The impact of emotional distress on prostate cancer decision-making

According to a newly published paper in the Journal of Urology,

Emotional distress may motivate men with low risk prostate cancer to choose more aggressive treatment. Addressing emotional distress before and during treatment decision making may reduce a barrier to the uptake of active surveillance.

Now this does not come as a surprising finding to your Sitemaster (and probably not to a lot of readers of this blog either). We all have a tendency to make less reasonable decisions about lots of things when we feel stressed. But it remains a critical issue in the diagnosis of prostate cancer and its management for one very simple reason: most physicians (at least in America) have little motivation to address the issue of emotional distress in all of its forms (for financial reasons and because of time pressures), and in their distress it is all too easy for men to make inappropriate decisions about treatment.

So what did the authors mean by “emotional distress” in this study?

To measure emotional distress, Odom et al. used a tool called the Distress Thermometer. This is a well-validated tool that measures “distress” on a scale from 0 (no distress) to 10 (extreme distress). And they measured the patients’ distress level twice: once after their diagnosis but before they had made any decision about treatment and then again after a decision had been made about type of treatment. You should also be aware that the Distress Thermometer is a recommended distress screening tool for use in patients with prostate cancer (which does not mean that most physicians are using it!).

Your Sitemaster has been able to read the entire text of this paper. Here is the quick summary of what Odom et al. did and found:

  • Between July 2010 and August 2014, they enrolled 1,531 patients, newly diagnosed with localized prostate cancer at two academic medical centers and three community practices.
  • The ethnicities of the patients broke down as follows:
    • Non-hispanic white, 83 percent
    • Non-hispanic black, 11 percent
    • Hispanic, 6 percent
  • With regard to patient’s risk levels, the breakdown was
    • 35.7 percent were low risk
    • 49.1 percent were intermediate risk
    • 15.2 percent were high risk
  • When it came to treatment choices
    • 24.2 percent elected active surveillance
    • 27.4 percent elected radiation therapy of some type
    • 48.4 percent elected surgery
  • Overall, men who were more emotionally distressed at diagnosis were more likely to choose surgery compared to active surveillance (RRR = 1.07; p = 0.02).
  • Men who were more distressed close to the time they made a treatment choice were more likely to choose
    • Surgery over active surveillance (RRR = 1.16;  p < 0.001)
    • Surgery over radiation therapy (RRR =1.12; p = 0.001).
  • These choice patterns were also evident in men diagnosed with low-risk prostate cancer.
  • In men with high-risk disease, distress was not associated with treatment choice.

In addition

  • Higher educational level was associated with a lower likelihood of choosing surgery or radiation over active surveillance.
  • Being black as opposed to white was associated with a higher likelihood of choosing radiation over active surveillance or surgery.
  • Being married was associated with a higher likelihood of choosing surgery over active surveillance and (in the distress at decision-making model) a greater likelihood of choosing surgery over radiation.
  • Being older was associated with a lower likelihood of choosing surgery over active surveillance or radiation.

In the full text of their article, Odom et al. also note that

Our findings support recent trends in promoting screening for emotional distress, but highlight the value of doing so early on, before men make treatment decisions. … Our study and recent work on the role of fear of treatment and side effects indicate the importance of emotional processes in men’s [prostate cancer] treatment decisions.

The “New” Prostate Cancer InfoLink has long believed that it takes many men some time and supportive care to make the best possible decision (for each individual) about how to have their prostate cancer managed or treated. This is not about whether Treatment A is “right” and Treatment B is “wrong”. It is about whether the patient (and his partner/spouse) fully understand the implications of each possible and appropriate form of treatment and whether their decision is being made once they have had time to both absorb this information accurately and address their emotional response(s) to the diagnosis.

For most people over about 60 years of age (which includes most prostate cancer patients), the word “cancer” alone is scary enough to induce a significant set of emotional responses, because we were all brought up believing that “cancer” was a short-term death sentence (which often it no longer is). Before anyone gets hurried into an operating room or a radiation suite, we need time and education to truly get past that set of emotional responses and understand the implications of the different forms of management. This, at least in your Sitemaster’s opinion, means time with a good nurse educator and an experienced patient navigator who can make sure that the newly diagnosed patient has had time to “calm down” and really make the best possible decision that will work for him.

Most men with low- or intermediate-risk prostate cancer don’t need to have treatment immediately. They have time to get the relevant information and make good decisions. The situation is different for men diagnosed with high-risk and advanced forms of prostate cancer — but even for them there is an essential education process that should be implemented before they are asked to commit to a specific type of treatment.

4 Responses

  1. This is SO important. Thanks for posting.

  2. The cited article requires payment — it is not freely accessible.
    Steve Barchet, MD

  3. Thank you for pointing this out Dr. Barchet. My error. I have adjusted the text and links above.

  4. Emotional distress may motivate men with low-risk prostate cancer to choose more aggressive treatment. Addressing emotional distress before and during treatment decision making may reduce a barrier to the uptake of active surveillance.

    Gee … Ya think!? Who needed a study to figure this out? More money thrown down the can that might have actually been used to help someone. Odom should change his name to Dr. Obvious.

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