Mental Health Challenges in Men With Prostate Cancer

Sandra Nikulina
Department of Psychiatry, Lithuanian University of Health Sciences (LSMU)

A diagnosis of prostate cancer can have a significant negative impact on men's mental health. The most common psychological consequences include distress, anxiety, depression, sexual dysfunction, and cognitive impairment.

Prostate cancer (PC) is one of the most common malignancies affecting older men worldwide. According to the Lithuanian Cancer Registry, until 2011 prostate cancer was the second leading cause of cancer-related death among Lithuanian men after lung cancer [1]. Similar trends have been reported across Western Europe [2].

Early-stage prostate cancer can be detected by measuring prostate-specific antigen (PSA). Introduced into clinical practice after its discovery in 1980, PSA became an important biomarker for the early diagnosis of prostate cancer. Widespread PSA screening has enabled cancers to be diagnosed at earlier stages, contributing to increased incidence rates.

Early-stage prostate cancer is usually asymptomatic and rarely causes pain or functional impairment. Consequently, most men diagnosed through PSA screening consider themselves healthy until they receive the diagnosis. Cancer is commonly perceived as a life-threatening disease [3].

Although treatment often prolongs survival, it may adversely affect health-related quality of life.

Men with prostate cancer may experience a range of psychological changes, the severity of which varies depending on several factors. Commonly reported influences include awareness of the diagnosis, disease stage (localized or advanced), and the treatment received.

Treatment options include radical prostatectomy (surgical removal of the prostate), external beam radiotherapy, prostate brachytherapy, and conservative management, including androgen deprivation therapy or active surveillance without immediate treatment [4,5].

The most frequently reported psychological consequences include distress, anxiety, depression, sexual dysfunction, and cognitive impairment.

The following review summarizes current evidence regarding the impact of prostate cancer on men's mental health.

Impact of a Prostate Cancer Diagnosis

The psychological impact of a prostate cancer diagnosis has not yet been fully clarified.

Earlier studies evaluating health-related quality of life generally assessed men shortly before treatment or immediately after treatment had begun [6]. Very few studies evaluated mental health before the diagnosis itself.

To accurately determine the psychological impact of prostate cancer, baseline mental health must be assessed before diagnosis. However, conducting such studies is difficult because it is impossible to predict who will develop cancer and when. Consequently, very large study populations are required.

One of the largest studies addressing this issue was the European Randomized Study of Screening for Prostate Cancer (ERSPC), which primarily investigated whether early detection and treatment reduced prostate cancer mortality [7].

One component of the study examined mental health outcomes.

Participants completed the emotional well-being and vitality domains of the Short Form-36 (SF-36) health-related quality-of-life questionnaire.

Before screening, 3,800 men completed the questionnaire (response rate: 88%). Prostate cancer was diagnosed in 82 men, of whom 52 (response rate: 63%) completed additional assessments before primary treatment (approximately one month after diagnosis) and again six months after treatment had begun.

Mental health deteriorated significantly during the first month following diagnosis (p ≤ 0.04).

Although scores improved after six months and no longer differed significantly from pre-treatment values, they did not fully return to baseline levels [6].

A large population-based study conducted in the United States using data from the Surveillance, Epidemiology, and End Results (SEER) program and the Medicare Health Outcomes Survey (MHOS) also evaluated changes in health-related quality of life among men with prostate cancer using the SF-36 questionnaire.

The study included 445 men with prostate cancer and 2,225 control participants.

Before diagnosis, health-related quality of life was similar in both groups.

Following diagnosis, men with prostate cancer experienced significant deterioration in mental health, physical functioning, and social functioning compared with controls.

The greatest decline occurred during the first six months after diagnosis.

One year later, quality-of-life measures in both groups were comparable. However, patients with prostate cancer did not fully recover to their pre-diagnosis levels [4].

Overall, these findings indicate that a diagnosis of prostate cancer negatively affects men's psychological well-being.

Providing patients with clear information regarding available treatment options for early-stage disease and the generally favorable prognosis may help reduce distress and improve mental health.

Depression and Anxiety

The U.S. population study found that men treated conservatively or with external beam radiotherapy were more likely to experience depression.

Their mental health scores were significantly worse than those of men without cancer.

Men whose diagnosis had been established more than 19 months earlier had approximately 2.2 times greater odds of depression than men without prostate cancer [4].

Other studies likewise demonstrate that older men with cancer are more likely to develop depression [8–11].

Several factors may contribute to depressive symptoms, including androgen deprivation therapy, prolonged treatment, and age-related limitations in physical functioning [10].

Pain associated with localized prostate cancer has also been identified as a potential predictor of both depression and anxiety [5].

A Japanese study published in 2012 reported high levels of state anxiety among men undergoing different treatment modalities.

Severe or very severe anxiety was reported by:

• 47.6% of men treated with radical prostatectomy;
• 40.0% of men treated with brachytherapy;
• 37.5% of men treated with external beam radiotherapy.

However, severe or very severe trait anxiety was significantly lower among men treated with radical prostatectomy (23.7%).

Trait anxiety was associated with state anxiety and overall mental health status [12].

Sexual Dysfunction

Considerable attention has been given to the effects of prostate cancer (PC) and its treatment on male sexual function. Findings from multiple studies show that men with localized PC report sexual dysfunction more frequently than age-matched men without cancer. Men undergoing radical treatment experience the most severe impairment shortly after treatment, and recovery of sexual function to pre-treatment levels is often difficult. One study found that sexual function returned to baseline within one year in only 31% of men after radical treatment. Regardless of treatment, men with PC have a higher risk of physiological impotence than men of the same age without cancer. Physiological impotence was reported by 86% of men treated with radical prostatectomy, 57% of those treated with external beam radiotherapy, and 57% of those managed with active surveillance. In these groups, sexual dysfunction was already present at baseline and persisted after one to two years of follow-up [5].

To date, there is a lack of studies comparing the sexual function of men with advanced prostate cancer and healthy men of similar age. Consequently, the independent effect of advanced disease on sexual function remains difficult to determine. However, longitudinal studies assessing health-related quality of life have shown that men with advanced prostate cancer already had severely impaired sexual function before treatment. The degree of dysfunction was comparable to that observed in men with localized disease who had undergone radical treatment. These findings suggest that advanced disease itself may contribute to impaired sexual function [5].

At the beginning of one study, men in both the active surveillance and hormone therapy groups reported only minimal sexual problems. After one to two months of treatment, men receiving hormone therapy more frequently reported reduced sexual interest and satisfaction than those under active surveillance. After six months, the hormone therapy group more commonly reported worsening erectile function together with reduced sexual interest and satisfaction. Although absolute numbers were not reported, men receiving hormone therapy consistently experienced a greater overall burden of sexual dysfunction, generally of moderate severity. These findings suggest that less aggressive treatment approaches may be associated with better preservation of sexual function [5].

Recent studies evaluating the effects of hormone therapy on male sexual function have identified a broad spectrum of sexual dysfunction, including impaired ejaculation and orgasm, decreased libido and sexual activity, and erectile dysfunction. These complications have a direct negative impact on quality of life and self-esteem [13]. However, definitive conclusions remain difficult because several studies assessed sexual function only once, often several years after treatment, and baseline differences in sexual function were not consistently taken into account.

Distress, Cognitive Function, and Comorbid Mental Disorders

In recent years, increasing attention has been paid to the identification and management of psychological distress in patients with prostate cancer. Numerous studies have shown that many patients with cancer, including those experiencing clinically significant distress, remain untreated because appropriate screening tools are lacking or are not routinely used. The implementation of validated screening instruments could help identify patients who require psychological support and intervention. In recent years, there has been a growing number of studies investigating psychological distress in men with prostate cancer.

Summary

Prostate cancer is one of the most common malignancies affecting older men worldwide. According to data from the Lithuanian Cancer Registry, until 2011 prostate cancer was the second leading cause of cancer-related death among Lithuanian men after lung cancer.

The most common mental health changes observed in men with prostate cancer include distress, anxiety, depression, sexual dysfunction, and cognitive impairment.

A diagnosis of prostate cancer has a negative impact on men's psychological well-being. Providing patients with information about treatment options and the favorable prognosis associated with early-stage disease may improve mental health and reduce distress.

Men treated conservatively or with external beam radiotherapy appear to be at greater risk of developing depression. Long-term treatment, age-related physical limitations, and pain may also contribute to the subsequent development of anxiety and depression.

Anxiety affects nearly half of men undergoing treatment for prostate cancer.

Men with prostate cancer are more likely to develop physiological impotence than age-matched men without cancer. Sexual dysfunction was reported by men with prostate cancer regardless of the treatment modality used.

Hormone therapy has a negative impact on cognitive function, particularly spatial and verbal memory.

Prostate cancer and comorbid mental disorders are associated with poorer quality of life. The psychological consequences of both the disease and its treatment adversely affect patients' health-related quality of life. Therefore, early recognition and treatment of these mental health disorders, together with timely management of psychological distress, are essential.

Source: Lithuanian Doctor's Journal