Anxiety predicts early use of hormone therapy

It is well known to readers of The “New” Prostate Cancer InfoLink that androgen deprivation therapy (ADT) is a commonly used form of treatment for patients who experience biochemical recurrence (BCR) after first- or second-line therapy. However, as is also well known, the optimal timing of ADT initiation is uncertain, and earlier initiation of ADT can cause toxicities that lower patients’ health-related quality of life (HRQOL).

Dale et al. set out to test the hypothesis that elevated cancer anxiety leads to earlier initiation of ADT after BCR among older men. Their test population was a group of 67 older patients (with an average age 68 years) with BCR after initial treatment for prostate cancer.

The patients all completed questionnaires at presentation and each follow-up visit until initiation of ADT. Prostate cancer-specific anxiety was measured using the Memorial Anxiety Scale for Prostate Cancer (MAX-PC). Other data collected included demographics, clinical information, and general anxiety information. The treating oncologists were also surveyed about their recommendations for initiation of ADT.

The results of the study ashowed the following:

  • 33 percent of patients initiated ADT at the first or second clinic visit.
  • Elevated prostate cancer-specific anxiety (MAX-PC > 16) was the most robust predictor of early initiation.
  • PSA level also independently correlated with early initiation.
  • PSA level did not correlate with MAX-PC, however.

The authors conclude that cancer anxiety independently and robustly predicts earlier ADT initiation in older men with BCR. They note, however, that among older patients with prostate cancer, earlier initiation of ADT may have limited impact on life expectancy and can negatively impact HRQOL.

This is yet another study that calls into question the ways we have been “rushing” from one therapy to the next in the attempt to “manage PSA levels” rather than effective managing life with progressive prostate cancer. All too often men have not understood the impact of ADT on quality of life until they have been on this type of treatment for several months. They also do not appreciate that early ADT may have little to no impact on their overall survival.

There is an increasing appreciation of the adverse consequences of ADT among the academic prostate cancer opinion-leaders, but the degree to which this appreciation is filtering down into community practcie is less clear as yet.

The question of when it is most appropriate to initiate hormone therapy is not well defined, largely because it is so dependent on a multiplicity of factors that include the patient’s age, general health, PSA velocity, prior treatments, personal preferences, and a whole range of other factors.

3 Responses

  1. “33 percent of patients initiated ADT at the first or second clinic visit.”

    Patient initiated ADT? Ya gotta wonder who’s been castrated here (sorry if this is in bad taste). Doctors should not perform treatments just because patients insist on it. I wonder if the scourge that is direct-to-consumer advertising has played a role in this. Patients see a drug on TV and demand that the doctor given it to them.

    This is a very important article because the findings can be useful in other PC settings. We know that patients have HT, which is of questionable benefit and very unpleasant, because they’re anxious. Also, patients with low-grade PC forgo active surveillance or convert to treatment because they’re anxious.

    The solution is to treat the anxiety. It can be done. I also think that if more men did not rush into treatment (which is common in other countries), some of the anxiety related to PC would abate. In the US our inclination is to always do something. So it’s understandable that no guy wants to be the odd man out who holds off. I think we need a cultural shift. Abolishing payments to docs based on the number of procedures they do would also help.

    PS: I’m not sure what the implications of this study are for younger patients.

  2. As a 76-year-old who has been on ADT3 for 10 months I can say without exaggeration that my QOL is nada, nil, nix, nothing, nauseous, nagging, nano-gram, nasty, naught, negative, and sucks. And these are only the ‘Ns” and “Ss”. I want my life back, whatever remains. Doc says I have to stay on it two more years!!! How am I going to do this?

  3. Leah says (and for once I don’t disagree with her — just joking Leah!), “The solution is to treat the anxiety. It can be done.

    Of course it can be done, but will it? I don’t think so, not while there are so many millions of dollars in play in creating anxiety about every facet of prostate cancer, from PSA testing/screening to the inappropriate tests and scans ordered, to the lack of clear indications of outcomes, to unneccesary adjuvant treatments (or should I say adjuvant treatments that have no demonstrable value … the list goes on. This anxiety drives men like beaters at a pheasant shoot, right into early treatment.

    In the midst of all this gloomy outlook there is the faintest glimmer of light. I have personally experienced the change in attitude to what was called, so inappropriately, watchful waiting and which is now commonly referred to as active surveillance.

    Thirteen years ago it was clear that the general view was that only fools and lunatics would consider such a step. The lunacy element has been removed now and men who follow this path, and the doctors who support that decisio,n are merely regarded as foolish. Perhaps as more time goes by and more studies are published, even that appellation might be removed.

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