Written by our own Richard Wassersug appearing in UroToday.com
BERKELEY, CA (UroToday.com) – Much has happened with the use of androgen deprivation to treat prostate cancer (PCa) patients since Charles Huggins first castrated a patient in order to alleviate the symptoms of advanced PCa. Back then, patients were generally elderly and symptomatic with either urethral obstruction or painful bone metastases. Now with the prostate-specific antigen (PSA) test, patients are being diagnosed at younger ages, before the cancer becomes symptomatic. What they must now endure is not so much the symptoms of cancer as the side effects of androgen deprivation therapy (ADT).
The Elliott, et al. 2010 paper is a consensus document about the supportive care needs of both PCa patients and their partners when patients begin ADT. The paper evolved from a workshop where some twenty oncology healthcare professionals and researchers reviewed the established strategies for managing the side effects of ADT.
There is voluminous literature addressing the physiological side effects of ADT. Although these are discussed in Elliott et al., we emphasize instead the psycho-social and sexual problems that come from androgen deprivation. Problems in these areas can be severe and substantially lower the quality of life (QoL) for patients and their partners, yet they are often understated and therefore under-treated. Patients often pursue ADT without being truly informed about the side-effects they may face.
As long ago as 1994, Kornblith et al.1 pointed out that the partners of patients who are androgen-deprived are often more distressed than the patients themselves. More recently Hagedoorn et al.2 (2008) confirmed that finding in a meta-analysis. This means that ADT not only produces iatrogenic problems for patients, but has epidemiological impacts on others. One of our paper’s strengths, we believe, is in the attention it gives to patients’ partners.
In our paper, we review a wealth of data showing that when ADT causes men to lose their libido, their partners often feel emotionally abandoned, which can lead to relational tension. The fact that males and females typically use different strategies to deal with stress can exacerbate the situation, particularly if one partner (usually female) needs to talk about their concerns while the other (usually male) prefers denial or avoidance as a psychological defense.
One could argue that an impact from ADT that extends beyond the patient is also beyond the scope and responsibility of urologists. However, ignoring the psychological challenges that ADT brings to the partners compromises the health and welfare of the patients themselves. A recent and relevant study (Kim et al. 2008) found that the psychological distress of the female partners predicts the ultimate health of male patients. To quote them, “women’s distress predict[s] men’s physical health, over and above the men’s distress…age, and cancer stage.”4 There are thus detrimental consequences for the patient if distress in the partner is left unattended. Clearly then, the health and welfare of the partners of PCa patients on ADT should be a concern of the prescribing physician.
The bottom line is that, if they want to provide the best medical care for their patients, physicians who put patients on ADT should provide support to both the patients and their partners. At the same time, we recognize that urologists are not typically trained to be marital or sex therapists. However, if they do not have psychological support programs within their own clinic, they should be making timely and appropriate referrals to mental health professionals or community-based organizations in the area to provide patient and partner support. Elliott et al. outlines various strategies that health care professionals in general can use to help couples deal with many of the psychological side effects of ADT including strategies for maintaining intimacy (both sexual and non-sexual) in the face of androgen deprivation.
To its credit, urology has taken to heart the need to treat erectile dysfunction (ED), acknowledging the psychological distress it can cause. It is sometimes mistakenly believed though that loss of libido completely eliminates concerns about loss of sexual intimacy and/or ED. However, there is more to sex than just erections, and there is more to intimacy than just sex. It is critical to appreciate that ADT’s side effects extend beyond the patient in multiple ways and those side effects cannot be managed at all if they go unrecognized and undiagnosed by physicians.
Patients who are sexually active when they begin ADT are likely to experience the most dramatic changes in their QoL upon androgen deprivation. A strong conclusion from Elliott et al. is that support should be offered, and offered preemptively, even if the patient or the couple does not perceive a need. Data collected by Walker and Robinson5 has shown that some couples find ways of remaining sexually active despite castrate levels of testosterone. A second study from our group (by Walker, Wassersug and Robinson, in prep.), suggests that patients and partners, who are fully informed at the time that ADT is prescribed about what to expect from the treatment—and provided then and there with strategies managing ADT’s side effects—fare better than couples provided with usual care.
As a last point, it may not be enough for a urologist to ask a couple, in passing, whether they think they might need psychological support to deal with the impact of ADT. In the surgeon’s office, a couple may elect to present themselves as a co-supportive team. If the patient says he is doing fine, his partner may then feel obliged to say the same. If the urologist asked them individually instead, he/she might find that one or both of the individuals needs additional support but were reluctant to admit that in front of their partner.
1. KornblithAB, Herr HW, Ofman US, Scher HI, Holland JC. Quality of life of patients with prostate cancer and their spouses. The value of a data-base in clinical care. Cancer 1994;73:2791-802
2. Hagedoorn M, Sanderman R, Bolks HN, Tuinstra J, Coyne JC. Distress in couples coping with cancer: A meta-analysis and critical review of role and gender effects. Psychol Bull 2008;134:1-30
3. Roesch SC, Adams L, Hines A, Palmores A, Vyas P, Tran C, Pekin S, Vaughn AA, Coping with prostate cancer: A meta-analytic review. J Behav Med 2005;8:281-93
4. Kim Y, kashy DA, Wllisch DK, Spillers RL, Kaw CK, Smith TG. Quality of life of couples dealing with cancer: Dyadic and individual adjustment among breast and prostate cancer survivors and their spousal caregivers. Ann Behav Med 2008;134:230-8
5. Walker LM, Robinson JW. A description of heterosexual couples’ sexual adjustment to androgen deprivation therapy for prostate cancer. Psyco-oncology. DOI: 10.1002/pon.1794. 11th July 2010
Corresponding author: Richard Wassersug, PhD
Department of Anatomy & Neurobiology, Sir Charles Tupper Medical Building
Halifax, Nova Scotia Canada B3H 1X5, CANADA
Richard Wassersug, PhD, Lauren M. Walker, MSc, John W. Robinson, PhD, David M. Latini, PhD, and Stacy Elliott, MD as part of Beyond the Abstract on UroToday.com. This initiative offers a method of publishing for the professional urology community. Authors are given an opportunity to expand on the circumstances, limitations etc… of their research by referencing the published abstract.
Androgen deprivation therapy for prostate cancer: Recommendations to improve patient and partner quality of life – Abstract
UroToday.com Prostate Cancer Section