Anxiety And Distress During Active Surveillance For Early Prostate Cancer

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology;  Cancer / Oncology;  Men's health
Article Date: 16 Nov 2009 - 4:00 PDT

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UroToday.com - The present study found that the majority of men with early prostate cancer (PC) included in a protocol-based program for active surveillance (AS) show favorable anxiety and distress scores when compared to reference values and to groups of patients with PC who underwent other treatments. A perceived important role of the physician in the shared treatment decision-making, a poor physical health score, a high neuroticism score, and a high PSA value were found to be significantly associated with worse scores on decisional conflict, depression, generic anxiety, and PC specific anxiety.

Here, we would like to further discuss the relevance, and the strengths and limitations of our study and discuss the future research directions.

What is the relevance of the findings of this study for clinical urological practice? Our results suggest that the potential disadvantage of AS regarding the burden of living with untreated cancer is small in men who have chosen this option. This adds to the feasibility of AS as a realistic strategy for men diagnosed with low risk PC. Equally important, awareness that patient-related factors are associated with levels of anxiety and distress may be useful in the shared treatment decision-making process in general, or in the selection of patients for AS.

A strength of the present study is the high compliance rate of 86%. We used an extensive questionnaire consisting mainly of standardized measures, allowing the simultaneous collection of many different relevant parameters. Furthermore, implementing the quality of life study within the prospective PRIAS study (www.prias-project.org) allowed a directly prospective approach to all participants. The relatively short follow-up after PC diagnosis of a median of 2.7 months decreases the bias of selecting only those patients with a favorable clinical follow-up.

Our study also has some limitations. Firstly, it focused on a selected patient group who had already selected AS to be the initial treatment strategy for their disease. They may have made this decision because they experienced low levels of anxiety and distress. The results of the present study should therefore not be generalized to patients with early PC before the treatment decision. Another limitation of this study is the lack of comparison groups within the same protocol. Instead, scores were compared with reference values and patient cohorts from the literature. Finally, as the current study design was cross-sectional, the predictive value of the parameters found to be significantly related to anxiety and distress could not be determined.

The following possible future research directions regarding the quality of life of men on AS should be mentioned.

A longitudinal study approach is indicated. This will reveal whether decisions on treatment options or on switching to deferred radical treatment during AS are influenced by the levels of anxiety and distress. Furthermore, such a study will reveal whether the small group of men who show higher levels of anxiety and distress during AS will actually show less negative emotions after they have received radical treatment. A man may rather be a bad patient to have PC‚ than be a bad candidate for AS specifically. Also, the potential changes in anxiety and distress levels during follow-up and the potential relation with changes in PSA should be studied. To do this, men who are included in the current study receive follow-up quality of life questionnaires. Also, within the European Randomized Study of Screening for Prostate Cancer (ERSPC), men who are diagnosed with PC and eligible for AS are sent questionnaires before they have made a decision regarding treatment. These men then are followed, independent of treatment choice. This design will clarify how levels of anxiety and distress influence treatment decisions. Special attention should be paid to patients who start on AS at a moment they are in good physical condition and who due to comorbidity during follow-up are no longer candidates for radical treatment, and in whom progression of the prostate tumor is seen. In those men, the window of curative therapy has been missed due to patient-specific factors, a situation that may have particular negative psychological and physical effects.

Secondly, a randomized study design is indicated. A quality of life study within a trial randomizing for treatment option, such as the ProtecT study, is indicated for this purpose. Besides studying anxiety and distress issues, these studies should also focus on urinary, sexual, and bowel domains. The effects of AS when compared to radical treatment on patients' quality of life are supposed to include a favorable effect on urinary, sexual, and bowel domains and a potential unfavorable effect on anxiety and distress levels. Although the aim of AS is to avoid side effects of radical treatment, the evidence for this difference in favor of AS is limited. Expectant management may theoretically even have an unfavorable effect on physical domains. Sexual, bowel, and urinary function scores have been found to decrease more than expected from the aging process alone. Although found in a watchful waiting setting, it can be hypothesized that this decrease also occurs during AS. The delay between diagnosis and treatment due to AS may not compromise mortality outcomes, but may close off opportunities to perform health-related quality of life-preserving interventions such as nerve-sparing radical prostatectomy. This would result in a worsening of the urinary, sexual, and bowel domains of patients who start on AS and need active therapy later.

Thirdly, qualitative studies are necessary. As only a limited number of men with low risk PC who are suitable for expectant management actually choose AS, qualitative studies may clarify underlying reasons for a specific treatment choice. The values on the potential advantages and disadvantages of AS may differ between patients and affect treatment decisions. If it is known what the main reasons are for choosing a specific treatment, adequately fitted decision support may be provided. Qualitative studies of men who switch to radical therapy due to non-medical reasons may identify the motives of these men. If it is known why men switch to radical treatment due to non-medical reasons, these can be anticipated during follow-up with interventional strategies.

It is interesting to note that in the comments section of the questionnaire that was used in the current study, remarkably many men responded positively to filling in an extensive questionnaire. They especially appreciated the fact that the less-often discussed quality of life aspects of their disease were also investigated.

Written by Roderick C.N. van den Bergh MD, Marie-Louise Essink-Bot MD PhD, Monique J. Roobol MSc PhD, Tineke Wolters MD, Fritz H. Schröder MD PhD, Chris H. Bangma MD PhD, and Ewout W. Steyerberg MSc PhD, as part of Beyond the Abstract on UroToday.com

1: Department of Urology, Erasmus Medical Center, Rotterdam, The Netherlands
2: Institute of Social Medicine, Academic Medical Center, Amsterdam, The Netherlands
3: Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands

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