Psychological effects of androgen-deprivation therapy on men with prostate cancer and their partners

Development of a Novel Patient-Reported Outcome Measure to Assess Symptoms and Impacts of Androgen Deprivation Therapy for Advanced Prostate Cancer

INTRODUCTION

This qualitative research study was conducted to develop a novel, comprehensive, patient-reported outcome measure (PRO), the "Symptoms and Impacts of Androgen Deprivation Therapy (ADT) for Prostate Cancer" (SIADT-PC), assessing hormonal therapy-related symptoms and their impacts on men with advanced prostate cancer.

METHODS

Concept elicitation (CE) interviews were conducted among adult men with prostate cancer to evaluate their experiences with ADT. Based on key symptom and impact concepts mentioned, an initial PRO measure was developed. The draft measure was further assessed in cognitive debriefing (CD) interviews with men with prostate cancer, in which participants reviewed items, response options, and recall periods. Initial item-based psychometric analyses were conducted using interview data. The draft questionnaire was revised on the basis of participant feedback, quantitative psychometric results, and consultation with clinical experts.

RESULTS

A total of 21 participants were interviewed (CE concept elicitation, n = 12; CD cognitive debriefing, n = 17; n = 8 completed both). Mean participant age (SD) was 59.7 (8.7) years and 76.2% were white. The de novo SIADT-PC measure consists of 27 items: 11 symptoms (e.g., fatigue, hot flashes, and erectile dysfunction), 2 long-term symptoms (e.g., weight gain), 10 impacts (e.g., impacts on physical activities and relationships), and 4 related to mode of administration (i.e., injection-site reactions). Items were assessed with a 5-point verbal rating scale, with answer choices that capture frequency or severity.

CONCLUSIONS

Once fully validated, this de novo measure may be used in clinical studies and clinical practice to assess hormone therapy-related symptoms and impacts, enabling physicians to identify timely and appropriate interventions.

What is the nature and impact of cognitive difficulties following hormonal treatments for prostate cancer?: An interpretative phenomenological analysis

OBJECTIVE

Prostate cancer hormonal treatments (e.g. androgen deprivation therapy) yield clinical benefits. However, there is increasing evidence these treatments may adversely impact cognitive functioning. This study aimed to qualitatively characterise the nature and impact of cognitive difficulties following these treatments.

METHODS

Prostate cancer survivors (PCS) self-reporting cognitive difficulties following hormonal treatments (via an online survey) and their partners were invited to participate in semi-structured interviews. Telephone or videoconferencing interviews were conducted, then transcribed, double-coded and analysed using the Framework Method, following the principles of Interpretative Phenomenological Analysis.

RESULTS

Eleven participants (six PCS and five partners) were interviewed. PCS reported a range of cognitive difficulties, verified by their partners, including forgetfulness, "fogginess", fatigue and slowed processing speed. For some PCS, word-finding difficulties, tangential speech and memory problems were apparent during interviews. The aetiology of the reported cognitive difficulties was unclear as it was attributed to a possible combination of cancer treatments, compounding side-effects (e.g. fatigue, sleep problems, hot flashes), exacerbation of pre-existing conditions and/or age-related changes. Cognitive difficulties were reported to have led to shifts in self-perception, interpersonal dynamics and increased emotionality. Engagement in cognitively-stimulating activities and reliance on compensatory strategies were reported to be helpful in managing some cognitive difficulties. All participants endorsed the potential benefits of neuropsychological intervention.

CONCLUSIONS

There are a diverse range of cognitive difficulties following hormonal treatments for prostate cancer experienced by PCS and their partners. Understanding the impact of these difficulties is important for the development of targeted neuropsychological interventions.

Five-year outcomes of fractionated stereotactic body radiotherapy for oligometastatic prostate cancer from the TRANSFORM phase II trial

Metastasis-directed therapy (MDT) for oligometastatic prostate cancer (PCa), including stereotactic body radiotherapy (SBRT), has shown promise but is still considered investigational. This is the 5-year analysis of the TRANSFORM trial, the largest prospective cohort of men with oligometastatic PCa treated with SBRT-based MDT. The primary endpoint was 5-year treatment escalation-free survival (TE-FS), defined as freedom from any new cancer therapy other than further SBRT. In total, 199 men received SBRT; 76.4% were hormone-naïve at baseline. The rate of 5-year TE-FS was 21.7% (95% confidence interval [CI]: 15.7%-28.7%) overall and 25.4% (95% CI: 18.1%-33.9%) in the hormone-naïve subgroup. The subgroups with International Society of Urological Pathology Grade Groups 4-5 disease (hazard ratio [HR] = 1.48, 95% CI: 1.05-2.01, p = .026), a higher baseline prostate-specific antigen (PSA) (HR = 1.06, 95% CI: 1.03-1.09, p < .001) and those who received prior androgen deprivation therapy (ADT) (HR = 2.13, 95% CI: 1.40-3.26, p < .001), were at greater risk of treatment escalation. Outcomes for participants with four or five initial lesions were comparable to those with one to three lesions. At last follow-up, 18.9% (95% CI: 13.2%-25.7%) of participants were free from treatment escalation (median follow-up of 67.9 months) and two participants had an undetectable PSA level. No treatment-related grade three or higher adverse events were reported. The findings of this study demonstrate that SBRT-based MDT is an effective option for delaying systemic treatment escalation in the context of oligometastatic PCa. Future randomised trials comparing SBRT-based MDT to standard-of-care ADT-based approaches are required to evaluate the impact of delaying ADT on survival.

Effect of hormonal therapies for prostate cancer on cognition: The ongoing search for clarity

Hormonal therapy for advanced prostate cancer with androgen deprivation and novel androgen‐receptor axis–targeted therapy have produced mixed results on cognitive effects in previous studies. The most robust meta‐analysis to date shows a lack of objective cognitive changes across all domains at 6 months of treatment, although significant patient‐perceived, subjective decline suggests that concerns remain warranted, and further high‐quality, prospective studies are ultimately needed for greater certainty on longer term outcomes.

Improving Distress Screening for People with Prostate Cancer: Evaluation of an E-Learning Course to Increase Healthcare Professionals' Knowledge

OBJECTIVES

Psychological distress can occur following diagnosis and treatment for prostate cancer, compromising psychosocial wellbeing. Improved recognition and management of distress by healthcare professionals can enhance clinical practice and promote evidence-based prostate cancer care. This paper explores the effectiveness and feasibility of the online Distress Screening for Prostate Cancer course, designed to improve healthcare professionals' understanding of screening for prostate cancer-related distress. It aims to evaluate whether this e-learning course increases learners' knowledge of distress screening for prostate cancer.

METHODS

Healthcare professionals were invited to enroll in the online course and complete optional evaluation questions. The pretest posttest design identified changes in learners' knowledge about distress screening for people with prostate cancer, including prevalence, risk factors, assessment and management strategies for distress (n = 149). Learners also rated satisfaction in a cross-sectional survey (n = 116). Most respondents were nurses, including Prostate Cancer Specialist Nurses.

RESULTS

Learners' knowledge of distress screening was higher after course completion. Improvement between pre- and posttest results was statistically significant for four of ten items, including risk of prostate cancer-related distress, and suicidality, and the purpose of distress screening. Learners reported high satisfaction with course content, structure, engagement, relevance, and approach. They particularly valued the narrative-based approach and interactivity. Small numbers encountered technological problems and some offered suggestions to improve learner feedback.

CONCLUSIONS

The course improved healthcare professionals' knowledge of distress among people affected by prostate cancer. Learners found the e-learning format feasible and acceptable.

IMPLICATIONS FOR NURSING PRACTICE

Deeper understanding of the psychological implications of diagnosis and treatment of prostate cancer can help healthcare professionals respond to and manage distress among men and their families, and provide supportive care to improve health-related quality of life. Access to an online course can offer effective, feasible education on distress screening.

Effectiveness of educational and psychological survivorship interventions to improve health-related quality of life outcomes for men with prostate cancer on androgen deprivation therapy: a systematic review

OBJECTIVES

Androgen deprivation therapy (ADT), a common treatment for prostate cancer, has debilitating impacts on physical and psychological quality of life. While some interventions focus on managing the physical side effects of ADT, there is a paucity of interventions that also address psychosocial and educational needs. The objective of this systematic review was to identify psychological and educational survivorship interventions targeting health-related quality of life (HRQoL) outcomes in men on ADT.

DESIGN

A systematic review of randomised controlled trials.

DATA SOURCES

Web of Science, Cochrane, EBSCO Host, PubMed, SCOPUS from inception (1984) to 28 January 2023.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Psychological and/or educational survivorship interventions targeting HRQoL outcomes for men on ADT; minimum 80% of participants on ADT; used a validated HRQoL outcome measure; published in English in a peer-reviewed journal.

DATA EXTRACTION AND SYNTHESIS

Data extraction using pre-specified study criteria was conducted. Heterogeneity of eligible studies precluded a meta-analysis.

RESULTS

A total of 3381 publications were identified with eight meeting the criteria. Interventions were either psychological with a cognitive behavioural approach (n=4), or educational with (n=2) or without (n=2) psychoeducational components.Two studies reported a statistically significant improvement using a specific HRQoL measure. Most studies were not adequately powered and/or included small sample sizes limiting the conclusions that can be drawn on effectiveness. The most effective interventions were (i) individually based, (ii) educational with a psychoeducational component, (iii) supplemented with information packages and/or homework and (iv) included personalised needs assessments.

CONCLUSION

There is a paucity of literature reporting psychological and educational survivorship interventions targeting HRQoL outcomes for men on ADT. What is urgently needed are person-centred survivorship interventions that are flexible enough to identify and address individual needs, taking into account the impact ADT has on both physical and psychological quality of life.

PROSPERO REGISTRATION NUMBER

CRD4202230809.

Fatigue in Prostate Cancer: A Roundtable Discussion and Thematic Literature Review

Context

Cancer and its treatments cause fatigue in up to 90% of men with advanced prostate cancer. As men with prostate cancer are surviving longer, cancer-related fatigue is becoming increasingly important for clinicians to understand and proactively manage.

Objective

The aim of this work is to identify knowledge gaps that may support healthcare professionals to recommend personalised fatigue management strategies.

Evidence acquisition

This manuscript is based on a roundtable discussion held during the European Association of Urology 2022 Annual Symposium, combined with a review of the literature. Five core themes were generated from the roundtable: (1) meaning of fatigue in prostate cancer patients, (2) impact of fatigue, (3) association between fatigue and treatment selection, (4) benefits of managing fatigue, and (5) barriers to exercise.

Evidence synthesis

Cancer-related fatigue has complex underlying aetiology and is a subjective experience that may be under-reported. Some studies have shown that techniques such as education, cognitive behavioural therapy, guided imagery, and progressive muscle relaxation can result in clinically meaningful improvements in fatigue. However, the largest body of evidence, and a theme echoed in the roundtable discussions, was the benefit of exercise on fatigue. Despite the benefits of exercise, for some men, objective barriers to exercise exist and knowledge of benefits does not automatically translate into implementation and adherence.

Conclusions

Understanding the specific health needs of individual patients and their desired health outcomes is essential to identify personalised strategies for minimising fatigue. As an outcome of the roundtable meeting, we developed a quick reference guide for healthcare providers. A high-resolution copy can be downloaded from https://patients.uroweb.org/library/fatigue-in-prostate-cancer-patients-guide/.

Patient summary

This article is based on dialogue between a group of specialists, patients, and caregivers, which took place at a roundtable meeting during the European Association of Urology 2022 Annual Symposium. The group discussed how healthcare providers can best support their patients who experience fatigue. The group subsequently developed a guide to help healthcare providers during appointments.

Racial Disparities in Diagnosis and Treatment of Depression Associated with Androgen Deprivation Therapy for Prostate Cancer

OBJECTIVE

To analyze potential racial disparities in the diagnosis and management of depression associated with androgen deprivation therapy.

METHODS

TriNetX health record network was queried for prostate cancer patients treated with androgen deprivation therapy from 2003-2023. Differences in rates of depression diagnosis and treatment were compared between White and Black patients. Means, odds ratios, and t tests were calculated in univariate analysis with 95% confidence intervals (CI).

RESULTS

Data were queried from 93 health care organizations to yield 78,313 prostate cancer patients treated with androgen deprivation therapy. Patients on androgen deprivation therapy had 60% greater odds of developing depression vs other patients [9% vs 6%; odds ratio (OR) 1.6; 95% CI (1.5-1.7); P <.0001]. Of those with depression secondary to androgen deprivation therapy, only 35% were treated with antidepressants. After starting androgen deprivation therapy, White patients had 30% greater odds of being diagnosed with depression, compared to Black patients [10% vs 8%; OR 1.3; 95% CI (1.2-1.4); P <.001]. White patients also had higher odds of being treated with a first line antidepressant than Black patients [56% vs 48%; OR 1.4, 95% CI (1.2-1.6), P <.001].

CONCLUSION

This analysis confirms a significant association between androgen deprivation therapy and the development of clinical depression, and highlights its medical undertreatment. Importantly, our findings also indicate significant racial disparities in the identification and treatment of depression. Routine screening initiatives that account for social determinants of health may alleviate this disparity. Limitations of this study include retrospective design and lack of data describing severity of depression, which might correlate with need for medication.

Psychological Distress, Emergency Room Utilization, and Mortality Risk Among US Adults With History of Prostate Cancer

PURPOSE

Adults with a history of prostate cancer experience several physical and mental stressors. However, limited information is available about the prevalence of psychological distress in this population and its association with clinical outcomes in a nationally representative sample.

METHODS

We identified adults with history of prostate cancer from a nationally representative cohort (2000-2018 US National Health Interview Survey) and its linked mortality files through December 31, 2019. The six-item Kessler Psychological Distress Scale (K6) was used to assess psychological distress. The associations between psychological distress severity, emergency room (ER) usage, and mortality risk were estimated using multivariable logistic and Cox proportional hazards models, which were both adjusted for age, survey year, race/ethnicity, region, education, health insurance, comorbidities, functional limitations, and time since cancer diagnosis.

RESULTS

Among the 3,451 adults with history of prostate cancer surveyed, 96 (2.4%), 434 (11.3%), and 2,921 (86.3%) reported severe, moderate, or low/no mental distress, respectively. During the 12 months preceding the survey, 812 (22.8%) adults with history of prostate cancer visited the ER. After a median follow-up of 81 months, 937 (25.5%) deaths occurred. Compared with participants with low/no mental distress, those with severe mental distress reported the highest utilization of the ER (adjusted odds ratio [aOR], 2.57 [95% CI, 1.51 to 4.37]) and exhibited the highest all-cause mortality (adjusted hazard ratio [aHR], 1.83 [95% CI, 1.29 to 2.60]), followed by those with moderate mental distress (ER use aOR, 1.76 [95% CI, 1.29 to 2.42]; all-cause mortality aHR, 1.22 [95% CI, 0.92 to 1.62]).

CONCLUSION

Among US adults with history of prostate cancer, psychological distress was associated with increased ER use and mortality risk. Notably, severe psychological distress was correlated with the highest rates of ER visits and mortality risk. However, given the retrospective nature of this study, uncontrolled confounding variables need to be considered when interpreting the findings.

Low Social Well-Being in Advanced and Metastatic Prostate Cancer: Effects of a Randomized Controlled Trial of Cognitive Behavioral Stress Management

BACKGROUND

Social well-being impacts cancer patients' health-related quality of life (HRQOL) and coping style. This secondary analysis was conducted to examine whether advanced prostate cancer survivors who had experienced low social well-being would benefit from a web-based cognitive behavioral stress management (CBSM) intervention.

METHOD

APC survivors (N = 192) who had received androgen deprivation therapy (ADT) were randomized to a 10-week CBSM or a health promotion (HP) control condition. A subsample of participants (n = 61) with low pre-intervention SWB (measured by social support from and relationship satisfaction with family and friends) was included in the study. Multilevel models compared participants' PC-specific quality of life (sexual, hormonal, urinary), affect-based psychosocial burden (cancer-related anxiety and distress), and coping strategies at baseline, 6 months, and 12 months. Covariates were included in all models as appropriate.

RESULTS

Participants randomized to the CBSM condition showed significantly greater improvements in fear of cancer recurrence and cancer-related intrusive thoughts than those in the HP control condition. A significant condition by time interaction was also found, indicating that CBSM improved participants' PC-related fear in both short- (6 months) and long-term (12 months). However, the CBSM intervention did not significantly impact APC-related symptom burden. Only for the urinary domain, clinically meaningful changes (CBSM vs HP) were observed. In addition, all participants, regardless of condition, reported less coping (e.g., emotion-, problem- and avoidance-focused) over time.

CONCLUSION

As predicted, the CBSM intervention improved several affect-based psychosocial outcomes for APC survivors with low baseline SWB.

Psychological Distress, Emergency Room Utilization, and Mortality Risk Among US Adults With History of Prostate Cancer

PURPOSE

Adults with a history of prostate cancer experience several physical and mental stressors. However, limited information is available about the prevalence of psychological distress in this population and its association with clinical outcomes in a nationally representative sample.

METHODS

We identified adults with history of prostate cancer from a nationally representative cohort (2000-2018 US National Health Interview Survey) and its linked mortality files through December 31, 2019. The six-item Kessler Psychological Distress Scale (K6) was used to assess psychological distress. The associations between psychological distress severity, emergency room (ER) usage, and mortality risk were estimated using multivariable logistic and Cox proportional hazards models, which were both adjusted for age, survey year, race/ethnicity, region, education, health insurance, comorbidities, functional limitations, and time since cancer diagnosis.

RESULTS

Among the 3,451 adults with history of prostate cancer surveyed, 96 (2.4%), 434 (11.3%), and 2,921 (86.3%) reported severe, moderate, or low/no mental distress, respectively. During the 12 months preceding the survey, 812 (22.8%) adults with history of prostate cancer visited the ER. After a median follow-up of 81 months, 937 (25.5%) deaths occurred. Compared with participants with low/no mental distress, those with severe mental distress reported the highest utilization of the ER (adjusted odds ratio [aOR], 2.57 [95% CI, 1.51 to 4.37]) and exhibited the highest all-cause mortality (adjusted hazard ratio [aHR], 1.83 [95% CI, 1.29 to 2.60]), followed by those with moderate mental distress (ER use aOR, 1.76 [95% CI, 1.29 to 2.42]; all-cause mortality aHR, 1.22 [95% CI, 0.92 to 1.62]).

CONCLUSION

Among US adults with history of prostate cancer, psychological distress was associated with increased ER use and mortality risk. Notably, severe psychological distress was correlated with the highest rates of ER visits and mortality risk. However, given the retrospective nature of this study, uncontrolled confounding variables need to be considered when interpreting the findings.

Examining the impact of androgen deprivation therapy, masculine self-esteem, and psychological flexibility on distress and quality of life in men with prostate cancer

OBJECTIVE

Studies suggest that androgen deprivation therapy (ADT) exacerbates psychological and quality of life (QoL) issues associated with prostate cancer (PCa). However, quantitative research examining underlying psychosocial mechanisms for this is limited. We examined the association of PCa symptoms with distress and QoL in ADT-treated and ADT-naïve patients, and the influence of masculine self-esteem and psychological flexibility (PF) on these relationships.

METHODS

Secondary analysis of a quantitative, cross-sectional survey of 286 PCa patients. Independent samples t-tests, moderation, and conditional process analysis were used to assess relationships between predictor, mediator, moderator, and outcome variables.

RESULTS

ADT was associated with greater PCa symptomology, lower masculine self-esteem, and lower QoL. Moderation analysis showed that ADT potentiated adverse impacts of PCa symptomology on distress and QoL. High PF attenuated these relationships, though less so for ADT-treated participants. Conditional process analysis showed that masculine self-esteem mediated the predictive effect of symptoms on distress across treatments. However, ADT did not moderate this indirect effect, nor was moderation conditional on PF.

CONCLUSION

PF appears to: (1) attenuate psychological distress in ADT patients; and (2) improve distress, QoL, and masculine self-esteem in ADT-naïve patients. Interventions targeting PF may thus be a viable adjunct to established approaches. However, their effects may be comparatively limited in ADT patients, who may benefit from more intensive and tailored treatment.

Family Wellbeing and Sexual Health of Patients Receiving Treatment for Prostate Cancer

Purpose

Prostate cancer and its treatment may affect patients' sexual function and social wellbeing. This study investigated the relationship between social/family wellbeing and sexual health in patients with prostate cancer. Additionally, the moderating effect of clinical characteristics on this relationship was also explored.

Patients and Methods

This is a descriptive correlational study using baseline data of a longitudinal study enrolling 137 patients with prostate cancer. Sexual Function (SF) and Sexual Function Distress (SFD) data were collected using the Symptom Index questionnaire. Demographic data were obtained during study intake and clinical data were obtained from chart review. Bivariate correlation determined the correlations among continuous demographic/clinical data, social/family wellbeing, and sexual health. Moderated regression analysis determined the moderating effects of clinical characteristics on the relationship of social/family wellbeing and sexual health.

Results

Moderate positive correlation was found between social/family wellbeing and SF, whereas a weak negative correlation was noted between social/family wellbeing and SFD. Depression was significantly correlated with social/family wellbeing and SFD. Both sexual health domains were significantly correlated with Gleason score. A significant difference was noted in the social/family wellbeing and both SF and SFD in participants receiving androgen deprivation therapy (ADT) compared to those not receiving ADT. Concomitant ADT use was the only clinical characteristic found to be a significant moderator of the relationship between social/family wellbeing and SFD, but none of the clinical characteristics was found to have a moderating effect on the relationship of social/family wellbeing and SF. Among patients who were not receiving ADT, high social/family wellbeing was associated with low SFD. Patients who were receiving ADT reported slightly higher SFD despite having higher social/family wellbeing.

Conclusion

Ensuring sexual health in patients with prostate cancer requires a comprehensive approach to address factors contributing to sexual health such as side effects of treatment and family wellbeing.

The Experiences of Female Partners of Patients With Erectile Dysfunction Due to Prostate Cancer Treatment in China: A Qualitative Exploration

BACKGROUND

Because of sociocultural factors, Chinese female partners of patients with prostate cancer (PC) may have perspectives and needs that differ from the more published reports of female partners living in Western cultures.

OBJECTIVES

The aim of this study was to explore the experiences of female partners of patients with PC experiencing erectile dysfunction in China.

INTERVENTIONS/METHODS

In this interpretive descriptive design, qualitative data were collected from semistructured telephone interviews with purposively sampled participants from the urology outpatient unit in a hospital in South China. The interviews were audiotaped, transcribed, and analyzed using a constant comparison approach.

RESULTS

Three themes emerged from the analysis of the participants' narratives: (a) acceptance of ceasing sex; (b) preserving intimacy through caregiving; and (c) the need for sexual health-related information.

CONCLUSION

Participants in this study reported that their own sexuality and intimacy were affected by their partner's erectile dysfunction, but they adjusted to sexuality and intimacy changes through their caregiving of their husbands owing to Chinese traditional perspectives on women's obligations. They also reported having unmet informational needs in improving sexual well-being for the sake of their partners, lending further support to the likely benefit of couple-based educational interventions addressing sexual wellness in dyads affected by PC and erectile dysfunction.

IMPLICATIONS FOR PRACTICE

The present study findings highlighted the need for more research attention to the support of Chinese female partners of patients with PC regarding sexual and intimate topics.

Supportive interventions for carers of men with prostate cancer: systematic review and narrative synthesis

PURPOSE

The objective of this study was to summarise the literature on current interventions available for carers of men with prostate cancer and analyse the outcomes of these interventions in supporting carers' needs.

METHODS

A systematic review was conducted, searching databases MEDLINE, PsycINFO, CINAHL, Scopus and Cochrane, using terms related to prostate cancer, carers and interventions. Randomised controlled trials and non-randomised controlled trials of interventions for informal carers with or without patients were included. Data were analysed using descriptive and frequency statistics; interventions and their impact on carers' outcomes were reported on narratively. The SwiM guidelines were applied to guide data synthesis.

RESULTS

Overall, 24 articles were included in the review. On average, participants were spouses (92%) and women (97%). Interventions largely rwere delivered face-to-face (42%) or used a combination of face to face and online modalities (38%). Two-thirds (63%) showed a significant improvement in carer's outcomes including psychological, sexual, physical and relationship/marital. The majority of studies (79%) tailored contents to carers' circumstances, most within a couples counselling format. Over one-third (42%) of studies focused on a range of supportive care needs, most commonly were psychological (58%), sexual (42%) and informational (25%).

CONCLUSIONS

Interventions for carers of men with prostate cancer were largely face to face, patient-spouse focused and two-thirds had some measurable impact on carer's outcomes. Research continues to underserve other patient-carer roles, including non-spousal carers. Interventions delivered solely for carers are required to meet gaps in care, and determine the impact on carer outcomes. Further research and more targeted interventions are needed.

PROSPERO REGISTRATION NUMBER

CRD42021249870.

Effects of stigma, anxiety and depression, and uncertainty in illness on quality of life in patients with prostate cancer: a cross-sectional analysis

PURPOSE

Although much work has been carried out on stigma, anxiety and depression, and quality of life(QoL) in cancer patients, far less work has been done to examine their associations. This study explores the effects of stigma, anxiety and depression, and uncertainty in illness on QoL in prostate cancer patients.

METHODS

A cross-sectional study surveyed levels of stigma, anxiety and depression, QoL, and uncertainty in illness in 263 people diagnosed with prostate cancer from the First Affiliated Hospital, Zhejiang University School of Medicine. The main study variables were analyzed by structural equation modeling.

RESULTS

Anxiety and depression were significantly negatively related to QoL, with a standardized regression coefficient (β=-0.312, S.E. =0.478, p < 0.05), which means that participants reporting higher levels of anxiety reported decreased levels of QoL. Stigma was positively related to anxiety and depression (β = 0.135, S.E. =0.203, p < 0.001) and uncertainty in illness (β = 0.126, S.E. =2.194, p < 0.05). Stigma has direct effects on QoL (β=-0.209, S.E. =1.655, p < 0.001), but in the presence of a third variable (anxiety and depression overall), direct effects are reduced, as indirect effects emerge through the variable anxiety and depression overall, with an indirect effect size of - 0.054.

CONCLUSIONS

Stigma impacts mental health, such as anxiety and depression, uncertainty in illness, and QoL. Health care professionals may help patients alleviate feelings of anxiety, depression, and uncertainty in illness to improve QoL outcomes.

Mapping European Association of Urology Guideline Practice Across Europe: An Audit of Androgen Deprivation Therapy Use Before Prostate Cancer Surgery in 6598 Cases in 187 Hospitals Across 31 European Countries

BACKGROUND

Evidence-practice gaps exist in urology. We previously surveyed European Association of Urology (EAU) guidelines for strong recommendations underpinned by high-certainty evidence that impact patient experience for which practice variations were suspected. The recommendation "Do not offer neoadjuvant androgen deprivation therapy (ADT) before surgery for patients with prostate cancer" was prioritised for further investigation. ADT before surgery is neither clinically effective nor cost effective and has serious side effects. The first step in improving implementation problems is to understand their extent. A clear picture of practice regarding ADT before surgery across Europe is not available.

OBJECTIVE

To assess current ADT use before prostate cancer surgery in Europe.

DESIGN, SETTING, AND PARTICIPANTS

This was an observational cross-sectional study. We retrospectively audited recent ADT practices in a multicentre international setting. We used nonprobability purposive sampling, aiming for breadth in terms of low- versus high-volume, academic, versus community and public versus private centres.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Our primary outcome was adherence to the ADT recommendation. Descriptive statistics and a multilevel model were used to investigate differences between countries across different factors (volume, centre type, and funding type). Subgroup analyses were performed for patients with low, intermediate, and high risk, and for those with locally advanced prostate cancer. We also collected reasons for nonadherence.

RESULTS AND LIMITATIONS

We included 6598 patients with prostate cancer from 187 hospitals in 31 countries from January 1, 2017 to May 1, 2020. Overall, nonadherence was 2%, (range 0-32%). Most of the variability was found in the high-risk subgroup, for which nonadherence was 4% (range 0-43%). Reasons for nonadherence included attempts to improve oncological outcomes or preoperative tumour parameters; attempts to control the cancer because of long waiting lists; and patient preference (changing one's mind from radiotherapy to surgery after neoadjuvant ADT had commenced or feeling that the side effects were intolerable). Although we purposively sampled for variety within countries (public/private, academic/community, high/low-volume), a selection bias toward centres with awareness of guidelines is possible, so adherence rates may be overestimated.

CONCLUSIONS

EAU guidelines recommend against ADT use before prostate cancer surgery, yet some guideline-discordant ADT use remains at the cost of patient experience and an additional payer and provider burden. Strategies towards discontinuation of inappropriate preoperative ADT use should be pursued.

PATIENT SUMMARY

Androgen deprivation therapy (ADT) is sometimes used in men with prostate cancer who will not benefit from it. ADT causes side effects such as weight gain and emotional changes and increases the risk of cardiovascular disease, diabetes, and osteoporosis. Guidelines strongly recommend that men opting for surgery should not receive ADT, but it is unclear how well the guidance is followed. We asked urologists across Europe how patients in their institutions were treated over the past few years. Most do not use ADT before surgery, but this still happens in some places. More research is needed to help doctors to stop using ADT in patients who will not benefit from it.

Effects of oestradiol treatment on hot flushes in men undergoing androgen deprivation therapy for prostate cancer: a randomised placebo-controlled trial

OBJECTIVE

Most men undergoing androgen deprivation therapy (ADT) for prostate cancer experience hot flushes. Current treatments have low or limited evidence of efficacy. It is likely that oestradiol depletion is the mediator of these hot flushes, and transdermal oestradiol might be an effective treatment.

DESIGN

This is a 6-month randomised, placebo-controlled trial with the hypothesis that oestradiol would reduce hot flush frequency and intensity and improve quality of life (QoL).

METHODS

Seventy-eight participants receiving ADT were randomised to 0.9 mg of 0.1% oestradiol gel per day or matched placebo. Hot flush frequency and severity were assessed by 7-day diary at baseline, month 1, month 3, and month 6. QoL was assessed by validated questionnaire.

RESULTS

Oestradiol reduced daily hot flush frequency, with a mean adjusted difference (MAD) of -1.6 hot flushes per day (95% CI: -2.7 to -0.5; P = 0.04). The effect on weekly hot flush score was non-significant, with a MAD -19.6 (95% CI: -35.5 to -3.8; P = 0.11). On per protocol analysis, E2 significantly reduced daily hot flush frequency, with a MAD of -2.2 hot flushes per day (95% CI: -3.2 to -1.1; P = 0.001), and weekly hot flush score, with a MAD of -27.0 (-44.7 to -9.3; P = 0.02). Oestradiol had no significant effect on QoL.

CONCLUSION

We confirmed our hypothesis of a clinical effect of assignment to oestradiol to reduce hot flush frequency in men with castrate testosterone due to ADT. Transdermal oestradiol could be considered for men with burdensome hot flushes in whom other treatments have failed as long as the risk of breast effects and fat gain are considered.

Symptom burden profiles in men with advanced prostate cancer undergoing androgen deprivation therapy

To identify symptom burden profiles among men with advanced prostate cancer undergoing androgen-deprivation therapy and examine their association with baseline sociodemographic and medical characteristics and psychosocial outcomes over time. Latent profile analysis was employed to identify distinct groups based on the Expanded Prostate Index Composite and the McGill Pain Questionnaire at baseline. Psychosocial outcomes were assessed at baseline, 6- and 12-month follow-ups. Three profiles emerged: "high symptom burden," "high sexual bother," and "low symptom burden." Men with "high symptom burden" were younger and exhibited higher baseline levels of depression, stress, cancer-specific distress, and anxiety than men in the other two groups. However, men with "high symptom burden" also demonstrated improvement in these psychosocial outcomes over time. Men with advanced prostate cancer who experience multiple co-occurring symptoms demonstrate worse psychosocial adjustment. Patients with substantial symptom burden, and specifically young men, may benefit from prompt referral to supportive care services.

Telemedicine and Telehealth in Urology-What Do the 'Patients' Think About It?

Telemedicine is the delivery of healthcare to patients who are not in the same location as the physician. The practice of telemedicine has a large number of advantages, including cost savings, low chances of nosocomial infection, and fewer hospital visits. Teleclinics have been reported to be successful in the post-surgery and post-cancer therapy follow-up, and in offering consulting services for urolithiasis patients. This review focuses on identifying the outcomes of the recent studies related to the usage of video consulting in urology centers for hematuria referrals and follow-up appointments for a variety of illnesses, including benign prostatic hyperplasia (BPH), kidney stone disease (KSD), and urinary tract infections (UTIs) and found that they are highly acceptable and satisfied. Certain medical disorders can cause embarrassment, social exclusion, and also poor self-esteem, all of which can negatively impair health-related quality-of-life. Telemedicine has proven beneficial in such patients and is a reliable, cost-effective patient-care tool, and it has been successfully implemented in various healthcare settings and specialties.

Depression, Anxiety, and Patterns of Mental Health Care Among Men With Prostate Cancer Receiving Androgen Deprivation Therapy

BACKGROUND

Androgen deprivation therapy (ADT) use is associated with an increased risk of developing depression and anxiety. Little is known about how the mental health of these men is treated.

MATERIALS AND METHODS

We identified men with prostate cancer who received ADT between 2001 and 2015 using Optum's de-identified Clinformatics Data Mart Database. We determined the incidence of depression or anxiety diagnoses, mental health treatments, and the specialty of providers initiating psychotropic medications, after the start of ADT. Outcomes were compared with those of men with prostate cancer not receiving ADT and men without prostate cancer.

RESULTS

Of 37 388 men with prostate cancer treated with ADT, 3964 (10.6%) received a new diagnosis of depression or anxiety. Of those 3964 men, 1892 (47.7%) did not receive a documented treatment, 10 (0.3%) received psychotherapy, 1321 (33.3%) a selective serotonin reuptake inhibitor, and 744 (18.8%) a benzodiazepine. The median time from initiation of ADT to a depression or anxiety diagnosis was 9.3 months. Primary care physicians were the most common prescribers of psychotropic medications (72.2%). The proportion of men not receiving mental health treatments of interest (47.7%) was similar compared to men without prostate cancer (49.1%), but statistically significantly lower compared to men with prostate cancer not receiving ADT (52.7%).

CONCLUSIONS

In men with prostate cancer receiving ADT with a new diagnosis of depression or anxiety, nearly half are not receiving mental health care while one in five is introduced to a benzodiazepine. Further investigation toward improving the mental health care for men on ADT is needed.

Feasibility, Acceptability, and Clinical Significance of a Dyadic, Web-Based, Psychosocial and Physical Activity Self-Management Program (TEMPO) Tailored to the Needs of Men with Prostate Cancer and Their Caregivers: A Multi-Center Randomized Pilot Trial

Background: Prostate cancer is the most common cancer diagnosis among men. Family caregivers (often female spouses) play a key role in ensuring patients’ needs are met, frequently assuming their role with no formal training, which can contribute to a high burden. The purpose of this study was to pilot TEMPO—the first dyadic, Tailored, wEb-based, psychosocial and physical activity self-Management PrOgram for men with prostate cancer and their caregivers. Methods: 49 men with prostate cancer and their caregivers were randomized to TEMPO or usual care. Baseline and follow-up questionnaires were completed to assess feasibility, acceptability, and clinical significance. A priori benchmarks for these outcomes were set. Thirteen exit interviews were conducted to further explore acceptability. Results: Feasibility benchmarks were met with the exception for recruitment with on average 6.1 dyads recruited/month (benchmark: 8 dyads/month). Benchmarks of acceptability focused on attrition (<25%) and system usability, which were met. Using the strict criteria for adherence of 100% of the module viewed and participants spending at least 15 min on the module, 45% of participants were adherent. The clinical significance on anxiety and quality of life was supported for caregivers, and mostly supported for the men with prostate cancer. Conclusion: This pilot trial was successful, with minor modifications needed prior to a large trial.

Body image, self-esteem, and sense of masculinity in patients with prostate cancer: a qualitative meta-synthesis

PURPOSE

Body image, self-esteem, and masculinity are three interconnected constructs in men with prostate cancer, with profound effects on quality of life. This meta-synthesis aimed to evaluate all known qualitative studies published studying the effect of prostate cancer on these constructs.

METHODS

A systematic review utilising PubMed, Embase, MEDLINE, and PsycINFO databases up to May 2020 was conducted in line with PRISMA and ENTREQ guidelines. All qualitative studies of men's experiences with body image, self-esteem, and masculinity whilst living with prostate cancer were included. A thematic meta-synthesis was conducted to identify emergent descriptive and analytical themes under the main study constructs.

RESULTS

Of 2188 articles identified, 68 were included. Eight descriptive themes were identified under two analytical themes: 'Becoming a Prostate Cancer Patient' and 'Becoming a Prostate Cancer Survivor'. These described the distress caused by changes to body image, sexual functioning, sense of masculinity, and self-esteem, and the subsequent discourses men engaged with to cope with and manage their disease. A key element was increased flexibility in masculinity definitions, and finding other ways to re-affirm masculinity.

CONCLUSIONS

Prostate cancer has an important effect on men's health post-diagnosis, and we identified strong relationships between each construct evaluated. The role of hegemonic masculinity is important when considering men's coping mechanisms and is also a key factor when addressing these constructs in counselling post-treatment.

IMPLICATIONS FOR CANCER SURVIVORS

This meta-synthesis provides key topics that uniquely affect prostate cancer survivors, enabling these patients to be effectively counselled, and have their concerns recognised by clinicians.

Self-reported lack of energy or feeling depressed 12 months after treatment in men diagnosed with prostate cancer within a population-based registry

OBJECTIVE

Feeling depressed and lethargic are common side effects of prostate cancer (PCa) and its treatments. We examined the incidence and severity of feeling depressed and lack of energy in patients in a population based PCa registry.

METHODS

We included men diagnosed with PCa between 2015 and 2019 in Victoria, Australia, and enrolled in the Prostate Cancer Outcomes Registry. The primary outcome measures were responses to two questions on the Expanded Prostate Cancer Index Composite (EPIC-26) patient reported instrument: problems with feeling depressed and problems with lack of energy 12 months following treatment. We evaluated associations between these and age, cancer risk category, treatment type, and urinary, bowel, and sexual function.

RESULTS

Both outcome questions were answered by 9712 out of 12,628 (77%) men. 981 patients (10%) reported at least moderate problems with feeling depressed; 1563 (16%) had at least moderate problems with lack of energy and 586 (6.0%) with both. Younger men reported feeling depressed more frequently than older men. Lack of energy was more common for treatments that included androgen deprivation therapy than not (moderate/big problems: 31% vs. 13%), irrespective of disease risk category. Both outcomes were associated with poorer urinary, bowel, and sexual functional domain scores.

CONCLUSIONS

Self-reported depressive feelings and lack of energy were frequent in this population-based registry. Problems with feeling depressed were more common in younger men and lack of energy more common in men having hormonal treatment. Clinicians should be aware of the incidence of these symptoms in these at-risk groups and be able to screen for them.

Exercise as a supportive care strategy in men with prostate cancer receiving androgen deprivation therapy at a regional cancer centre: a survey of patients and clinicians

PURPOSE

To understand how frequently exercise is discussed and/or prescribed as a supportive care measure and the barriers and facilitators to exercise uptake for men with prostate cancer receiving androgen deprivation therapy (ADT) at a regional cancer centre.

METHODS

An observational, cross-sectional study was conducted at a regional cancer centre in three stages: (1) Retrospective chart review of men with prostate cancer undergoing ADT to identify the frequency of discussion and/or prescription of supportive care measures; (2) prospective patient survey exploring barriers and facilitators to exercise; and (3) prospective clinician survey exploring barriers, facilitators and awareness of exercise guidelines in men with prostate cancer.

RESULTS

Files of 100 men receiving ADT (mean age 73 years; mean ADT duration =12 months) in the medical oncology (n = 50) and radiation oncology (n = 50) clinics were reviewed. Exercise was discussed with 16% of patients and prescribed directly to 5%. Patient survey (n = 49). 44.2% of patients reported participating in exercise at a high level. Common barriers to exercise participation included fatigue (51.0%), cancer/treatment-related weakness (46.9%) and joint stiffness (44.9%). 36.7% of patients reported interest in a supervised exercise program. Clinician survey (n = 22). 36.4% identified one or more exercise guidelines, and 40.9% correctly identified national exercise guidelines. Clinicians reported low knowledge of referral pathways to a supervised exercise program (27.3%). Clinicians believe physiotherapists (95.5%) are most suited to exercise prescription and 72.7% stated that exercise counselling should be part of supportive care. Limited time (63.6%) and patient safety (59.1%) were the two most common barriers to discussing exercise with patients. Clinicians reported that only 21.9% of their patients asked about exercise. The most endorsed facilitators to increase exercise uptake were patient handouts (90.9%) and integration of exercise specialists into the clinical team (86.4%).

CONCLUSION

Despite a third of patient respondents indicating an interest in a supervised exercise program, only 16% of patients with prostate cancer undergoing ADT at a regional cancer centre engaged in a discussion about exercise with their treating clinicians. Physical limitations and fatigue were the greatest barriers for patients. Clinicians indicated a need for more clinician education and better integration of exercise specialists into clinical care. A tailored, integrated approach is needed to improve the uptake of exercise in men with prostate cancer.

Supervised exercise therapy compared with no exercise therapy to reverse debilitating effects of androgen deprivation therapy in patients with prostate cancer: a systematic review and meta-analysis

Background

Androgen deprivation therapy (ADT) in patients with prostate cancer can have several debilitating side effects. Supervised exercise is recommended to ameliorate these negative effects.

Objective

To systematically evaluate the effect of supervised exercise therapy compared to no exercise therapy in patients with prostate cancer undergoing ADT, primarily according to the patient critical outcomes, ‘disease-specific quality of life’ and ‘walking performance’ measured at end of treatment.

Methods

We searched PubMed/Medline, Embase, Cochrane Library, Cinahl and Pedro, to identify randomised controlled trials (RCTs), which investigated the effect of supervised exercise therapy compared to no exercise therapy in patients with prostate cancer receiving ADT, last search: June 2021. Two independent reviewers extracted data, and assessed risk of bias using Cochrane Risk of Bias Tool and evaluated the certainty of evidence using the GRADE-method.

Results

Eigthteen RCTs (n = 1477) comprised patients with prostate cancer stages T1-T4 were included in the meta-analyses. Compared to no exercise therapy, supervised exercise therapy showed clinically relevant improvements in ‘disease-specific quality of life’ and ‘walking performance’. The standardised mean differences were 0.43 (95% confidence interval (CI): 0.29, 0.58) and −0.41 (95% CI: −0.60, −0.22), respectively. The overall certainty of evidence was moderate due to serious risk of bias.

Conclusions

Evidence of moderate quality shows that supervised exercise therapy probably is superior to no exercise therapy in improving ‘disease-specific quality of life’ and ‘walking performance’ in patients with prostate cancer undergoing ADT. The results apply to all patients receiving androgen deprivation therapy regardless of cancer stage. The results support a strong recommendation for supervised exercise therapy for managing side effects in this population.

Protocol registration

NKR-38-Focused-questions-PICOs-for-updating1.ashx (sst.dk)

Impact of lifestyle in prostate cancer patients. What should we do?

Objective:

This review aimed to analyze interventions raised within primary and tertiary prevention concerning the disease's incidence, progression, and recurrence of Prostate Cancer (PCa). Priority was given to the multidisciplinary approach of PCa patients with an emphasis on modifiable risk factors.

Materials and Methods:

We conducted a comprehensive literature review in the following databases: Embase, Central, and Medline. We included the most recent evidence assessing cohort studies, case-control studies, clinical trials, and systematic reviews published in the last five years. We only included studies in adults and in vitro or cell culture studies. The review was limited to English and Spanish articles.

Results:

Preventive interventions at all levels are the cornerstone of adherence to disease treatment and progression avoidance. The relationship in terms of healthy lifestyles is related to greater survival. The risk of developing cancer is associated to different eating habits, determined by geographic variations, possibly related to different genetic susceptibilities.

Discussion:

PCa is the second most common cancer in men, representing a leading cause of death among men in Latin America. Prevention strategies and healthy lifestyles are associated with higher survival rates in PCa patients. Also, screening for anxiety and the presence of symptoms related to mood disorders is essential in the patient's follow-up concerning their perception of the condition.

A Cross-Sectional Analysis of Barriers Associated With Non-Attendance at a Urology Telehealth Clinic in a Safety-Net Hospital

OBJECTIVE

To analyze the factors associated with non-attendance at a urology telehealth clinic in a large urban safety-net hospital after institutional-mandated transition to telehealth due to COVID-19.

METHODS

We identified all encounters scheduled for telehealth after March 17, 2020 and in the subsequent 8 weeks. Logistic regression was used to identify factors associated with attendance.

RESULTS

In total there were 322 telehealth encounters, 228 (70.8%) of which were attended and 94 (29.2%) that were not attended. Racial/ethnic minorities accounted for 175 (77.0%) of attended and 73 (76.7%) of non-attended encounters. On multivariable regression, single/divorced/widowed (odds ratio [OR] 2.36, 95% confidence interval [CI] 1.26-4.43), current substance use disorder (OR 5.33, 95% CI 2.04-13.98), and being scheduled for a new patient appointment (OR 1.81, 95% CI 1.04-3.13) were associated with higher odds of not attending a telehealth encounter. Race/ethnicity, primary language, and country of birth were not associated with odds of attendance.

CONCLUSION

Our findings identify several social factors (social support, substance use) associated with non-attendance at outpatient telehealth urology encounters at an urban safety-net hospital during the early stages of the COVID-19 pandemic. These barriers may have a greater impact specifically within a safety-net healthcare system and will inform equitable provision of urology telehealth programs in the future FUNDING: Goldberg-Benioff Endowed Professorship in Cancer Biology. The sponsors had no involvement with this study.

Couples coping with advanced prostate cancer: An explorative study on treatment decision making, mental deterioration, partnership, and psychological burden

OBJECTIVES

The aim of this study was to evaluate the role of spouses and the relevance of quality of life (QoL) and life expectancy (LE) in the treatment decision-making process of patients with advanced prostate cancer (CaP). We also addressed the role of possible mental deterioration, partnership quality, QoL, distress, anxiety, and depression in patients and their spouses.

METHODS AND MATERIAL

This was a cross-sectional non-interventional explorative study. We administered questionnaires to 96 patients with advanced CaPand their spouses. Both patients and their spouses were asked about the influence of the spouses on treatment decision making, if they prefer quality of life or life expectancy as main goal of treatment and the perceived deterioration of the patients' mental abilities. Additional questionnaires were used to assess medical history, partnership, global quality of life, distress, depression, and anxiety. We performed statistical tests to compare patients with spouses and correlations to detect associations between variables.

RESULTS

The spouses (65 ± 9 years) were significantly younger than the patients (69 ± 9 years). Ninety-five percent of the patients and 91% of the spouses reported that the spouses were involved in making treatment decisions. There was a high similarity within couples with regard to their preference for QoL or LE during treatment. Between couples, this preference differed markedly. Emotional control and motivation were the areas most commonly reported to have deteriorated among patients' mental abilities. The quality of the partnership was rated as being higher than average by both partners. Among the spouses, the quality of partnership correlated significantly with the preference for LE with regard to treatment decision making. Patients and spouses reported high psychological burdens in all areas, with higher levels of distress and anxiety in spouses (P< 0.01). Reduced quality of life and greater distress, depression, and anxiety were significantly correlated with the amount of deterioration of the patients' mental abilities.

CONCLUSIONS

Spouses of patients with advanced CaP seem to respond to different aspects of the disease by adjusting both their involvement in treatment decision making and their preferred goal of treatment. Due to mental deterioration in the patients and pronounced anxiety in their spouses, we suggest that it is important for the attending physician to provide detailed information and support to both partners. Overall, the high-stress situation seems to affect both partners to similar degrees.

Sexual function outcomes of radiation and androgen deprivation therapy for localized prostate cancer in men with good baseline function

BACKGROUND

Sexual dysfunction, including erectile dysfunction and loss of libido, are common among men undergoing treatment for localized prostate cancer. Both local treatments and systemic androgen deprivation therapy may contribute to these outcomes and are differentially indicated based on disease characteristics. We sought to compare sexual function through 5 years after radiation treatment with and without androgen deprivation therapy in men with good baseline sexual function to better understand long-term effects in this understudied subset of patients.

METHODS

We retrospectively reviewed a prospectively assembled population-based cohort of men who underwent radiation with and without androgen deprivation therapy for intermediate or high-risk localized prostate cancer. Sexual function was assessed longitudinally over 5 years. Men with erections sufficient for intercourse at baseline were selected for inclusion.

RESULTS

Out of 167 patients included, 73 underwent radiation alone and 94 received androgen deprivation therapy plus radiation (51 with intermediate and 43 with high-risk disease). Androgen deprivation therapy use was associated with worse sexual function through 1 year regardless of disease risk. This difference was no longer statistically significant at 3 years in the intermediate-risk group. Compared to radiation alone, androgen deprivation therapy in high-risk disease was associated with worse sexual function at 3 years (effect: -20.3 points, CI [-31.8, -8.8], p < 0.001) but not at 5 years (effect: -3.4, CI [-17.2, 10.5], p = 0.63).

CONCLUSIONS

Androgen deprivation therapy plus radiation is associated with worse sexual function through 3-years follow-up in men with high-risk prostate cancer compared to radiation alone. The addition of androgen deprivation therapy in the treatment of intermediate-risk disease does not appear to result in worse sexual function at 3 or 5-year follow-up compared to radiation alone.

Differences in the Psychological, Sexual, and Childhood Experiences Among Men with Extreme Interests in Voluntary Castration

Some genetic males seek voluntary castration. We designed a survey to compare the psychological, sexual, and childhood experiences for subgroups of men with extreme interest in castration. The survey was posted on the Eunuch Archive, an online platform for individuals interested in the topic. Data from 822 individuals were included in the analyses. Respondents were divided into four groups: Interested (claiming only an interest in castration topics), Fantasy (fantasize about castration sexually, but not desiring castration), Wannabe (considering being castrated in the future), and Castrated (already castrated). More individuals desiring castration (Wannabe and Castrated groups) claimed equal attraction to both sexes than individuals in the Interested group. The Interested group was more religious than the other groups, and the Fantasy group had lower sexual guilt than those with castration desire. All groups had similar psychological well-being and body image acceptance, despite the Castrated group having lower sexual functioning than the others. Childhood trauma was more common in those with castration desire than those without. The Interested group had a lower desire for castration, lower erotic attraction to castration, and pretended to be castrated at a younger age than the others. Childhood trauma and sexual guilt are common, but not limited, predictors for castration desire and erotic attraction to castration, respectively. In conclusion, childhood experiences, as well as psychological and sexual parameters, may vary in different subgroups of males with interests in castration.

The development of a theory and evidence-based intervention to aid implementation of exercise into the prostate cancer care pathway with a focus on healthcare professional behaviour, the STAMINA trial

Background

Twice-weekly supervised aerobic and resistance exercise for 12 weeks reduces fatigue and improves quality of life in men on Androgen Deprivation Therapy for prostate cancer. Despite the National Institute for Health and Care Excellence (NICE) proposing this as standard of care, it does not routinely take place in practice. Healthcare professionals are in a prime position to deliver and integrate these recommendations. A change in the behaviour of clinical teams is therefore required.

In this paper, we describe the development of a training package for healthcare professionals using theory and evidence to promote delivery of such recommendations as standard care.

Methods

The intervention development process was guided by the Medical Research Council guidance for complex interventions and the Behaviour Change Wheel. Target behaviours were identified from the literature and thirty-five prostate cancer care healthcare professionals (including oncologists, consultant urologists, clinical nurse specialists, physiotherapists, general practitioners and commissioners) were interviewed to understand influences on these behaviours. The Theoretical Domains Framework was used to identify theoretical constructs for change. Behaviour change techniques were selected based on theory and evidence and were translated into intervention content. The intervention was refined with the input of stakeholders including healthcare professionals, patients, and exercise professionals in the form of rehearsal deliveries, focus groups and a workshop.

Results

Seven modifiable healthcare professional target behaviours were identified to support the delivery of the NICE recommendations including identifying eligible patients suitable for exercise, recommending exercise, providing information, exercise referral, providing support and interpret and feedback on progress. Ten domains from the Theoretical Domain’s Framework were identified as necessary for change, including improving knowledge and skills, addressing beliefs about consequences, and targeting social influences. These were targeted through twenty-two behaviour change techniques delivered in a half-day, interactive training package. Based on initial feedback from stakeholders, the intervention was refined in preparation for evaluation.

Conclusions

We designed an intervention based on theory, evidence, and stakeholder feedback to promote and support the delivery of NICE recommendations. Future work will aim to test this training package in a multi-centre randomised trial. If proven effective, the development and training package will provide a template for replication in other clinical populations, where exercise has proven efficacy but is insufficiently implemented.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06266-x.

Analysis of Brain Functions in Men with Prostate Cancer under Androgen Deprivation Therapy: A One-Year Longitudinal Study

The relationship between cognitive decline and androgen deprivation therapy (ADT) under luteinizing hormone-releasing hormone (LHRH) analogues is unclear, and there is a scarcity of longitudinal studies considering the interaction between cognition, depressive symptoms and sleep quality in men with prostate cancer (PCa) treated with ADT. This study aimed to determine if there were differences in the scores obtained in cognitive assessment, depressive symptoms, and sleep quality after one year of ADT and determine the interrelations between sleep, mood, and cognitive status. A prospective longitudinal observational study was designed, in which a cohort of men (mean age was 70.8 years) newly treated with androgen-deprivation therapy was assessed in the first six months of treatment and 12 months later. Analysis of cognitive function by the Mini-Mental State Examination (MMSE) scores indicated a significant (p < 0.05) increase after one year of treatment and by the Brief Scale for Cognitive Evaluation (BCog) scores indicated no changes in the scores before and after one year of treatment. Analysis of depressive symptoms with the Geriatric Depression Scale and sleep quality with the Athens Insomnia Scale (AIS) scores showed significant (p < 0.05) changes after one year of treatment with ADT, with men describing more depressive symptoms and more sleep disturbances. No statistically significant differences were found in the cognitive performance between men with impaired sleep or depression results and those without them. Our study showed no clinical evidence of the relationship between ADT under luteinizing hormone-releasing hormone (LHRH) analogues and cognitive deterioration in 1-year follow-up, but there are impairments in the sleep quality in men with PCa undergoing ADT and an increase in depressive symptoms which has important implications for clinicians as they would impair quality of life and adherence to treatment.

Cognitive and Psychological Impacts of Different Treatment Options for Prostate Cancer: A Critical Analysis

Objectives

Psychological morbidity as well as cognitive impairment are increasingly reported in prostate cancer (PCa) patients. However, despite growing numbers of PCa survivors and the well estimated negative impact of cognitive decline and emotional distress on survivors' quality of life, no study has assessed the whole range of cognitive and psychological sequelae as a response to treatment options for PCa. The objective of the present review was to systematically characterize the types and estimate the prevalence of the cognitive impairment and emotional burdens that were found in PCa survivors secondary to different treatment options.

Methods

Systematic, general reviews, meta-analysis, and overviews of review studies in English, that were published in PubMed during the last 10 years until l August 2019 and that reported psychological distress, anxiety, depression, cognitive decline, or dementia among individuals with PCa exposed to a particular treatment option were analyzed.

Results

A total of 21 articles were reviewed. Some of the studies described one or more cognitive or psychological consequences of only one therapeutic strategy while others compared the psychological impacts among different strategies. Most of these studies suggested that either radical prostatectomy or active surveillance and radiotherapy were well-tolerated treatments in terms of psychological modifications. However, many of these patients may require additional emotional support. There is also increasing evidence that androgen deprivation therapy may be associated with depression, while controversy surrounding the association between cognitive dysfunction, dementia, and androgen deprivation therapy remains ambivalent.

Conclusion

Emotional distress and cognitive decline may accompany every PCa treatment option to different degrees. Accurate information on the short- and long-term effect of treatments on cognitive and psychological aspects should be provided to patients during treatment decision-making. There is also a need to develop well-targeted psychological and neurological interventions that could help those experiencing ongoing post-treatment difficulties.

[Adverse drug reactions profiles for abiraterone and enzalutamide: A pharmacovigilance descriptive analysis]

OBJECTIVE

The aim of this study was to describe the profile of adverse drug reactions (ADRs) observed with abiraterone and enzalutamide, based on cases registered in the French regional pharmacovigilance centres to identify potential pharmacovigilance signals.

METHODS

We extracted from the French pharmacovigilance database all cases of ADRs or drug interactions involving abiraterone or enzalutamide from the time they market authorization date until December 31st, 2017. Signal detection results have been transmitted by the French Agency for Health Products (ANSM). The data were compared with those of the risk management plans for each drug and the literature.

RESULTS

Among the 233 observations analyzed, nearly 62% involved abiraterone as a suspect drug and 38% involved enzalutamide; only 1 case involved both drugs. The ADRs profile is different between the drugs. Abiraterone is mostly associated with expected cardiac diseases (heart failure, and QT prolongation), expected with the drug. Also described, several cases of hepatotoxicity have been reported, however some cases with fatal outcome suggest that despite a follow-up of the liver function tests, it is difficult to anticipate this risk. Signals concerning acute renal failure and ischemic stroke have arisen. Enzalutamide is more particularly associated with various neurological disorders (convulsions, hallucinations, fatigue, and memory impairment) expected with the drug. While ischemic heart disease is also expected, signals of heart failure and atrial fibrillation have arisen. A potential hepatotoxicity of the molecule is discussed because of cases of cholestatic hepatitis.

CONCLUSION

The analysis of the French pharmacovigilance database cases allows to confirm an expected and monitored risk profile in the risk management plan for both drugs. Several signals have arisen, some of which will be investigated through a pharmacoepidemiology study.

The depressive effects of androgen deprivation therapy in locally advanced or metastatic prostate cancer: a comparative study

AIM

To investigate association of androgen deprivation therapy (ADT) with depression and the effect of depression on cognitive functions in men with locally advanced or metastatic prostate cancer.

METHODS

A total of 144 patients were evaluated in a prospective, comparative study. Group1 consisted of 72 patients with locally advanced or metastatic prostate cancer who received complete ADT treatment continuously for 12 months and group2 (control group) consisted of 72 patients who underwent radical prostatectomy without any additional treatment. MoCA (The Montreal Cognitive Assessment) and HAM-D (Hamilton depression rating scale) tests were used to assess the effects of ADT on depression and cognitive functions.

RESULTS

According to post-treatment results of MoCA test, patients had lower mean total scores in both the groups. The deficits were especially prominent in the areas of language ability and short-term memory capacity. In the comparison of two groups according to HAM-D tests, the scores were significantly higher in group1 at baseline-6 month, at baseline-12 month and at 6-12 month follow-up period (p = .003, p < .001, p = .023).There was a relationship between depression and deterioration of language and memory functions at 6th (p < .001, p = .002) and 12th months (p < .001, p = .046). Attention function was deteriorated in these patients at 6th (p < .001) and 12th months (p < .001).

CONCLUSIONS

ADT causes increase in depression and the deterioration of cognitive functions. ADT should be given carefully to these older group of patients with concomitant morbidities.

Recovery of serum testosterone following neoadjuvant androgen deprivation therapy in Japanese prostate cancer patients treated with low-dose rate brachytherapy

OBJECTIVE

To investigate the time course of total testosterone (TT) recovery after cessation of androgen deprivation therapy (ADT) in Japanese patients treated with brachytherapy.

METHODS

In total, 125 patients with prostate cancer received 6 months of neoadjuvant ADT (nADT) followed by low-dose rate (LDR) brachytherapy. TT was measured every 3 months after cessation of nADT, and some predictive factors affecting TT recovery were analyzed.

RESULTS

The cumulative incidence rates of TT recovery to normal levels (TT ≥ 3.0 ng/mL) after 12 and 24 months cessation were 49.6% and 81.6%, respectively. The median interval to recover to normal TT was 15 months. In multivariate analysis, the use of a gonadotropin-releasing hormone (GnRH) antagonist as nADT significantly earlier improved to recovery to normal TT level (p = 0.046). Conversely, higher body mass index (BMI) and hypertension significantly prolonged TT recovery to normal (p = 0.026 and p = 0.026, respectively).

CONCLUSIONS

Approximately one-fifth of patients still had low TT levels 2 years after the cessation of 6 months nADT before LDR brachytherapy. Use of a GnRH agonist, higher BMI, and hypertension were the predictive factors for slower TT recovery to normal TT levels after the cessation of nADT.

A qualitative exploration of South African men's perceived effects of Androgen Deprivation Therapy (ADT) as a treatment for advanced prostate cancer

OBJECTIVE

We undertake qualitative research with men treated in a Pretoria, South Africa Oncology clinic to address men's self-reported experiences on androgen deprivation therapy (ADT).

METHODS

Analyses rely upon 22 men's responses to open-ended questions during interviews. These men were 63-78 years of age, and almost all married (three widowed), had children and were no longer engaged in paid work.

RESULTS

In addressing questions about the anticipated and experienced positive and broader side effects of ADT, men referred to its treatment for prostate cancer, with several generally specifying health or life. Patients also referred to a variety of more specific effects such as pain, nausea, difficulties urinating, gaining weight, low energy and sleep disruptions that appeared to reflect a mixture of influences of prostate cancer, ADT and oncological treatment. In addressing a question about the effects of ADT on romantic/sex life, 16 of 19 married men referred to deleterious impacts on their sex lives. With respect to perceived family, work or broader social life impacts, some men noted others' worries and social support.

CONCLUSION

Findings are situated within discussions of existing research on ADT largely from North American or European samples, and broader views of testosterone and male social behavior.

Antidepressant prescriptions and associated factors in men with prostate cancer and their female partners

Purpose

To estimate the risk of first-time antidepressant prescriptions as a proxy for depression or anxiety and associated risk factors in patients with prostate cancer and their female partners.

Methods

We followed all men (n = 25,126) and their female cohabiting partners (n = 8785) without a history of cancer or antidepressants from the Danish Diet, Cancer and Health cohort from 1997 to 2014 or 2010, respectively. We estimated the cumulative incidence of first-time antidepressant prescriptions in men with prostate cancer compared with cancer-free men and their respective female partners, using the Danish National Prescription Registry. Sociodemographic, lifestyle-related, and clinical risk factors were assessed using Cox regression models.

Results

A total of 1828 men were diagnosed with prostate cancer of whom 15% received antidepressants. The unadjusted hazard ratio of antidepressant prescription was 2.18 (95%CI, 1.92, 2.48) for men with prostate cancer and 1.27 (95%CI, 0.87, 1.85) for their partners, compared with cancer-free men and their partners, respectively. After adjusting for sociodemographic, lifestyle-related, and comorbidity factors, this risk was 2-fold to 4-fold increased among patients, but not significantly increased among partners. Significant risk factors among patients were curative and palliative treatment (vs. active surveillance and watchful waiting), nonlocalized disease, and short education.

Conclusions

Men with prostate cancer have a higher risk of receiving antidepressant medication than cancer-free men. Clinical characteristics can help clinicians in identifying patients at a high risk of depression or anxiety.

Implications for Cancer Survivors

Men with prostate cancer who experience symptoms of depression or anxiety should seek professional help early on. Patient education could aid in raising awareness and reducing the stigma associated with mental disorders.

Electronic supplementary material

The online version of this article (10.1007/s11764-020-00947-y) contains supplementary material, which is available to authorized users.

Prostate Cancer Survivors' and Caregivers' Experiences Using Behavior Change Techniques during a Web-Based Self-Management and Physical Activity Program: A Qualitative Study

Both men with prostate cancer and their caregivers report experiencing a number of challenges and health consequences, and require programs to help support the cancer patient–caregiver dyad. A tailored, web-based, psychosocial and physical activity self-management program (TEMPO), which implements behavior change techniques to help facilitate behavior change for the dyads was created and its acceptability was tested in a qualitative study. The purpose of this secondary analysis was to explore the dyads’ experiences using behavior change techniques to change behavior and address current needs and challenges while enrolled in TEMPO. Multiple semi-structured interviews were conducted with 19 prostate cancer-caregiver dyads over the course of the program, resulting in 46 transcripts that were analyzed using an inductive thematic analysis. Results revealed four main themes: (1) learning new behavior change techniques, (2) engaging with behavior change techniques learned in the past, (3) resisting full engagement with behavior change techniques, and (4) experiencing positive outcomes from using behavior change techniques. The dyads’ discussions of encountering behavior change techniques provided unique insight into the process of learning and implementing behavior change techniques through a web-based self-management program, and the positive outcomes that resulted from behavior changes.

Lack of AR in LepRb Cells Disrupts Ambulatory Activity and Neuroendocrine Axes in a Sex-Specific Manner in Mice

Disorders of androgen imbalance, such as hyperandrogenism in females or hypoandrogenism in males, increase risk of visceral adiposity, type 2 diabetes, and infertility. Androgens act upon androgen receptors (AR) which are expressed in many tissues. In the brain, AR are abundant in hypothalamic nuclei involved in regulation of reproduction and energy homeostasis, yet the role of androgens acting via AR in specific neuronal populations has not been fully elucidated. Leptin receptor (LepRb)-expressing neurons coexpress AR predominantly in hypothalamic arcuate and ventral premammillary nuclei (ARH and PMv, respectively), with low colocalization in other LepRb neuronal populations, and very low colocalization in the pituitary gland and gonads. Deletion of AR from LepRb-expressing cells (LepRbΔAR) has no effect on body weight, energy expenditure, and glucose homeostasis in male and female mice. However, LepRbΔAR female mice show increased body length later in life, whereas male LepRbΔAR mice show an increase in spontaneous ambulatory activity. LepRbΔAR mice display typical pubertal timing, estrous cycles, and fertility, but increased testosterone levels in males. Removal of sex steroid negative feedback action induced an exaggerated rise in luteinizing hormone in LepRbΔAR males and follicle-stimulating hormone in LepRbΔAR females. Our findings show that AR can directly affect a subset of ARH and PMv neurons in a sex-specific manner and demonstrate specific androgenic actions in the neuroendocrine hypothalamus.

Human reproductive behavior, life history, and the Challenge Hypothesis: A 30-year review, retrospective and future directions

The Challenge Hypothesis (Wingfield et al., 1990) originally focused on adult male avian testosterone elevated in response to same-sex competition in reproductive contexts. The purpose of the present paper is to demonstrate how the Challenge Hypothesis has shaped ideas about human life histories. We conduct a citation analysis, drawing upon 400 Google Scholar citations in the human literature to identify patterns in this body of scholarship. We cover key factors, such as context and personality traits, that help explain variable testosterone responses such as winning/losing to adult competitive behavior. Findings from studies on courtship and sexual behavior indicate some variation in testosterone responses depending on factors such as motivation. A large body of research indicates that male testosterone levels are often lower in contexts of long-term committed partnerships and nurturant fathering and aligned with variation in male mating and parenting effort. As the Challenge Hypothesis is extended across the life course, DHEA and androstenedione (rather than testosterone) appear more responsive to juvenile male competitive behavior, and during reproductive senescence, baseline male testosterone levels decrease just as male life history allocations show decreased mating effort. We discuss how research on testosterone administration, particularly in older men, provides causal insight into effects of testosterone in humans, and how this "natural experiment" can be viewed in light of the Challenge Hypothesis. We synthesize central concepts and findings, such as an expanded array of costs of testosterone that inform life history tradeoffs between maintenance and reproductive effort, and we conclude with directions for future research.

Mediterranean-style dietary pattern improves cancer-related fatigue and quality of life in men with prostate cancer treated with androgen deprivation therapy: A pilot randomised control trial

BACKGROUND & AIMS

Cancer-related fatigue (CRF) is a prevalent and persistent symptom from androgen deprivation therapy (ADT) in prostate cancer. The Mediterranean-style dietary pattern (MED-diet) offers a plausible mechanism to mitigate CRF through reducing inflammation and improving body composition. This study aimed to evaluate the effects of a 12-week MED-diet, compared to usual care, on CRF and quality of life in men with prostate cancer treated with ADT.

METHODS

Twenty-three men (65.9 ± 7.8 years; body mass index: 29.6 ± 2.7 kg/m²; ADT duration: 33.8 ± 35.6 months) receiving ADT for ≥3 months were randomly assigned (1:1) to 12-weeks of usual care or the MED-diet involving six individualised nutrition consults. Primary outcomes included CRF [Functional Assessment of Chronic Illness Therapy (FACIT)-Fatigue scale (FACIT-F) and quality of life [FACIT-General (FACIT-G)], secondary outcomes included body mass/composition and interleukin (IL)-6 and IL-8 concentrations measured at baseline, 8-weeks and 12 weeks. Intervention feasibility was measured by intervention safety, study completion rate, consult attendance, and adherence to the MED-diet through the Mediterranean-diet adherence screener (MEDAS). Intention to treat linear mixed models were used to determine changes in outcomes between the MED-diet and usual care at baseline, 8-weeks and 12-weeks.

RESULTS

The MED-diet improved CRF (FACIT-F) at 8-weeks [+4.8 (0.0, 9.8); P = 0.05] and 12-weeks [+7.2 (2.2, 12.0); P = 0.005], quality of life (FACIT-G) at 12-weeks [+9.2 (2.7, 15.8); P = 0.006], reduced total body mass at 8-weeks [-2.51 kg (-4.25, -0.78); P = 0.005] and 12-weeks [-2.97 kg (-4.71, -1.25); P = 0.001], lean mass at 8-weeks [-1.50 kg (-2.91, -0.10); P = 0.036], and IL-8 at 8-weeks [-0.18 ng/ml (-0.34, -0.02); P = 0.029] compared to usual care. The MED-diet demonstrated zero adverse events, 91% study completion, 100% attendance, and 81% adherence to the MEDAS.

CONCLUSION

The MED-diet is safe and feasible, and has the potential to improve CRF and quality of life in overweight men treated with ADT compared to usual care. Further exploration of the MED-diet is warranted in a larger powered sample size to consolidate these findings.

Adherence to guidelines for androgen deprivation therapy after radical prostatectomy: Swedish population-based study

Background: Androgen deprivation therapy (ADT) is a non-curative but essential treatment of prostate cancer with severe side effects. Therefore, both over- and underuse should be avoided. We investigated adherence to guidelines for ADT following radical prostatectomy through Swedish population-based data.Material and methods: We used the database Uppsala/Örebro PSA cohort (UPSAC) to study men with localised or locally advanced prostate cancer at diagnosis (clinical stage T1-T3, N0-NX, M0-MX, and prostate-specific antigen (PSA) <50 ng/ml) who underwent radical prostatectomy 1997-2012. 114 men were treated with ADT and selected as cases; 1140 men with no ADT at the index date were selected as controls within 4-year strata of year of radical prostatectomy. All men with a biochemical recurrence and a PSA doubling time <12 months and/or a Gleason score of 8-10 were considered to have an indication for ADT according to the European Association of Urology (EAU) guidelines.Results: No indication for ADT was found in 37% of the cases. Among these, 88% had clinical stage T1-2 at diagnosis, 57% had a biopsy Gleason score 2-6, 98% had an expected remaining lifetime over 10 years, 12% received castration, and 88% received antiandrogen monotherapy. 2% of controls were found to have an indication for ADT, and 96% of these had an expected remaining lifetime over 10 years.Conclusion: Our results indicate that overtreatment with ADT after radical prostatectomy is common, whereas undertreatment is unusual. Interventions to improve adherence to guidelines are needed to avoid unnecessary side-effects and long treatment durations with ADT.

Football Compared with Usual Care in Men with Prostate Cancer (FC Prostate Community Trial): A Pragmatic Multicentre Randomized Controlled Trial

Background

Physical activity has been shown to mitigate the unwanted psychological and physiological side effects of prostate cancer treatments, but sustainable exercise possibilities are limited.

Objective

Our objective was to examine whether football in a real-world setting (i.e., local football clubs) was safe and feasible in practice and could improve quality of life, mitigate decline in muscle mass and bone density, and increase fat mass in patients with prostate cancer.

Methods

In this pragmatic, multicentre, parallel randomized controlled trial, men diagnosed with prostate cancer were recruited from five Danish urological departments. Men (N = 214) diagnosed with prostate cancer were randomly allocated, using random generated lists (block size 4–8) stratified for center and androgen-deprivation therapy status, to either 1 h of football twice weekly in a local football club or to usual care, which was a 15- to 30-min telephone session covering their options for physical activity or free-of-charge rehabilitation delivered as standard in Denmark. Allocation was concealed from the trial investigator performing the randomization, but—given the nature of the intervention—this was not possible for personnel and participants. Assessments were performed at baseline, 12 weeks, and 6 months. The primary outcome was mean change difference in prostate cancer-specific quality of life at 12 weeks. Secondary outcomes were body composition, 12-Item Short Form Health Survey (SF-12) physical and mental health, and safety—reported as fractures, falls, and serious adverse events.

Results

Attrition was 1 and 3% at 12 weeks, and 5% and 5% at 6 months for the usual care and football groups, respectively. Prostate cancer-specific quality of life was equal between groups at 12 weeks (mean difference + 1.9 points, 95% confidence interval [CI] –1.0–4.8; P = 0.20) and at 6 months (+ 0.5 points, 95% CI –2.8–3.8; P = 0.76). Fractures were equally distributed, with two fractures in the usual care group and one in the football group. Likewise, body composition outcomes were equal. Mental health improved after 6 months of football (mean difference + 2.7 points, 95% CI 0.8–4.6; P = 0.006).

Conclusions

In this trial, community-based football was a feasible exercise strategy for men with prostate cancer. Football did not improve prostate cancer-specific quality of life but did improve mental health; the clinical significance of this is unclear.

Trial registration

ClinicalTrials.gov: NCT02430792.

Electronic supplementary material

The online version of this article (10.1007/s40279-018-1031-0) contains supplementary material, which is available to authorized users.