Prostate cancer, the second leading cause of cancer death in men, is the most common cancer in males in the United States. Out of an estimated 230,000 new cases in 2004, more than 70% will occur in men over age 65. Close liaison between urologists, prostate oncologists, radiation oncologists and psychiatrists allows for improved information transfer and proper referrals, as well as improved identification of the symptoms as being either physical, psychological or both.
April Bonus Edition 2005
Prostate cancer is the most common cancer in males in the United States with an estimated 230,000 new cases in 2004, more than 70% of which will occur in men over age 65 (American Cancer Society, 2004). It is the second leading cause of cancer death in men. Prostate cancer incidence rates are 32% higher for African-American men than white men, and the mortality rates are twice as high for African-American men. This is likely because African-American men are diagnosed during later stages of the disease. The psychological reactions of this generally older population of men will depend on available supports, psychiatric history and other significant life events, such as recent death of a spouse, divorce, entering dating situations as older men, retirement or previously losing loved ones to cancer. Roth and colleagues (1998) found that 15.2% of men with prostate cancer met the cutoff for probable case of depression using the Hospital Anxiety and Depression Scale (HADS). They also reported that about one-third of the men experienced significant anxiety. A significant amount of anxiety is also found in men screened for prostate cancer (Cormier et al., 2002).
American Cancer Society guidelines recommend a yearly digital rectal examination along with an annual prostate specific antigen (PSA) test for men age 50 and older (American Cancer Society, 2004). Men who are at high risk, such as African-Americans or those with a strong family history of prostate cancer, are advised to begin testing starting at age 45. Routine screening PSA tests for younger men that have yielded cancer results have led to heightened anxiety and confusion, as there seems to be little consensus about the benefits versus complication ratio for treatment in younger men.
Early Phases of Diagnosis
Apart from the general worries of a new cancer diagnosis, there is still controversy about selection of primary treatments for prostate cancer, making the decision about treatment difficult. Primary treatment options are radical prostatectomy, radiation therapy and "watchful waiting," which can lead to differences in specific areas of functioning such as sexual function, urinary functioning or bowel functioning over time (Table 1) (Penson and Litwin, 2003).
Differences of professional opinion often trickle down to patients, creating uncertainty and making their decision about treatment difficult. Watchful waiting (deferred therapy) is often recommended for those over age 70 with significant comorbid illness, low-grade indolent cancers and <10 years life expectancy.
In men who are healthy enough to endure treatment, surgery (prostatectomy) has historically been thought of as the definitive treatment. Not all urologists perform the newer "nerve-sparing" procedure that has decreased the rate of impotence and urinary incontinence complications (Garnick, 1994). Even successful nerve-sparing surgery does not guarantee sexual potency afterward. Radiation therapy, either conventional or brachytherapy with seed implants, may yield less incidence of impotence and urinary problems. However, there are more risks of difficulties with bowel function, depending on factors of technique and total dose delivered. Three-dimensional conformal external radiation therapy has decreased the incidence of local complications and has increased the ability to control these cancers.
For more advanced disease, hormonal manipulations are used to decrease the synthesis of testosterone, which promotes prostate cancer cell growth. Today, this is most often accomplished with oral gonadotropin-releasing hormone agonist medications such as leuprolide (Eligard, Lupron, Viadur) or goserelin (Zoladex), in conjunction with antiandrogenic agents that reduce production of testosterone in the adrenal glands such as flutamide (Eulexin) or bicalutamide (Casodex). Medical hormonal therapy may be preferred over orchiectomy by men due to improved body image and therefore improved quality of life, though medical therapy carries an ongoing, significant financial burden. A number of side effects of androgen blockade have been reported (Holzbeierlein et al., 2004). Table 2 lists some of the more common side effects. There have been increased reports of significant symptoms of depression (Pirl et al., 2002), anxiety and irritability in these men. Chemotherapeutic agents are used for more advanced tumors as palliative measures.
Early treatment decisions are fraught with the sense of having to choose between quality of life and longevity, although without a good crystal ball, it is unclear what the outcome will be on either side of the balance. Many men entertain multiple second opinions regarding their primary therapy, which may add to confusion and distress because of the lack of agreement among practitioners. Patients take in information from reasonable and reliable sources and any number of unverified sources on the Internet. This onslaught of information can lead to significant anxiety while trying to make a reasonable treatment decision.
Side effects of medications used for prostate cancer such as hormonal therapy, steroids and pain medications cause distress as well. The side effects of hormonal therapies can be particularly distressing for otherwise asymptomatic males and has led to the use of intermittent hormonal therapy to decrease the morbidity of therapy. Men may experience anxiety, irritability or depression. However, it has been found that those most likely to get depressed are those who have previous histories of depression (Pirl et al., 2002).
Athough there may be considerable variations between the patients' and urologists' evaluation of performance status, pain and pain relief (Litwin et al., 1998), awareness and education about these problems as well as continued attempts to resolve or cope better with them can significantly reduce psychological tension.
Sexuality. Erectile dysfunction, likely the most feared complication of treatment, can occur from aging, the cancer itself, surgery, radiation or hormonal therapy. If erectile dysfunction is prolonged after treatment, men wonder when or if they will be able to have sex again.
For those men who are particularly bothered by sexual dysfunction, sex therapy with a trained therapist can help a man express the feelings engendered by this dysfunction and also to help a couple learn alternative ways of sharing sexual intimacy. Consultation with a urologist who specializes in male sexual dysfunction can be helpful.
Men are quite resistant to penile injections with vasodilating agents, Vacutainers, penile suppositories or penile implants. They are more willing to try medications such as sildenafil (Viagra), tadalafil (Cialis) or vardenafil (Levitra), although these medications are quite variable in their erectile-enhancing effects in this population. Hormonal therapy also eliminates libido; feelings of being emasculated occur. Sometimes this lack of libido obviates the pressure to correct erectile dysfunction.
Urinary incontinence and bowel changes. The fear of urine leaking, smelling of urine, bowel accidents and having to use diapers feels regressive and is humiliating to many men. Soon after prostatectomy, men may worry, "When will the urinary catheter come out and when will I stop leaking?" Many men begin to shun social contact. This social withdrawal is often mistaken for major depression; this situation, however, if disregarded can lead to significant anxiety and depression, which may then need to be treated by anxiolytics or antidepressants. Supportive and cognitive-behavioral therapy (CBT) can assist a man in coping with these changes in lifestyle. In order to help men cope with this symptom it is important to identify the etiologies of incontinence, educate patients and families about this problem, and provide ideas to alleviate or reduce symptoms. Urinary incontinence can be alleviated with pelvic muscle re-education, bladder training, anticholinergic medications and even artificial sphincter surgery.
Coping with pain. Pain due to bone metastases is often a symptom of advanced prostate cancer. Older men are often reluctant to take pain medications or dosages adequate to truly help. It is not clear to what degree this relates to a fear of side effects, such as constipation and fatigue, or to a machismo attitude of feeling compelled to endure the pain. Support of the use of pain medications by the medical team as well as vigilant efforts to reduce or manage side effects can facilitate improved quality of life.
Fatigue and lack of motivation. These symptoms are particularly upsetting to men who have led active and independent lives. They usually result in increased dependence on family or friends, which are further reminders of the contrast with how patients were before the cancer. Because of the possible overlap in symptoms between a fatigue syndrome and depression and anxiety syndromes, these entities must be identified as completely as possible and distinguished from each other, as they each require different treatment strategies. Fatigue and lack of motivation can be caused by the illness, hormonal therapy, pain medication, steroids, chemotherapy and other factors. Helping patients to reorganize their schedule and set realistic goals may result in less distress. A psychostimulant such as methylphenidate (Ritalin, Concerta, Metadate) titrated from 5 mg/day in two divided doses early in the day, or modafinil (Provigil) titrated from 50 mg/day to 100 mg/day, may decrease fatigue, increase motivation, enhance appetite, elevate a patient's mood and counter the sedating effects of opioids. If depression is present, activating antidepressants such as fluoxetine (Prozac) or bupropion (Wellbutrin) can be used.
Hot flashes. In men, hot flashes are caused by many of the hormonal therapies, including orchiectomy. Symptoms include diaphoresis and feelings of intense heat and chills--similar to symptoms that women have during menopause. At times, hormonal therapy must be stopped because of the drenching sweats and discomfort caused by hot flashes, especially when sleep is disturbed. This has led to a strategy of intermittent hormonal use to decrease the side-effect burden. There have been anecdotal reports and small trials that suggest antidepressants--particularly selective serotonin reuptake inhibitors such as sertraline (Zoloft) and paroxetine (Paxil), and the serotonin-norepinephrine reuptake inhibitor venlafaxine (Effexor)--reduce the frequency and intensity of hot flashes (Barton and Loprinzi, 2004).
It is not clear whether these medications relieve the distress of having the hot flash symptoms or work in some way to alleviate the flashes themselves. Changes in habits that stimulate onset of the hot flashes such as decreasing caffeine, alcohol and hot fluid intake may be useful.
Anxiety and PSA hypervigilance . After treatment for prostate cancer or after a recurrence, many men become hypervigilant about their PSA tests, equating any change in their PSA test with "being a dead man." This PSA anxiety can lead to panic symptoms and insomnia and may be relieved with education, support and anxiolytic medications, if needed (Roth et al., 2003). Estimates of anxiety in men with prostate cancer have hovered around 33% (Roth et al., 1998), while depression has been estimated between 12% and 15%. Lofters et al. (2002) found significant anxiety in 15% of men before receiving PSA tests. Education about PSA levels as well as acknowledging some of the fears of what a rising PSA might mean, while recognizing how constant worry about the future negates the whole reason these men fear losing their lives, can help reduce this worry.
A PSA level can be normal even in the presence of cancer. It is also not cancer-specific, so there may be false positive results, as seen with prostatitis, benign prostatic hypertrophy and with manipulation of the prostate such as with biopsies. Although there are different assays for this test in someone not yet diagnosed with this cancer, in general, a PSA reading <4 is considered normal, 4 to 10 is questionable, and >10 is worrisome for cancer. If the level goes to zero after a prostatectomy, a rise in the level is worrisome for return of the cancer.
Clinical experience has found that men with prostate cancer respond to education and various kinds of brief psychotherapy including supportive therapy, CBT and insight-oriented therapy. To date, there have been no comparative studies looking at the efficacy of different psychotherapies in this population. There have been some promising results from a number of educational and small cognitive-behavioral interventions. Unfortunately, some men are reluctant to participate in therapy, particularly if they have never done so previously (Nelson et al., 2005). Often, men are more amenable to psychotherapy if the spouse or partner is present. This is often a good opportunity to work on issues that have become problems for the couple as well as the individual patient. There are also support groups available specifically for men with prostate cancer. National support groups available to men include Us TOO (<www.ustoo.com>), American Cancer Society's Man to Man (<www.cancer.org>) and Malecare (<www.malecare.com>).
At a time when a couple's communication needs to be at its best, it is often at its worst because of the stress of the situation. Some men tend to be uncomfortable sharing emotions. They often have a need to be seen as the protector and provider for the family, however incompatible this is with the reality of their physical deterioration. It has been noted that spouses suffer significant distress coping with their husbands' cancer (Kornblith et al., 1994). Family members are often concerned when they see the suffering and pain in their loved ones, yet often feel powerless to change the course of events. Although there have been no efficacy studies of couples therapy in prostate cancer, clinical experience has found that couples counseling can improve the ability of a couple to cope with the cancer. Sexual and relationship issues are particularly bothersome for men who are single, divorced or widowed when they wonder if, how or when they should bring up the issue of their cancer or sexual difficulties on a date. Some men avoid dating altogether. Psychotherapy to address these issues and perhaps to rehearse different scenarios may help alleviate some of the fears these men have, though there are no studies to confirm this clinical observation.
When psychiatric symptoms of depression and anxiety are severe, psychotropic medications can be effective and should be used with the general rule for older patients: start with low doses and go slowly. The SSRIs are safe and well tolerated and can alleviate depressive symptoms caused by hormonal therapy. Benzodiazepines and atypical antipsychotics are useful in treating symptoms of anxiety caused either by hormonal agents or corticosteroid regimens. There are no efficacy studies of the use of antidepressants, benzodiazepines or antipsychotics in men with prostate cancer. Most information is anecdotal or by case reports. These men may have more difficulty tolerating medications with anticholinergic side effects because of urinary sequelae. The SSRIs are generally well tolerated by these men, though they may be reluctant to take any additional medications that are not treating their cancer. Selective serotonin reuptake inhibitors, benzodiazepines and antipsychotics do not have significant interactions with most hormonal and chemotherapy agents used to treat prostate cancer. Psychostimulants, if tolerated, may be useful in treating fatigue caused by hormonal treatment, radiation therapy, chemotherapy, and other medications such as opioids or the disease process in these men.
Prostate cancer is affecting a larger proportion of our male population as detection methods are improving. The illness and treatments affect patients' quality of life in multiple spheres. Issues such as sexual dysfunction, urinary incontinence, bowel changes, fatigue, pain, hot flashes, body image changes and forced lifestyle changes lead to psychological distress. The PSA tumor marker that is used to follow treatment outcomes can be a significant source of anxiety.
Assessment of these problems is not easy, particularly in distinguishing between physical and psychological etiologies of distress. Discomfort and beliefs about stigma on the part of the patient, family and health care provider in discussing these issues provide formidable barriers to evaluation and resolution of distress. Psychological and psychiatric interventions provide avenues for decreased stress and improved quality of living. Avoidance of these issues leads to increased suffering, significant psychological distress and feelings of despair, isolation, hopelessness, and passive thoughts of wanting to die.
Medical caregivers should have a low threshold for identification of these problems as well as referral to mental health practitioners. Once assessed, management of these areas would include a spectrum of psychologic and psychiatric interventions: education, support, individual and group psychotherapy, couples therapy, sex therapy, behavioral interventions, and psychotropic medications. These referrals may be facilitated by increased knowledge on the part of the patient, the oncology team, and the mental health practitioner about the illness and treatment-specific stressors.
Close liaison between urologists, prostate oncologists, radiation oncologists and psychiatrists allows for improved information transfer and proper referrals as well as improved identification of the symptoms as being either physical, psychological or both. It is useful for psychiatrists treating men with prostate cancer to have a familiarity with the disease process and its treatments, as well as the psychophysiological implications. A familiarity with these issues often enhances a psychotherapeutic alliance.
Dr. Roth is associate attending psychiatrist in the department of psychiatry at Memorial Sloan-Kettering Cancer Center in New York.
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