More should be done to prevent the harmful effects of long-term androgen ablation therapy in prostate cancer

Androgen-deprivation therapy, dementia, and cognitive dysfunction in men with prostate cancer: How much smoke and how much fire?

Androgen-deprivation therapy (ADT) remains the cornerstone of management for patients with metastatic prostate cancer. Although the toxicities of ADT are well established, there is increasing controversy surrounding the association between cognitive dysfunction and the receipt of ADT, with some evidence suggesting an increased risk of dementia. The authors conducted a literature search to identify pertinent clinical studies in this field. This general review outlines the key findings and discusses the relative strengths and weaknesses when drawing conclusions about the risk of cognitive dysfunction or dementia with ADT use. Cancer 2018;124:1326-34. © 2018 American Cancer Society.

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

The clinical benefits of androgen-deprivation therapy (ADT) for men with prostate cancer (PC) have been well documented and include living free from the symptoms of metastases for longer periods and improved quality of life. However, ADT comes with a host of its own serious side effects. There is considerable evidence of the adverse cardiovascular, metabolic, and musculoskeletal effects of ADT. Far less has been written about the psychological effects of ADT. This review highlights several adverse psychological effects of ADT. The authors provide evidence for the effect of ADT on men's sexual function, their partner, and their sexual relationship. Evidence of increased emotional lability and depressed mood in men who receive ADT is also presented, and the risk of depression in the patient's partner is discussed. The evidence for adverse cognitive effects with ADT is still emerging but suggests that ADT is associated with impairment in multiple cognitive domains. Finally, the available literature is reviewed on interventions to mitigate the psychological effects of ADT. Across the array of adverse effects, physical exercise appears to have the greatest potential to address the psychological effects of ADT both in men who are receiving ADT and in their partners.

Depressive symptomatology in men receiving androgen deprivation therapy for prostate cancer: a controlled comparison

OBJECTIVE

Prostate cancer patients who receive androgen deprivation therapy (ADT) often experience many physical and psychological side effects. ADT may be associated with increased risk for depression, but the relationship between ADT and depression is not fully understood. This study used a longitudinal design to assess depressive symptomatology in patients receiving ADT compared with two groups of matched controls.

METHODS

Participants were men initiating ADT treatment (ADT+ group; n = 61) and their matched controls: prostate cancer patients treated with radical prostatectomy (ADT- group; n = 61), and no-cancer controls (CA- group; n = 61). Depressive symptomatology was assessed using the Center for Epidemiological Studies Depression Scale at ADT initiation and again 6 months later. Differences in depressive symptomatology and rates of clinically significant depressive symptomatology were analyzed between groups at each time point and within groups over time.

RESULTS

Between baseline and follow-up, ADT+ participants demonstrated increased depressive symptomatology and increased rates of clinically significant depressive symptomatology (ps < 0.05). ADT+ participants also reported greater depressive symptomatology than both control groups at follow-up (ps < 0.001). Rates of clinically significant depressive symptomatology were higher in the ADT+ group than the ADT- and CA- groups at both time points (baseline: 28%, 5%, 12%; follow-up: 39%, 9%, 11%).

CONCLUSIONS

Findings support the hypothesis that ADT administration yields increases in depression and suggest that the mechanism behind ADT's association with depression should be explored and that prostate cancer patients treated with ADT should receive particular focus in depression screening and intervention.

Cognitive changes associated with ADT: a review of the literature

The use of androgen deprivation therapy (ADT) has increased since the early 1990s after early detection efforts and greater use of the prostate-specific antigen (PSA) test. Although ADT is associated with favorable clinical outcomes, ADT has been associated with an increased risk for cardiovascular disease, increased serum cholesterol, triglycerides, insulin resistance, body mass index and fat body mass. Here we review findings from 11 clinical studies examining the effects of ADT on cognition as measured by standardized tests in cognitive domains such as verbal and spatial memory. Most of these studies have important limitations, including small sample sizes, suboptimal control groups and baseline group differences in confounding factors. Despite these limitations, the best designed studies, those comparing patients on ADT to healthy controls, generally suggest that spatial memory might be especially sensitive to the effects of ADT. Critically, to date there is only one study involving random assignment of ADT versus close clinical observation. That study revealed a decrease in verbal memory with ADT, but was limited in sample size and did not include a measure of spatial memory. A recent observational study revealed no substantial evidence of cognitive impairment with ADT, even in the domain of verbal memory. Like the randomized study, however, this large observational study lacked a measure of spatial memory. Overall, the studies with the best controls suggest a potential negative impact of ADT on spatial memory, and perhaps verbal memory, and a need for continued investigation of the impact of ADT on cognition, particularly in these two cognitive domains.

Cognitive impairment in men treated with luteinizing hormone-releasing hormone agonists for prostate cancer: a controlled comparison

GOALS OF WORK

Data suggest that treatment with luteinizing hormone-releasing hormone (LHRH) agonists may be associated with reduced cognitive functioning. The purpose of the current study was to compare rates of clinically significant cognitive impairment in men treated with LHRH agonists to a matched sample of healthy men without cancer.

MATERIALS AND METHODS

Participants were 48 men receiving LHRH agonist therapy for prostate cancer and 48 men with no history of cancer matched to patients on age and education. Participants were administered a battery of neuropsychological tests assessing the domains of verbal memory, verbal fluency, visuospatial memory, visuospatial abilities, and executive function. Clinically significant impairment on individual tests was defined as -1.5 SD below the normative mean; overall impairment was defined as impaired performance on two or more tests.

MAIN RESULTS

Patients did not differ from comparison subjects in age, ethnicity, race, education, or annual household income (p's > 0.05). No statistically significant differences in test means were found. Nevertheless, patients displayed greater overall impairment in cognitive functioning than comparison subjects (42% of patients versus 19% of comparison subjects, p < 0.05). Among patients, prior prostatectomy was associated with impaired immediate and delayed verbal memory (p's < 0.05).

CONCLUSIONS

Current findings suggest that LHRH agonists and surgery for prostate cancer are associated with clinically significant impairment in cognitive functioning. Longitudinal studies are needed to examine changes in cognitive impairment before and after surgical and hormonal treatment for prostate cancer. Patients undergoing LHRH agonist therapy should be monitored for cognitive changes while on treatment.

Cognitive effects of hormone therapy in men with prostate cancer: a review

BACKGROUND

Men who receive androgen-deprivation therapy (ADT) for prostate cancer experience several side effects from this treatment. A few recent studies have examined the cognitive implications of ADT and how they impact a patient's treatment decision-making, occupational pursuits, and quality of life. For this report, the authors explored possible mechanisms for this association, reviewed research in animal studies and aging men, and examined the growing literature focused on the relation between ADT and cognitive functioning in patients with prostate cancer.

METHODS

A systematic literature search was conducted using the PubMed and Information Sciences Institute Web of Knowledge-Web of Science databases to identify relevant studies that investigated the relation between ADT in men with prostate cancer and its cognitive effects.

RESULTS

Testosterone and its derivatives may have an impact on cognition through several mechanisms in the brain, as supported by studies of animals and in aging men. Studies that researched the impact of ADT on cognition in patients with prostate cancer patients were designed relatively well but suffered from small sample sizes. Between 47% and 69% of men on ADT declined in at least 1 cognitive area, most commonly in visuospatial abilities and executive functioning. Some studies reported contradictory results with increased functioning in verbal memory.

CONCLUSIONS

There is a strong argument that androgen-ablation therapy is linked to subtle but significant cognitive declines in men with prostate cancer. The authors believe that clinicians should become aware of this correlation as the use of ADT increases and should inform and monitor patients for this possible side effect of treatment.