Cognitive therapy and living with advanced forms of prostate cancer


A group of researchers in four states in Australia have reported the initiation of a randomized clinical trial designed to reduce psychological distress and improve quality of life among men with advanced prostate cancer.

Men with advanced forms of prostate cancer (i.e., metastatic and castration-resistant forms of the disease) tend to have higher levels of psychological distress, poorer quality of life, and increased risk of suicide when compared to men diagnosed with localized disease that can be treated with curative intent. In Australia, according to Chambers et al.,  about 20 percent of men with prostate cancer have advanced disease.

In their paper published online in BMC Cancer in February, Chambers and her colleagues present the protocol for a randomized, controlled clinical trial to assess the effectiveness of a professionally-led, mindfulness-based cognitive therapy (MBCT) group intervention to improve psychological well-being in men with advanced prostate cancer. The authors state that they are not aware of any prior psychological intervention research specifically targeting men with advanced prostate cancer, and neither is The “New” Prostate Cancer InfoLink.

The study described by Chambers et al. has the following design:

  • 190 men will be recruited at major treatment centers in the Australian states of Queensland, New South Wales, Victoria, and Western Australia.
  • Eligible patients must
    • Have either evident metastatic disease or castration-resistant disease and biochemical progression
    • Be able to read and speak English
    • Have no previous history of head injury, dementia or psychiatric illness
    • Have no other concurrent form of cancer
    • Have phone access.
  • Patients will be randomized (1:1) to either
    • Telecommunications-based, group MBCT intervention over a period of 8 weeks or
    • More basic patient information and education (standard medical management and a package containing existing evidence-based patient education materials)
  • Validated, reliable surveys will be administered to all patients at baseline/recruitment, and at 3, 6, and 9 months after the initiation of intervention.
  • Primary study outcomes will include levels of anxiety, depression, and cancer-specific distress.

Additional information about recruitment of patients into this trial is available on the Australian New Zealand Clinical Trial Registry web site.

Chambers et al. define “mindfulness” as follows:

Mindfulness involves open awareness of current experience and the intention to observe habits of reacting to difficulties as they arise. Over time, this practice leads the person to gain the ability to be less reactive to difficult experiences and approach equanimity regarding the content of the illness experience, including negative emotions and thoughts.

They go on to state that:

MBCT specifically targets the cognitive processes associated with depression by encouraging participants to disengage from reactive and ruminative states of mind, such as those that are commonly reported by cancer patients.

They have previously reported data from a 19-man pilot study. In that study, group MBCT was able to induce significant changes in both general psychological and cancer-specific distress among men with advanced prostate cancer and that acceptance of and learning from other group members were key aspects of the group context that contributed to acceptance of living with progressive disease.

The “New” Prostate Cancer InfoLink sees this study by Chambers and her colleagues as a potentially important contribution to our greater understanding of how to help men with advanced forms of prostate cancer (and perhaps their families as well) to “live well” with a severe and incurable form of cancer. We look forward to hearing the outcomes of this study, which may encourage study of similar forms of intervention in other developed nations.

3 Responses

  1. Mike

    It is good to hear someone recognizes this issue. Makes me think maybe I am not as crazy as I often think I am.

    Bill

  2. For those who are interested, Prof. Chambers has let me know that she has published a book entitled Facing the Tiger: A Guide for Men with Prostate Cancer and the People Who Love Them.

    All royalties from this book are donated to the Prostate Cancer Foundation of Australia. One can acquire copies of this book through either Amazon.com or directly from Australian Academic Press.

  3. POTENTIAL CONFOUNDING ISSUES FOR MEN WITH VERY ADVANCED PROSTATE CANCER

    I’m glad this research will be done, but I’m thinking the protocol probably needs to be tweaked up front to make it more robust against some fairly likely confounders that are likely not on the radar for the research team. I hope Dr. Chambers and the other research team members will consider these issues.

    (1) Simple attention versus MBCT. What spurred this thought was the protocol provision for “evidence-based medicine” information for the men in the control group. In essence, the MBCT group is going to get a lot of on-going attention, in addition to usual treatment, while the control group gets a package of evidence-based medicine materials, plus usual treatment. On its face, regardless of the substantive value of the intervention, it is possible that the amount of extra attention alone will create a favorable effect. Personally, having majored in research-oriented psychology as an undergraduate, I consider that likely. The classic industrial psychology experiment resulted in what is known as the “Hawthorne effect,” which is nicely described by Wikipedia.

    On the other hand, it might be useful to determine whether in an advanced patient population simply that extra attention (or just some attention, not in comparison to another group) has a favorable influence on quality of life, etc.

    However, it would be much better if the effect of MBCT could be teased out of the effect of just getting more attention. I suspect that could be done with a group providing an equivalent amount of attention but focused on something other than MBCT, but of interest. I’m thinking out-of-the-box here, but perhaps sports would do nicely in sports-mad Australia. (Who knows –the sports group might do the best!)

    (2) Access to care in an era when effective but often expensive therapies for late-stage prostate cancer patients are rapidly emerging, an environment that is not typical for most other cancers (at least yet). Dr. Chambers, the lead author, does not specialize in prostate cancer, but is more expert in psychology and in cancers generally. She and her team may be unaware that new and exciting therapies are rapidly emerging for the very population she will be studying. I’m thinking of drugs like Provenge, Zytiga, Xtandi, Yervoy, and well-done second-line ADT (perhaps including Leukine, ketoconazole, and estradiol in combination) to name a few, plus imaging and treatment advances coupled with concepts like potentially curable oligometastatic cancer. That environment raises at least the following issues.

    (2a) Some patients in either study arm may enjoy both access and success with one or more of the emerging new therapies to the extent that their prognosis is profoundly altered. It seems to me that would be likely to drown out the effect from the intervention and would perhaps merit censoring of data from such patients. It does not appear that the patient’s view of his prognosis will be assessed in the trial.

    (2b) Unfortunately, some patients may become aware of therapies with exciting potential for their own cases but with no path to access. That could well lead to discouragement, and such discouragement might drown out any intervention effect.

    (2c) “Evidence-based medicine” usually means medicine supported by Phase III clinical trials leading to subsequent approvals by government health authorities. However, at least in prostate cancer, many of us are convinced that some of the best work for advanced patients is being done by a number of doctors dedicated just to prostate cancer who are thinking outside the box and crafting treatments in the van of “evidence-based medicine.” I am absolutely convinced that is the case regarding androgen deprivation therapy, and, as the researchers are aware, ADT is the common ground for men with advanced cases. Moreover, at least one of the vanguard doctors, Charles “Snuffy” Myers, has quite a following in Australia (via actual patients as well as online video, books, recorded talks and a newsletter), and another, Dr. Stephen Tucker, practices in Singapore, not that far away.

    In this Internet/social media age, I’m thinking the approaches of such doctors are fairly likely to be picked up by a substantial proportion of the participants, and, if so, the approaches of these doctors might well appear in favorable but stark contrast to the contents of the “evidence-based medicine” package. That could easily degrade the credibility of the package and even generate some hostility toward the provider of what could be viewed as inferior information.

    If I were on the research team, I would at least probe in advance of recruitment for awareness of this vanguard thinking among the pool of potential participants. If awareness is minimal, this issue could probably be ignored. If awareness is substantial, the issue would require attention. Perhaps at a minimum some mention of the existence of vanguard thinking could be made in the education package. (In reality as contrasted with conjecture, if I were on the research team I would want all patients in both arms to get at least introductory information about vanguard thinking and links to more detail.)

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