Differences in major depressive disorder and generalised anxiety disorder symptomatology between prostate cancer patients receiving hormone therapy and those who are not

Androgen deprivation therapy and depression in the prostate cancer patients: review of risk and pharmacological management

Purpose: Despite the effectiveness of androgen deprivation therapy in advanced prostate cancer, serious neuropsychiatric consequences in androgen deprivation therapy (ADT)-treated patients, mainly depression, have been concerning and gained more attention recently. This narrative review aims to shed light on the risk and pharmacological management of ADT-induced depression in PCa patients.Methods: We searched PubMed, Scopus and Google Scholar databases using MESH keywords "Prostate cancer OR prostate neoplasm" AND "Depression" AND "Androgen Deprivation Therapy" AND "antidepressants". Search was limited to English and studies conducted on humans. Studies' titles and abstracts were screened, and further information were obtained from the text, if necessary, to decide whether studies are to be included in this review.Results: Our review revealed 23 studies confirming the occurrence and worsening of depressive symptoms in ADT-treated patients, which frequently require pharmacological interventions; whereas 10 studies indicated otherwise. All studies were prospective, retrospective, cross-sectional or case reports. Based on the incidence of depression provided by the observational studies, the average among ADT-treated patients was 18.23% (range: 2.1-46.9%), while it was 8.42% (range: 1.4-23.3%) in the non-ADT patients. Although several treatments have been used for depression in cancer patients, current knowledge lacks observational and controlled studies as well as clinical guidelines that demonstrate efficacy and safety of antidepressants and guide clinicians to the appropriate treatment in these patients, respectively. On the other side, a few clinical studies have been published regarding the efficacy of selective serotonin reuptake inhibitors, selective serotonin and norepinephrine reuptake inhibitors and/or saftey on other ADT associated adverse effects.Conclusions: Our work supports the recent attention towards mood issues as an adverse effect of ADT, and that greater awareness of this is warranted among clinicians. Clinical studies published regarding the use of antidepressants for other ADT associated adverse effects established the foundation that can be adopted to examine these therapies on ADT-induced depression.

Prostate-specific antigen (PSA) and distress: - a cross-sectional nationwide survey in men with prostate cancer in Sweden

Background

The prostate-specific antigen (PSA) -value is often used during the prostate cancer trajectory as a marker of progression or response to treatment. Concerns about PSA-values are often expressed by patients in clinical situations. Today there is a lack of larger studies that have investigated the association between PSA-value and distress. The aim was to investigate the association between PSA-values and distress adjusted for sociodemographic factors, hormonal therapy and quality of life (QoL), among men with prostate cancer.

Methods

In this cross-sectional survey of 3165 men with prostate cancer, members of the Swedish Prostate Cancer Federation, answered questions about sociodemographic factors, PSA, distress, QoL and treatments. Descriptive statistics, and bivariate and multivariable analyses were performed. The result was presented based on four PSA-value groups: 0–19, 20–99, 100–999, and ≥ 1000 ng/ml.

Results

Of the men, 53% experienced distress. An association between distress and PSA-values was found where higher PSA-values were associated with higher OR:s for experiencing distress in the different PSA-groups: 0–19 ng/ml (ref 1), 20–99 ng/ml (OR 1.25, 95% CI 1.01–1.55), 100–999 ng/ml (OR 1.47, 95% CI 1.12–1.94), ≥1000 ng/ml (OR 1.77, 95% CI 1.11–2.85). These associations were adjusted for sociodemographic factors and hormonal therapy. In the multivariable analyses, beside PSA-values, higher levels of distress were associated with being without partner or hormonal therapy. When adding QoL in the multivariable analysis, the association between PSA and distress did not remain significant.

Conclusion

These results indicate that the PSA-values are associated with distress, especially for those with higher values. However, to be able to support these men, continued research is needed to gain more knowledge about the mechanisms behind the association between emotional distress and PSA-values.

Cognitive Impacts of Estrogen Treatment in Androgen-Deprived Males: What Needs to be Resolved

Background:

Many prostate cancer (PCa) patients are on androgen deprivation therapy (ADT) as part of their cancer treatments but ADT may lead to cognitive impairments. ADT depletes men of both androgen and estrogen. Whether estradiol supplementation can improve cognitive impairments in patients on ADT is understudied.

Objective:

To summarize data on the effects of estradiol treatment on cognitive function of androgen-deprived genetic male populations (PCa patients and male-to-female transsexuals) and castrated male animals.

Method:

Publications were identified by a literature search on PubMed and Google Scholar.

Results:

While some studies showed that estradiol improves cognitive function (most notably, spatial ability) for castrated rats, what remains uninvestigated are: 1) whether estradiol can improve cognition after long-term androgen deprivation, 2) how estradiol affects memory retention, and 3) how early vs. delayed estradiol treatment after castration influences cognition. For androgen-deprived genetic males, estradiol treatment may improve some cognitive functions (e.g., verbal and visual memory), but the findings are not consistent due to large variability in the study design between studies.

Conclusion:

Future studies are required to determine the best estradiol treatment protocol to maximize cognitive benefits for androgen-deprived genetic males. Tests that assess comparable cognitive domains in human and rodents are needed. What particularly under-investigated is how the effects of estradiol on cognitive ability intersect with other parameters; sleep, depression and physical fatigue. Such studies have clinical implications to improve the quality of life for both PCa patients on ADT as well as for male-to-female transsexuals.

[Psychological impact of prostate cancer on patients receiving a 6-month androgen deprivation therapy]

BACKGROUND

Prostate cancer (PCa) is often associated with psychopathological symptoms such as anxiety. This study evaluated the effects of the luteinizing hormone-releasing hormone agonist therapy leuprorelin acetate (LA) on anxiety and quality of life (QoL) over time in men with PCa.

METHODS

This observational, non interventional, multicenter study was conducted in France. Patients with PCa eligible for therapy with a 6-month LA depot were enrolled. Patients completed questionnaires assessing anxiety (memorial anxiety scale for prostate cancer [MAX-PC] ; state trait anxiety inventory [STAI]) and QoL (medical outcomes study 12-item short-form health survey [SF-12] physical summary component [PCS] and mental component summary [MSCS] subscales) at baseline and 6 months after 6-month LA depot administration.

RESULTS

Questionnaires were completed by 575 men at baseline and 315 men at 6 months. Mean age was 75.5 years; median time since first diagnosis was 0.4 years. At baseline, the mean (±standard deviation [SD]) MAX-PC score was 17.7±12.0, with anxiety primarily related to the PCa diagnosis. STAI-state and MAX-PC scores were consistent. Following 6 months of LA administration, the mean MAX-PC score decreased (-2.0±10.4 ; P<0.001). The PCa diagnosis negatively affected patients' QoL, as assessed by the SF-12 PCS and MCS subscores. At 6 months, the SF-12 vitality score significantly increased (1.2±9.8; P=0.0142) vs baseline and the SF-12 PCS score decreased by -2.0±8.0 from baseline.

CONCLUSION

After 6 months of leuprorelin 45mg therapy, prostate cancer patients appeared to be less anxious with a mental health improvement.

LEVEL OF EVIDENCE

3.

Association of androgen deprivation therapy and depression in the treatment of prostate cancer: A systematic review and meta-analysis

BACKGROUND

There is increasing evidence that androgen deprivation therapy (ADT) may be associated with depression. Existing studies have shown conflicting results.

METHODS

PubMed, Web of Science, Embase, and PsycINFO were queried on April 5, 2017. Eligible studies were in English and reported depression among individuals with prostate cancer exposed to a course of ADT vs. a lesser-exposed group (e.g., any-ADT vs. no ADT and continuous ADT vs. intermittent ADT). We used the MOOSE statement guidelines and the Cochrane Review Group's data extraction template. Study quality was evaluated by Newcastle-Ottawa Scale criteria. We conducted a random-effects meta-analysis to calculate summary statistic risk ratios (RRs) and 95% CIs. Heterogeneity was quantified using the I² statistic and prespecified subgroup analysis. Small study effects were evaluated using Begg and Egger statistics.

RESULTS

A total of 1,128 studies were initially identified and evaluated. A meta-analysis of 18 studies among 168,756 individuals found that ADT use conferred a 41% increased risk of depression (RR = 1.41; 95% CI: 1.18-1.70; P<0.001). We found a consistent strong statistically significant association when limiting our analysis to studies in localized disease (RR = 1.85; 95% CI: 1.20-2.85; P = 0.005) and those using a clinical diagnosis of depression (RR = 1.19; 95% CI: 1.08-1.32; P = 0.001). We did not find an association for continuous ADT with depression risk compared to intermittent ADT (RR = 1.00; 95% CI: 0.50-1.99; P = 0.992). There was no statistically significant evidence of small study effects. Statistically significant heterogeneity in the full analysis (I² = 80%; 95% CI: 69-87; P<0.001) resolved when examining studies using a clinical diagnosis of depression (I² = 16%; 95% CI: 0-60; P = 0.310).

CONCLUSION

The currently available evidence suggests that ADT in the treatment of prostate cancer is associated with an increased risk of depression.

Depressive symptoms are found to be potential adverse effects of androgen deprivation therapy in older prostate cancer patients: A 15-month prospective, observational study

OBJECTIVES

To evaluate the association between androgen deprivation therapy (ADT) and depression and to identify the risk factors for depressive symptoms among prostate cancer (PCa) patients who received ADT.

METHODS

We conducted a prospective, longitudinal, controlled study and assessed 3 groups of older patients: the ADT group (men who were presented with maximum androgen block); the radical prostatectomy (RP) group (PCa control group: men who underwent RP without ADT); and the benign prostatic hyperplasia (BPH) group (men who had BPH). All patients completed the demographic questionnaire at baseline and the Zung Self-Rating Depression Scale (SDS) at pretreatment baseline, 1 month, 6 months, 9 months, 12 months and 15 months.

RESULTS

A total of 146 patients completed the study during the 15-month follow-up. The Self-Rating Depression Scale scores of the 3 groups showed significant differences at 1 month (P < .001), 6 months (P = .009), 9 months (P < .001), 12 months (P < .001), and 15 months (P < .001). At 9 months, 12% of the men in the ADT group, 4.3% in the RP group, and 2% in the BPH group showed depressive symptoms, and there were no significant differences (P = .095). However, there were significant differences among the 3 groups relative to the incidence of depressive symptoms at 12 and 15 months (P < .001, P = .007, respectively). The analysis of the ADT subgroup indicated that alcohol consumption (odds ratio = 6.868; P = .046; 95% CI, 1.038-45.443) and smoking (odds ratio = 13.661; P = 0.013; 95% CI, 1.722-108.386) increased the risk for developing depressive symptoms.

CONCLUSIONS

Androgen deprivation therapy use does significantly increase the depressive scores and enhance the incidence of depression among PCa patients who received ADT. Smoking and alcohol consumption are associated with depressive symptoms among PCa patients receiving ADT.

Association of Androgen Deprivation Therapy With Depression in Localized Prostate Cancer

PURPOSE

Androgen deprivation therapy (ADT) may contribute to depression, yet several studies have not demonstrated a link. We aimed to determine whether receipt of any ADT or longer duration of ADT for prostate cancer (PCa) is associated with an increased risk of depression.

METHODS

We identified 78,552 men older than age 65 years with stage I to III PCa using the SEER-Medicare-linked database from 1992 to 2006, excluding patients with psychiatric diagnoses within the prior year. Our primary analysis was the association between pharmacologic ADT and the diagnosis of depression or receipt of inpatient or outpatient psychiatric treatment using Cox proportional hazards regression. Drug data for treatment of depression were not available. Our secondary analysis investigated the association between duration of ADT and each end point.

RESULTS

Overall, 43% of patients (n = 33,882) who received ADT, compared with patients who did not receive ADT, had higher 3-year cumulative incidences of depression (7.1% v 5.2%, respectively), inpatient psychiatric treatment (2.8% v 1.9%, respectively), and outpatient psychiatric treatment (3.4% v 2.5%, respectively; all P < .001). Adjusted Cox analyses demonstrated that patients with ADT had a 23% increased risk of depression (adjusted hazard ratio [AHR], 1.23; 95% CI, 1.15 to 1.31), 29% increased risk of inpatient psychiatric treatment (AHR, 1.29; 95% CI, 1.17 to 1.41), and a nonsignificant 7% increased risk of outpatient psychiatric treatment (AHR, 1.07; 95% CI, 0.97 to 1.17) compared with patients without ADT. The risk of depression increased with duration of ADT, from 12% with ≤ 6 months of treatment, 26% with 7 to 11 months of treatment, to 37% with ≥ 12 months of treatment (P trend < .001). A similar duration effect was seen for inpatient (P trend < .001) and outpatient psychiatric treatment (P trend < .001).

CONCLUSION

Pharmacologic ADT increased the risk of depression and inpatient psychiatric treatment in this large study of elderly men with localized PCa. This risk increased with longer duration of ADT. The possible psychiatric effects of ADT should be recognized by physicians and discussed with patients before initiating treatment.