Psychological Aspects of Prostate Cancer

A Clinical Review

A De Sousa; S Sonavane; J Mehta


Prostate Cancer Prostatic Dis. 2012;15(2):120-127. 

In This Article

An Overview of Anxiety and Depression in Prostate Cancer

Anxiety and Prostate Cancer

Anxiety is an affective state that can often occur without an identifiable triggering stimulus. As such, it must be distinguished from fear, which is an emotional response to a perceived threat. Additionally, fear is also related to specific behaviors of escape and avoidance, whereas anxiety is related to situations perceived as uncontrollable or unavoidable. Another form of anxiety is anticipatory anxiety, which is a future-oriented mood state in which one is anxious anticipating a future upcoming negative event.[7] Anxiety is seen in various forms in patients with prostate cancer. Anxiety may be seen while testing for prostate cancer (PSA testing), diagnosis, during treatment, while dealing with the social stigma, could be related to sexual function and an anxiety with a fear related to recurrence of the cancer after treatment.[8] Studies have shown that at any given time 20–60% of patients with prostate cancer may suffer from anxiety in general.[9]

PSA testing is associated with a significant amount of anxiety in prostate cancer patients. A blood test to measure PSA is considered the most effective test currently available for the early detection of prostate cancer, but this effectiveness has also been questioned due to risks of false positives and false negatives.[10] A study on anxiety in prostate carcinoma suggests that while screening for prostate carcinoma, anxiety levels vary plausibly over the clinical timeline in response to stress and uncertainty both before to testing and while awaiting the reports. Baseline levels of anxiety related to screening are much lower for older men than younger men with the illness.[11] Reducing anxiety by itself is a potential motivation for screening, because individuals may hope for reassurance from a normal test result. In fact, urologists are well aware of the anxiety, physical and emotional distress undergone by men who are getting their PSA tested and those who have elevated PSA levels, a condition called PSAdynia.[12]

It is also essential that one distinguishes between anxiety 'trait', which may be present as a background characteristic of the patient's personality, and anxiety 'state', which is a situational response to a stressor. Anxiety trait when present indicates that the patient is basically anxious by nature and shall carry the anxiety with him throughout the clinical process and treatment. Anxiety state in turn indicates a transient response of anxiety with regards to test results if bad, prognosis and certain treatment outcomes.[13] The memorial anxiety scale for prostate cancer is an appropriate tool that can be used for screening of anxiety in patients with prostate cancer. It consists of three subscales, which are anxiety related to prostate cancer, fear of recurrence and PSA-related anxiety.[14]

Our review identified a total of 39 studies between 1984 and 2011 that have evaluated anxiety in prostate cancer. In many of these studies, anxiety related to screening was paramount and seeking peace of mind via a negative result was the main reason to get testing done. Avoidance of screening was also related to anxiety. Having a family member with prostate cancer increased anxiety about having prostate cancer.[15] In most of the studies, 30–40% patients complained that the anxiety affected their day-to-day functioning. Anxiety levels were highest in a group awaiting biopsy results and were related to the test report and not doubts regarding the biopsy procedure. Even a diagnosis of prostate cancer when established did reduce anxiety as the uncertainty reduced, but this reduction in anxiety was not as much as on obtaining a negative result.[16] Most studies on anxiety in prostate cancer were small in size, and few were prospective in design. In areas where anxiety was studied most carefully, particularly in the realm of pursuing screening, anxiety changes were consistent with the hypothesis that anxious men were more likely to pursue screening, especially younger men and those who had relatives with a history of prostate carcinoma.[17] This may influence the choice of treatments for localized disease, as men who are more anxious may undergo surgery to avoid worry about cancer spread. One neglected area of our current understanding for the HRQOL and decision making in prostate carcinoma is the role of patient anxiety and our current knowledge does remain fragmentary in a sense. Future research needs to assess the role that patient anxiety would have in prostate cancer screening, treatment decisions and recovery.[18]

When and if a patient is diagnosed with prostate cancer via biopsy or after detection of elevated levels of PSA, it is essential that the urologist sends the patient for a psychological evaluation to help the patient cope with the news and also prepare him to cope with the treatment procedures that may follow. Along with this, it is also essential to involve the primary caregivers to understand the treatment process and psychological distress of the patient along with an allaying of their own anxieties. In our clinical experience, we have noted that awareness about the disease makes patients more comfortable, thereby making them feel in charge of their bodies and this may help them become more receptive to treatment options. Counseling helps patients understand their limitations, how to deal with the pain, anxiety and depression that follow. Counselors help to control the psychological dilemmas faced and may bridge the gap between doctors and patients.[19]

PSA Bounce Anxiety in Prostate Cancer

This section has been incorporated in this article to give the reader an insight into the PSA bounce phenomenon. It is a urological phenomenon that has psychological implications. This is an important phenomenon noteworthy for both the psychiatrist and the urologist who treat prostate cancer patients. Patients continue to experience anxiety in prostate cancer even after the treatment is over and after all the malignant tissue has been destroyed. Patients receiving external beam radiation therapy or ultrasound-guided prostate brachytherapy (seed implant) as treatment for early-stage prostate cancer may experience a benign rise in PSA value after the treatment. A study describes the phenomenon called 'PSA bounce', which can be mistaken for a rise in PSA resulting from biochemical failure. The PSA bounce can be a major source of anxiety for patients and families and can create diagnostic challenges for clinicians.[20] Clinicians should be aware of this complex phenomenon, observe PSA values and account for the PSA bounce in posttreatment management of their patients. Patient education and psychosocial support can be helpful for patients and families when PSA values rise after radiation treatment.

While assessing anxiety in a patient with prostate cancer, it is essential that urologists are taught and equipped to screen for anxiety-related phenomena in these cases. It would also be essential if a psychiatrist, psychologist and urologist could have a joint evaluation of the patient to work out an effective treatment plan as well as ascertain the causes of the underlying anxiety.

Depression and Prostate Cancer

The clinical significance of psychological distress, particularly depression, experienced by men with prostate cancer has yet to be addressed adequately in the research literature. Few studies have empirically examined the prevalence of depression in men with prostate cancer. Similarly, few experimental studies have tested the effectiveness of interventions targeting depression or mood as outcomes. Although the literature is sparse, a need exists to organize the available research to chart the direction for future investigations.[21] Men with prostate cancer at a risk for depression include those with advanced prostate cancer, prominent pain symptoms, side effects of treatment and a previous history of clinical depression.[22] Depression has been strongly correlated to fatigue and pain as symptoms in prostate cancer.[23] Rates of depression in older men with prostate cancer are lower than those typically reported in women with breast cancer.[24]

Prostate cancer pain appears to be associated strongly with depressive symptoms, whereas fatigue induced by radiation therapy or hormonal therapy has not been associated consistently with increasing depression.[25] QOL studies have found few prostate treatment variables associated with depression.[26] Rather, major findings from these studies indicate that being older, being married, having high social support, being optimistic and having less impairment in physical functioning are associated with decreased risk of depression.[27–30]

The profile of risk factors associated with depression in men with prostate cancer is highly consistent with the profile of factors empirically shown to be associated with risk of depression in general cancer populations.[31] The studies comparing men with prostate cancer and their partners suggest that partners' risk for psychological distress, including depressive symptoms, is as high as or higher than patients' risk. Notwithstanding, the research on informational interventions and comprehensive reviews of psychosocial cancer intervention research in prostate cancer indicate that the state of the science for supportive care interventions aimed toward men with prostate cancer is limited.[32] The modest amount of interest in addressing the psychological complications of prostate cancer as compared with breast cancer often is attributed to the common belief that older men generally are unlikely to experience depression, even when dealing with cancer.[33]

In the past 10 years, there has been new research into depression among men with prostate cancer. Nursing science is prominent in making contributions to this growing field of investigation. Nurses can use their current knowledge to identify men with prostate cancer at the highest risk for depression in their clinical settings.[34] The concept of male depression lacks sufficient empirical support, but this concept is useful to clinicians to assess men for maladaptive behavior, such as substance abuse, self-neglect, abusive behavior directed toward significant others, as well as an expression of depressed affect. Clinicians are advised to assess the psychological status of not only the male patient with prostate cancer but also the potential for depression in the patient's spouse.[35]

Anxiety about cancer as a diagnosis, lack of awareness, medical complications that ensue, the fear of death and financial burdens are some of the factors that lead to depression among prostate cancer patients. There is often a delay in diagnosis of this depression, which reduce the chances of long-term cancer survival by 10–20%.[36] Effective psychotherapeutic treatment for depression, along with antidepressant therapy, has been found to affect the course of prostate cancer. Psychotherapy results in reduced anxiety and depression, and often pain reduction. Psychotherapy also results in longer survival time for the patients.[37,38] The physiological or neurobiological mechanism for these findings has not yet been determined, but the possibilities for psychotherapeutic effects on physiological change include health maintenance behavior, health-care utilization, endocrine and hormonal changes and positive changes in immune function. Thus, effective treatment of depression results in better patient adjustment, reduced symptoms, reduced cost of care and may influence disease course.[39] A combined evaluation and treatment approach where the urologist and psychotherapist or psychiatrist work out an effective treatment plan considering psychological and urological perspectives on the etiology of depression is best for the patient.

Stress Related to Prostate Cancer Recurrence

Patients diagnosed with recurrent cancer may experience many of the same feelings experienced earlier when first diagnosed with cancer. Shock, disbelief, anxiety, fear, grief and a loss of control are all common emotions. Feelings of betrayal, anger that it could happen more than once, anger directed at the doctor for not curing the cancer the first time or anger at themselves are common and normal responses to what can be an especially difficult experience.[40] Many people with recurrent cancer also experience self-doubt about their original treatment decisions or choices after treatment. It is important that the doctor/psychologist make the patient understand that the choices the doctor made at the time of original treatment were based on the information available then, and possibly the best at that time.[41]

Understandably, patients diagnosed with recurrent cancer may feel that they cannot find the strength to cope with another round of tests and treatments. But many patients find that they are better prepared than at the time of the original diagnosis. Some of the factors patients with recurrent cancer find helpful include knowledge of the cancer, which helps reduce some of the fear and anxiety related to the unknown and previous relationships with doctors, nurses and clinic or hospital staff that ease stress during their visits to the hospital.[42] Along with this, a greater knowledge of the medical system and how to negotiate it, including an understanding of medical terms and a better understanding of the medical insurance system, has a vital role in adaptation to treatment. Familiarity with cancer treatments and their side effects, as well as what works best to lessen those side effects along with familiarity with different types of support, including support from family and friends, support groups and professionals trained in providing emotional support, all help in stress reduction. Most patients are also aware of the types of stress-reducing methods that work best, such as exercise, meditation or spending time with friends.[43]


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