brody B, et al: Dimensions of quality of life expressed by men treated for metastatic prostate cancer. Soc Sci Med 1997; 45:1299–1309
- Shrader-Bogen CL, Kjellberg JL, McPherson CP, et al: Quallity of life and treatment outcomes: prostate carcinoma patients' perspective after prostatectomy or radiation therapy. Cancer 1997; 79:1977–1986
- Onel E, Hammond C, Wasson JH, et al: Assessment of feasibility and impact of shared decision making in prostate cancer. Urology 1998; 51:63–66[CrossRef][Medline]
- Bennett CL, Buchner DA, Ullman M: Approaches to prostate cancer by managed care organizations. Urology 1997; 50:79–86 [CrossRef][Medline]
This article has been cited by other articles:
|
|
|
|
 
E. J. S. Kunkel, B. Meyer, C. Daskalakis, J. Cocroft, K. Jennings-Dozier, and R. E. Myers
Behaviors Used by Men to Protect Themselves against Prostate Cancer
Cancer Epidemiol. Biomarkers Prev.,
January 1, 2004;
13(1):
78 - 86.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. F. Penson, Z. Feng, A. Kuniyuki, D. McClerran, P. C. Albertsen, D. Deapen, F. Gilliland, R. Hoffman, R. A. Stephenson, A. L. Potosky, et al.
General Quality of Life 2 Years Following Treatment for Prostate Cancer: What Influences Outcomes? Results From the Prostate Cancer Outcomes Study
J. Clin. Oncol.,
March 15, 2003;
21(6):
1147 - 1154.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. A. Monti and C. Peterson
Mindfulness-Based Art Therapy (MBAT)
Integr Cancer Ther,
March 1, 2003;
2(1):
81 - 83.
[PDF]
|
|
|
Get information about faster international access.
Privacy Policy
Copyright © 2000
Academy of Psychosomatic Medicine.
All rights reserved.
Home
| Search
| Current Issue
| Past Issues
| Subscribe
| All APPI Journals
| Help
| Contact Us
|
TOP
ABSTRACT
BIOPSYCHOSOCIAL ASPECTS OF...
