05 May 2022
By Kalli Spencer
Any diagnosis of cancer can trigger a range of emotions and put one into an anxious state. These feelings may wax and wane through the various stages of the cancer journey and may persist. Wondering whether you have cancer; waiting for the results of diagnostic tests; going for treatment; dealing with the after effects of treatment and the fear of recurrence are just some of the potential triggers.
How many people are affected?
After diagnosis, between 15 – 18 % of people will experience depression and 15 – 27% will develop anxiety1. Prostate cancer patients are likely to have 2.5-fold higher odds of experiencing anxiety and 2-fold higher odds of experiencing depression as compared to the population without a lifetime history of cancer2. Across multiple studies on localized disease at different points: prior to treatment; immediately after radical prostatectomy or radiation therapy; those on active surveillance, Mundle et al noted a reported incidence of anxiety at 19.5%, depression at 11.4%, and distress at 28%2. Although general anxiety may not correlate with depression, the patients with prostate cancer-specific anxiety may show high frequency of coincident depression.
Prostate specific antigen (PSA) levels correlate with depression and anxiety. PSA related anxiety may be linked to the time of PSA testing only and specifically may coincide with disease progression when a rise in PSA is seen. It may be worsened if cancer returns while on androgen deprivation therapy and/or after disease spread (metastasis) especially in relation to repeated PSA testing. This is compounded by the fact that a well known side effect of androgen deprivation therapy is depression. On the other hand, cancer-related anxiety and general anxiety may be more directly relevant to prostate cancer survivorship regardless of PSA levels and may persist ten years after initial diagnosis2. There are several factors that influence the chance of long term distress: disease and treatment specific factors - high symptom burden, receiving several active treatments; individual factors - age and having multiple co-morbidities; socio-cultural factors - socioeconomic deprivation, unemployment and identifying as single1.
Impact on life
Living with the burden of treatment related side effects such as urinary, sexual, and bowel functioning may impact general quality of life, relationships, self-esteem, self-confidence, and social interactions2. Psychological factors are also associated with worse surgical outcomes such as increased postoperative pain, poorer wound healing, and increased length of hospital stay3. Additional risk factors aggravating outcomes include lower socioeconomic status, education and health literacy, younger age, advanced-stage disease and greater treatment morbidities.
Mundle et al reviewed several journal publications on psychological interventions for those with prostate cancer2. They found a strong positive correlation between change in distress with depression. Several studies used the Hospital Anxiety and Depression Scale (HADS) to measure the impact of their interventions and found a 15% improvement in depression; 28% improvement in anxiety and 24% improvement in distress. Researchers who used a combination of cognitive and educational strategies had superior outcomes to each of these strategies used in isolation. The authors concluded that treating patients with cognitive-behavioural solutions and/or appropriate education may be a preferable alternative, as opposed to immediately prescribing antidepressant or anti-anxiety medications.
Psychological flexibility (PF) is an important part of psychological health and is defined as “how a person adapts to varying psychological demands; applies mental resources flexibly; shifts their perspective depending on the context; how well they balance competing demands on them; and how flexibly they deploy coping strategies according to what is needed by the context”4. PF is the core mechanism of change in Acceptance and Commitment Therapy (ACT), a modern form of Cognitive Behavioural Therapy. Men with prostate cancer experiencing distress use a range of coping strategies including stoicism, acceptance, humour, escapism and avoidance. It is possible that the effectiveness of these coping strategies depends on the individual's current context and the flexibility with which these strategies are applied.
Higher PF can buffer the impact of fear of disease recurrence on distress, and ultimately quality of life. Contemporary treatment approaches focus on cognitive strategies to reduce levels of fear of recurrence, and Sevier-Guy et al in their research suggest that in addition to those strategies that aim to help an individual to reduce fear of recurrence (FoR), or manage distress, it might also be possible for an individual to be supported to behave in a more flexible way in response to FoR in order to reduce its psychosocial impact1. In ACT people learn to ‘unhook’ from distressing thoughts and actively pursue valued activities, rendering distressing thoughts less important.
The last twenty years have seen increasing recognition of the importance of integrating mental health therapies into routine cancer care, resulting in the development of international clinical practice guidelines and the integration of distress as the “6th Vital Sign” (after blood pressure, pulse, temperature, respiration, and pain). Grimmett et al have investigated whether exercise-focused and multimodal prehabilitation interventions (e.g., combining exercise and psychological support) are more effective at improving psychological health and health outcomes prior to surgery3.
Psychological intervention with educational and cognitive components may provide an easy, non-invasive, and effective solution if used in a timely manner while symptoms are mild to moderate. With the majority of prostate cancer patients being elderly and already having a significant burden of other medications, non-drug related interventions may be of particular value.
Most randomised trials for experimental anti-cancer drugs already include assessments of global or health related quality of life but it may worthwhile adding specific assessments of anxiety, distress and depression using validated tools like HADS for future research.
Mundle et al concluded from their analysis that the beneficial 20–40% lowering of anxiety, depression, and/or distress should direct medical practitioners to consider psychological intervention at all stages of the prostate cancer journey2.
1. Sevier-Guy L, Ferreira N, Somerville C, Gillanders D. Psychological flexibility, and fear of recurrence in prostate cancer. Eur J Cancer Care. 2021; 30:e13483.
2. Mundle R, Afenya E, Agarwal N. The effectiveness of psychological intervention for depression, anxiety, and distress in prostate cancer: a systematic review of literature. Prostate Cancer Prostatic Dis. 2021; 24:674–687.
3. Grimmett C, Heneka N, Chambers S. Psychological interventions prior to cancer surgery: a Review of reviews. Curr. Anesthesiol. Rep. 2022; 12:78–87.
4. Kashdan TB, Rottenberg KK. Psychological flexibility as a fundamental aspect of health. Clin Psychol Review 2010, 30, 865–878.
About the Author
MBBCh, FC Urol (SA), MMed (Urol), Dip.Couns (AIPC)
Kalli is an internationally renowned Urological Surgeon, specialising in oncology and robotic surgery. He trained and worked in South Africa, before relocating to Australia where he has worked at Macquarie University Hospital and Westmead Hospital. His passion for what he does extends beyond the operating room, through public health advocacy, education and community awareness of men’s health, cancer and sexuality.
Kalli has been involved with the Prostate Cancer Foundation of Australia for many years, advocating for improved cancer care and facilitating community prostate cancer support groups.