Prostate Cancer Patients Face a Host of Psychosocial Issues

PALM SPRINGS, Calif--Early diagnosis of prostate cancer can bea mixed blessing, bringing with it not only the chance of curebut also the psychological distress of choosing between watchfulwaiting and treatment, and if treatment is chosen, which treatment,Andrew Roth, MD, said at the Academy of Psychosomatic Medicinemeeting.

"There is controversy among oncolo-gists over the initialtreatment offered to men with early prostate cancer, and thiscontroversy trickles down and adds to the patient's confusionand distress, making decisions more difficult," said Dr.Roth, attending psychiatrist, Memorial Sloan-Kettering CancerCenter in New York City.

Recently researchers at Memorial Sloan-Kettering have shown thata low-fat diet coupled with vitamin supplements slows the progressionof prostate cancer in mice. "This might give men the opportunityfor more participation in their care," Dr. Roth said. "Thereis a lot of excitement among the men in our clinic who see thatthey can do something on their own that might possibly slow theprogression of their disease."

Evaluating Psychological Distress

Dr. Roth noted that with more men being diagnosed with prostatecancer, the psychological issues of this disease are becomingmore salient. Psychiatric interventions that address the emotionaldistress and symptom-related issues of men with prostate cancercan improve their quality of life, he said.

As psychiatric liaison to the prostate clinic at Memorial Sloan-Kettering,Dr. Roth meets with all new patients, evaluates their psychologicaldistress, introduces the multidisciplinary concept of addressingboth physical and psychoso-cial needs, and normalizes the conceptof discussing emotional reactions to stress. "The model thatwe use in our specialty clinic is one that could be used in primarycare settings as well," Dr. Roth said.

The psychological symptoms reported by men with prostate cancerinclude anxiety, anger, and dysphoria. These symptoms may stemfrom the patient's concerns about the disease, but may also havetheir etiology in either the disease process or the effects ofdrug therapy.

Although anxiety is expected at crisis points in the illness,such as diagnosis, treatment selection, PSA monitoring (see boxbelow), and news of disease progression, it may be a manifestationof physical symptoms that are not well controlled.

Dr. Roth said that a thorough psycho-social evaluation includesreview of the adequacy of social and psychological support; pastlosses, including deaths from cancer of significant individualsin the patient's life; adequacy of coping strategies; psychiatrichistory; and the presence of financial problems.

When evaluating emotional distress, it is important to considerthat many prostate cancer patients have just retired or are lookingforward to retirement, Dr. Roth pointed out, and the disappointmentof being diagnosed with cancer at a time in their lives when theywere anticipating a release from the pressure of work must beacknowledged.

He also noted that men with prostate cancer are at risk for undermanagementof their pain. They are often unwilling to take pain medicationor fail to take adequate amounts because of unwarranted fearsof side effects or concerns that taking pain medication is unmasculine.

For many men, the psychological issues associated with the sideeffects of prostate cancer can be overwhelming, Dr. Roth said.Impotence from surgery or other therapies can make men feel emasculated.Urinary incontinence and fear of leakage can lead to social withdrawal,which may cause family members to think that the patient is becomingdepressed.

Decreased libido, mood changes, weakness, and fatigue or hot flashesresulting from hormonal treatments can be psychologically distressing.

Psychological treatments that help men cope better and make betterdecisions include education. "Providing information aboutthe emotional impact of medication or the disease goes a longway toward helping a man know why he's depressed," Dr. Rothsaid.

Although men in this age group are often reluctant to engage inpsychotherapy, behavioral therapies including relaxation haveproven to be successful, he said. The treatment of anxiety withbenzodiazepines is also useful in this population, although menfrom this generation are often reluctant to take any psychotropicmedication. In some cases, sex therapy may be indicated.

Communication problems between prostate patients and their spousescan contribute to psychological distress. "At a time whencommunication should be at its best, it's often at its worst,"Dr. Roth said.

Research demonstrates that spouses often have more distress thanpatients, underscoring the need for spouses to receive adequatesupport or intervention.

"Men are often not comfortable sharing emotions, and theyoften feel the need to be the protector or the strong one,"he said, "but their wives can often see that they are deterioratingphysically and are in significant pain even though they won'tadmit it." He added that brief couples therapy can be usefulin some cases.

PSA Anxiety

In his presentation at the Academy of Psychosomatic Medicine meeting(see story above), Dr. Andrew Roth discussed a phenomenon seenin some prostate cancer patients that he and his colleagues atMemorial Sloan-Kettering have termed "PSA Anxiety,"ie, anticipatory anxiety prior to repeat PSA testing.

"We've found that PSA monitoring is a major stressor formany of these men," he said. "They get worried aboutslight increases and presume that their treatment is failing ortheir disease is progressing."

These men, many of whom are veterans of combat in World War II,have referred to this as their fear of being hit by the "PSAbullet."