Psychosocial outcomes of cancer: a comparative analysis of Hodgkin's disease and testicular cancer

PURPOSE

The psychosocial outcomes of testicular cancer and Hodgkin's disease were compared to test our hypotheses that more specific dysfunction and less hiding of symptoms would be found in the former group, as cancer visibly affects a sexual organ. Since those with Hodgkin's disease could more easily deny the disease, poorer psychosocial adjustment was predicted.

PATIENTS AND METHODS

The sample consists of 85 men with Hodgkin's disease and 88 men with testicular cancer (seminomatous, n = 39; or nonseminomatous, n = 49). They were interviewed once, at least 1 year following the end of treatment. Measures of sociodemographic characteristics, physical functioning, psychologic distress, and social outcomes were collected. Treatment data were collected from medical records.

RESULTS

Men with testicular cancer report more focused symptoms: less sexual enjoyment and poor health habits. Men with Hodgkin's disease report more generalized symptoms: fatigue, energy loss, and work impairment. Multivariate analysis indicates that most of these differences are site-related; independent effects of treatment on outcomes were found for more generalized symptoms. Contrary to expectations, both groups reported similar levels of infertility and erectile dysfunction.

CONCLUSION

The response to testicular cancer is site-specific, while the response to Hodgkin's disease is related to both site and treatment (stage-related).

Heterogeneity in responses to cancer. Part I: Psychiatric symptoms

Heterogeneity in psychiatric responses to disease specific diagnosis is demonstrated for two groups of cancer patients who are comparable in prognosis and treatment intensity. Implications of this heterogeneity are drawn for etiological study and for planning psychiatric interventions.

Psychological and mood disturbance associated with the diagnosis and treatment of testis cancer and other malignancies

Eighty-seven men with testis cancer (TC) and 35 men with other cancers (OC) completed measures of mood (Profile of Mood States) and of personality and psychopathology (Millon Clinical Multiaxial Inventory). Effects of primary disease, phase of diagnosis and treatment, locoregional vs. cytotoxic treatment, age, and marital status on these measures were examined. TC patients appeared more distressed during treatment, particularly during cytotoxic as compared to locoregional treatment, than before or after treatment, and more distressed than OC patients. Being married appeared to buffer the stress of cancer and its treatment. Although treatment, particularly cytotoxic therapy, appeared to result in transient distress, results did not offer strong evidence that cancer and its treatment typically precipitate severe psychopathology.

Long-term effects of testicular cancer on marital relationships

Thirty-four long-term survivors of testicular cancer and their wives were interviewed individually almost four years past the end of treatment to measure psychological and relationship functioning. Factors identified as important for couple adjustment to cancer--good communication, spousal support, and marital satisfaction--all acted positively to facilitate functioning in this sample. Good psychological adjustment was reflected in scores on the POMS, CES-D, Sense of Coherence, and Relationship Dimension of the Family Environment Scales. Several couples demonstrated lasting impairment, but, overall, the great majority of relationships were strengthened and couples emerged more tightly bonded.

Quality of life after treatment for testicular cancer--the patient's view

Twenty-eight patients cured of testicular cancer by cisplatin-based chemotherapy were asked for their own views of the long-term psychological and social effects of their treatment. Their views were compared with a group of 34 testicular cancer patients cured by radiotherapy who were matched for age, social class and time since treatment. A category rating type questionnaire was used with questions concerning general health, subjective side-effects of treatment, employment, relationships, reproduction and mood. The principal differences were (1) the chemotherapy group reported a greater prevalence of physical side-effects, (2) the radiotherapy group reported greater anxiety and depression since treatment and (3) a significant number of patients in the chemotherapy group felt that their illness had had beneficial effects on their relationships with family and friends.

Long-term effects of testicular cancer on sexual functioning in married couples

Long-term sequelae of testicular cancer have not been reported from the perspective of patient and spouse. As part of a larger study, both members of 34 married couples were interviewed individually, almost 4 years after treatment ended. Spouse and patient responses were compared for concordance (agreement) regarding psychosexual functioning and fertility issues. Wives perceived fewer long-term problems than husbands and were extremely supportive throughout their husbands' illnesses. At interview, whereas 23.5% of patients still felt less attractive as a result of treatment, no spouses shared this perception. Patients were more likely to report decreased, and wives increased sexual satisfaction compared to before cancer. However, both patients and spouses were more likely to report decreased frequency of intercourse than increased. In other areas as well, concordance was generally high. Few couples reported that infertility would pose a problem, but 53% were parents; men who banked sperm were less likely to already have children.

Testicular cancer

Testicular cancer, which predominantly occurs in young men, has become increasingly common; it is presently the most common malignancy in men aged 20-34. Despite a lack of knowledge of aetiology, empirical advances, particularly in the management of patients with advanced disease, have been dramatic. Prior to the development of effective chemotherapy in the 1970s, less than 10% of men with metastatic non-seminomatous germ cell tumours were cured; nowadays approximately 90% of patients are potentially curable. The introduction of effective chemotherapy has led to a reappraisal of surgery and radiotherapy in the management of early stage disease and the introduction of a policy of surveillance in patients without evidence of metastases at the time of removal of the primary tumour. Following chemotherapy, surgery is required in approximately 25% of patients with advanced disease to excise residual masses, which in one-fifth of cases will show evidence of residual malignancy. In a proportion of patients, testicular cancer develops on a background of long-standing infertility, whereas in many men there is temporary oligospermia, despite a previous history of fertility. The majority of patients with prior evidence of spermatogenesis recover this function following chemotherapy and there is no evidence that children fathered by such patients have an increased risk of malformation. Despite physician optimism and excellent prospects for cure, significant psycho-social morbidity is associated with the diagnosis and treatment of testicular cancer. Factors contributing to this are being identified and will lead, hopefully, to the minimisation of such problems by appropriate intervention.