Prostate cancer is the most
common malignancy in men and the second leading cause of cancer death in men
worldwide. Approximately 189,000 new cases will be diagnosed in the United
States in 2002. With advances in medical treatment, men with prostate cancer
are living longer, and the quality of their lives is improving.
Several high-profile cases, including former New York City mayor Rudolph
Giuliani and controversial financier Michael Milken, have thrust prostate cancer
and its impact on a man’s life into the public spotlight. Prostate cancer was
recently featured on the covers of several national news magazines such as Newsweek, and these articles highlighted the psychological struggles of men
coping with the disease.
Although the literature on the psychological complications of cancer has
grown over the past 20 years, research specific to prostate cancer has lagged
behind. Studies of the quality of life and psychological distress of men with
prostate cancer have only begun to appear in the past decade. Recognizing and
treating psychological distress is critically important because it has been
shown to lead to later presentations of cancer, decreased medical adherence,
increased hospital stays, and increased medical morbidity.[3,4]
This article will review previous studies of the psychological complications
of prostate cancer, identify important issues for men coping with prostate
cancer, and provide a basic guide for referrals and treatment.
Prevalence of Psychiatric Symptoms
High levels of psychological distress have been documented in cancer
patients, with estimates of actual psychiatric disorders nearing 25%. Although
few studies have specifically addressed psychological distress and psychiatric
disorders in men with prostate cancer, none have provided evidence to suggest
that men with prostate cancer are less affected than patients with other forms
of cancer. In fact, one study of many different types of cancer, including
prostate cancer, found no difference in levels of psychological distress among
patients with these cancers.
Focusing specifically on prostate cancer, current data on psychological
distress come from studies of quality of life, psychological distress, and
specific psychiatric disorders.
• Quality of LifeQuality of life has become a typical
measure of outcome in most studies of treatments for prostate cancer. Three
instruments are most frequently used to assess quality of life in men with
prostate cancer: the European Organization for Research and Treatment of Cancer
(EORTC) Quality of Life Questionnaire, the Functional Assessment of Cancer
Therapy-Prostate (FACT-P), and the Short Form (SF)-36.[6-8] Each of these
instruments includes domains of psychological well-being.
Although a thorough review of all prostate cancer treatment studies that
include quality of life as an outcome measure (well over 30 studies in the past
10 years) is beyond the scope of this review, most of these studies focus on the
significant differences in emotional well-being between treatment groups. Some
studies report that emotional well-being does not differ significantly with
different forms of treatment. However, a recent study has shown that different
forms of prostate cancer treatment are associated with significant differences
in quality of life. Men who underwent a prostatectomy or received
brachytherapy reported a higher overall quality of life. Men who received
radiation therapy reported a lower overall quality of life, but they also
reported fewer sexual and urinary symptoms. Men who received
androgen-deprivation therapy reported the lowest quality of life.
Whereas the EORTC instrument and the FACT-P were designed specifically for
men with prostate cancer, the SF-36 has been used in multiple populations, and
its psychological domains have been normed in the general population. According
to actual SF-36 mean domain scores for emotional well-being in many of these
quality-of-life studies (rather than the statistical differences between
treatment groups), men with prostate cancer do not report higher levels of
psychological and emotional distress than the general population, suggesting one
of two things: Either the emotional well-being of men with prostate cancer does
not differ from that of men in the general population, or these instruments are
not sensitive enough to detect clinically significant levels of distress in this
• Psychological DistressThe term "distress" is now
being used, with the hope of decreasing the stigma associated with
"psychological" problems in cancer patients and increasing awareness
and treatment of psychosocial difficulties. The National Comprehensive Cancer
Network (NCCN) defines distress as
an unpleasant experience of an emotional, psychological, social, or
spiritual nature that interferes with the ability to cope with cancer
treatment. It extends along a continuum, from common normal feelings of
vulnerability, sadness, and fears, to problems that are disabling, such as
true depression, anxiety, panic, and feeling isolated or in a spiritual
In contrast to the literature on quality of life, men with prostate cancer
experience a high rate of psychosocial distress. Screening studies of men at
ambulatory prostate cancer clinics show that 20% to 31% report levels of
distress high enough to warrant a psychiatric evaluation.[11,12] These studies
also demonstrate that significant percentages of these men report depressive
symptoms (8.1% to 15.2%) and anxiety (17.8% to 32.6%). Kornblith and colleagues
have found anxiety symptoms in men undergoing treatment for prostate cancer as
measured by the Intrusion Subscale of the Emotional Impact Scale. These
symptomsmainly intrusive thoughtsare also seen in posttraumatic stress
disorder, but actual diagnostic criteria for the disorder were not applied in
• Psychiatric DisordersAlthough studies of distress may
include the presence of psychiatric symptoms, they do not provide data on the
rates of actual psychiatric disorders. Psychiatric disorders are well-defined
clinical syndromes with standard diagnostic criteria that can be found in the
American Psychiatric Association’s Diagnostic and Statistical Manual
for Mental Disorders (DSM-IV). However, making a psychiatric
diagnosis in a cancer patient can be complicated by overlapping symptomatology
seen in both psychiatric disorders and cancer (eg, fatigue, weight loss, and
sleep disturbance). Substituting more psychological or cognitive symptoms (eg,
loss of pleasure) for these more biological symptoms may help establish a
diagnosis. Such substitutions aside, standard psychiatric assessments have been
shown to be adequate.
Little research has been conducted on the prevalence of psychiatric disorders
in men with prostate cancer. However, given the rates of depressive and anxiety
symptoms reported in studies of distress, one would expect that anxiety
disorders and major depression have a significant prevalence in this population.
In a finding similar to reported rates of depressive symptoms, Pirl and
colleagues noted a 13% rate of major depressive disorderas diagnosed
according to the Structured Clinical Interview for DSM-IV Axis I Disordersin
men with prostate cancer who were receiving androgen-deprivation therapy at an
ambulatory oncology clinic.[16,17] This rate falls within the range of other
studies of ambulatory cancer patients, but is still 12 times the rate of major
depression in men in the general population and 32 times that of men aged 65
years or over. Although there may be an association between androgen-deprivation
therapy and depression, further research is needed to provide more definitive
The literature describes psychiatric symptoms in patients with cancer, but
people with psychiatric illnesses are not exempt from developing cancer. The
rate of major mental illnesses such as psychotic disorders and bipolar disorder
in men with prostate cancer should be similar to that of the general population.
However, one report actually found a decreased incidence of prostate cancer
among psychiatric patients.
Medical Causes of Psychiatric Symptoms
Psychiatric symptoms in men with prostate cancer can result from both medical
and psychiatric causes. In a population with a high medical morbidity, possible
medical etiologies of psychiatric symptoms need to be considered first. Among
these possibilities are brain metastases, delirium, and medical factors that
contribute to mood disorders.
• Brain MetastasesApproximately 1% to 3% of patients with
prostate cancer have been reported to have brain metastases. Such patients can
present with confusion, seizures, or other neurologic symptoms.
• DeliriumDelirium is marked by confusion, a waxing and
waning sensorium, hallucinations or paranoia, and sometimes agitation. Mood
symptoms, either depressive or manic, can also be present in delirium. Delirium
always has a medical etiology; the first goal of treatment is to find the cause
and, if possible, treat it. Possible causes of delirium include medications,
infections, and metabolic imbalances. Hypercalcemia, for example, can be a cause
of delirium. However, it is rarely seen in prostate cancer patients despite
metastases to bone. Neuroleptics, such as haloperidol or atypical neuroleptics,
are the treatment of choice.
• Factors Contributing to Mood DisordersAlthough
depressive symptomalogy in men with prostate cancer is more fully described
below, clinicians should be aware of medical factors that can contribute to
depression. By treating or adjusting these medical issues, psychiatric symptoms
can be improved markedly. Some of these factors include pain, glucocorticoids,
hypothyroidism, and possibly androgen-deprivation therapy.
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