Mental Health Issues Common, Often Overlooked in Prostate Cancer

NEW ORLEANS -- More than a third of men with newly diagnosed prostate cancer had at least one mental health issue, which had a strong association with prior psychological wellbeing, a prospective cohort study showed.

Almost 30% of the men had a fear of cancer recurrence or poor prognosis, and 22% met diagnostic criteria for depression or anxiety. Issues with body image and masculinity were also common. Disease-specific factors had no association with mental wellbeing, reported Oliver Brunckhorst, PhD, of King's College London, at the American Urological Association annual meeting.

"Mental wellbeing issues are common early in the patient's cancer journey and go beyond depression and anxiety," said Brunckhorst. "Mental wellbeing should be considered routinely during follow-up. Evaluating the [mental] status at baseline is quite important for enabling us to have targeted screening and identifying the issues early, so that we can refer them early on for treatment and hopefully improve their quality of life."

The results contrasted somewhat with those of a study involving men who underwent biopsy for suspected prostate cancer. Investigators found no difference in quality-of-life outcomes for men with negative biopsies and those who had low-risk prostate cancer and opted for active surveillance, said Christopher Porter, MD, of Virginia Mason Medical Center in Seattle.

An unidentified member of the audience pointed out that quality of life can change over time in patients with prostate cancer. Serial assessment of patients might provide more insight into mental wellbeing as compared with a single point in time.

"We have actually found that people who have issues early on, within 3 or 6 months, tend to continue having poor mental wellbeing throughout," said Brunckhorst. "But it would be interesting to focus on that formally."

Other speakers questioned whether healthcare systems would have the resources to screen, detect, and manage mental health issues among prostate cancer patients if a third or more of patients have problems.

Brunckhorst agreed but pointed out that "we actually have clear cutoffs to refer people, whether that be to a family doctor or general practitioners or to local services. It's a little bit of a struggle to actually find enough people to be able to refer everyone, but the patients at the more severe end of the spectrum for depression and anxiety, we are able to make sure that they are referred."

The typically long survival for patients with prostate cancer places increased emphasis on survivorship issues that include both physical and mental wellbeing. Whereas physical effects of the disease and treatment -- such as sexual dysfunction and urinary incontinence -- have received considerable attention, only recently have clinicians and researchers begun to recognize the impact on mental health, said Brunckhorst.

Recent studies have shown that substantial proportions of men with prostate cancer have anxiety and depression. Beyond the "pure mental health conditions," peripheral issues come into play and can adversely affect quality of life, fear of cancer recurrence or disease progression, altered sense of masculinity, and body image issues, he added.

To gain more insight into mental wellbeing and factors that influence it, investigators recruited men with newly diagnosed prostate cancer into a multicenter prospective cohort study. Each patient in the ongoing study will be followed for 12 months, using online or mailed questionnaires every 3 months to assess mental, social, and physical wellbeing.

To date, the study has accrued 270 patients: 77 on active surveillance, 73 who underwent radical prostatectomy, 75 who had definitive radiation therapy, and 45 treated with hormonal therapy. The baseline assessment showed that 12.8% of the patients met criteria for depressive symptoms, 9.7% had anxiety, 9.7% had body-image issues, 29.6% expressed fear of cancer recurrence or disease progression, and 7.1% had masculinity/self-esteem issues. Overall, 36.2% of the men had at least one mental health issue.

Brunckhorst emphasized that the patients represented a range of severity for mental health issues.

"If a patient had depressive symptoms at baseline, not necessarily significant depressive symptoms, but some form of depressive symptoms, they were more likely to develop issues," he said. "We found that's the same for all of the outcomes that we analyzed."

Investigators performed a univariate analysis of 196 patients who have completed at least 3 months of follow-up. Factors that adversely affected mental wellbeing were hormonal monotherapy (HR 2.05, 95% CI 1.02-4.22), younger age (OR 1.04, 95% CI 1.02-1.08), Black ethnicity (OR 3.33, 95% CI 1.15-9.65), and previous psychological history (OR 2.97, 95% CI 1.15-7.67).

No oncologic factors had significant associations with mental wellbeing, including disease stage or grade and prostate-specific antigen level at diagnosis. Baseline functional factors also did not predict mental health wellbeing.

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