“Psychosocial interventions in prostate cancer offer limited benefits”

The heading above is the title of a Reuters-generated article on the Medcape Oncology web site. The article is based on a new review article just published in BJU International.

Parahoo et al. carried out a Cochrane systematic review of the available, published research on the “effectiveness of psychosocial interventions for men with prostate cancer in improving quality of life (QoL), self-efficacy and knowledge and in reducing distress, uncertainty and depression.” The original and complete Cochrane systematic review can be found on the Cochrane Library web site.

They come to the utterly non-astonishing conclusion that:

… this review shows that psychosocial interventions may have small, short-term beneficial effects on certain domains of wellbeing, as measured by the physical component of [general health-related] QoL and cancer-related QoL when compared with usual care. Prostate cancer knowledge was also increased. However, this review failed to show a statistically significant effect on other domains such as symptom-related QoL, self-efficacy, uncertainty, distress or depression. Moreover, when beneficial effects were seen, it remained uncertain whether the magnitude of effect was large enough to be considered clinically important. 

However, what the review does not seem to address at all is that the psychosocial interventions that are offered to men (and their spouses) are almost invariably too little and too late:

  • We generally fail to properly explain the psychosocial consequences of decisions about treatment for prostate cancer (and especially low-risk forms of prostate cancer) prior to the decision to have an invasive form of treatment.
  • Often, the questions of importance to spouses or partners of the patient are ignored or glossed over (and that’s if the spouse/partner is even given the opportunity to participate in the decision-making process at all).
  • The forms of psychosocial care that can be offered and made available after initial treatment have little chance of being able to address the underlying problems, because the patient is often so traumatized by the effects that he is unable to even talk about it.

It is past time for the prostate cancer treating community to make a far greater effort to understand and start to address the predictable impacts that invasive therapy can have on men who are diagnosed with localized prostate cancer and on their families, and to help men to truly understand the consequences of their decisions prior to treatment. No one thinks this is going to be easy. It requires a complete reassessment of the way many clinicians discuss cancer therapy with their patients.

What is more, there are clearly limits to what doctors and nurses can do. One cannot force a man who is determined to have his prostate out listen to why this is may be a bad idea if he is incapable of listening. On the other hand, it seems morally unconscionable to give a man a radical prostatectomy without at least asking him if he has discussed this with his wife/partner and whether she would like to have the opportunity to ask the doctor or a nurse questions as well.

At the other end of the scale, however, if the psychosocial help that we can offer to patients after the event is so limited, then isn’t there an imperative to minimize the risk for the need for such psychosocial help after treatment bey ensuring some really practical guidance pre-treatment?

4 Responses

  1. I wonder if the offer of a good sex therapist — an offer extended to both the patient and his partner — would make a difference.

  2. In theory asking the medical community to try to intervene on the psycho-social effects of diagnosis and then treatment of prostate cancer is novel, but I question if it is even practical. Certainly, driving home the point that any decisions a man makes after diagnosis are irreversible and likely debilitating is possible. But I tend to agree with Cochrane on this one. Support group leaders like myself I think will tend to agree it’s not the preparation that makes for good outcomes when things get altered in a man’s anatomy, it’s some good luck and good results that will ultimately make the experience more bearable.

    We need to keep in mind, also, that each individual is largely responsible for their own preparation for the aftermath. But few men do it. There is no easy way to prepare a man for the “you have cancer” event. And likewise, all the instruction a physician can give will not hinder the very large population of men that just want to “get it out”. For those men that say they do understand the ramifications of treatment, I’m not certain they feel the same way a year later.

    I have had many men tell me they wished they found our support group sooner. Perhaps recommending support is something I wish all doctors would do with a newly diagnosed man. It’s not always an option, but it’s better than trying to drive home the points needed in an examination room. But I know a lot of men that don’t like that option either.

  3. Clara: The offer of a good sex therapist would be helpful for some and not for others. (Many people just don’t even want to talk about any of that with a third party.)

    Tony: While I understand your reservations, my own perspective if that what we see currently is a reflection of our complete failure to address the real problem effectively. The real problem is that as a society we hear the word “cancer” and just want to make decisions about how to get rid of it, as opposed to being taught to appreciate how the decisions we make are going to affect the next 20 or 30 years of our lives. This is not a problem confined to prostate cancer. We spend way more time teaching children how to ride a bicycle (let alone how to drive a car). There is a complete absence of any sound guidance in the education process, and yet comparatively few men diagnosed with prostate cancer actually need immediate treatment within even 3 months of diagnosis.

  4. Sitemaster:

    I showed this write-up at our UsTOO meeting last night. It was a terrific discussion that ensued. As I pointed out, oncologists, no matter the mode of treatment, would be overwhelmed trying to decipher the psycho-social needs of each individual patient. My group agreed as a whole that individualized care on this front would require a Dr. Phil to determine the educational needs of each patient. Our discussions at SWOG reflect this as well.

    I do point guys to the cancer.net/survivorship web page on survivorship. But I get to the guys after the diagnosis and the deer in the headlights syndrome. Since our providers are pretty much not equipped to coach a patient, I do suggest that the oncology world recognize the need to offer support groups to men before treatment. This is a direction I will be taking at ASCO this year. I hope to see you there.

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