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The psychosocial impact of prostate cancer on patients and their partners

Jeremy W Couper, Sidney Bloch, Anthony Love, Gillian Duchesne, Michelle Macvean and David W Kissane
Med J Aust 2006; 185 (8): 428-432. || doi: 10.5694/j.1326-5377.2006.tb00640.x
Published online: 16 October 2006

Prostate cancer (PCA) is the most common non-skin cancer in men (over 11 000 cases in Australia in 2001), and, with a lifetime risk of 1 in 10 men, it is the second leading cause of death from cancer in men.1 Despite these statistics, there have been very few studies of the psychosocial impact on the patient and his family of PCA and its treatment, and limited research on psychosocial interventions to promote adaptive coping.2-4

Clearly, the negative psychosocial effects of this cancer represent a major health care issue. As with breast cancer, research on men’s reactions to the diagnosis and treatment of this intensely personal condition — without involving partners — risks overlooking a key relational dimension.5 As the side effects of mastectomy (disfigurement and scarring) and hormone therapy and chemotherapy (hair loss) can challenge a woman’s self-image as mother, wife and sexual partner, similarly the side effects of prostatectomy (impotence and urinary incontinence), hormone therapy (feminisation and loss of libido) and external beam radiotherapy (bowel disturbance) can shake a man’s view of himself in his various roles.

A review of the limited number of reports on the psychosocial impact of PCA on patient and partner demonstrates a pressing need for integrated research to establish the psychological needs of couples as they grapple with decisions about treatment and their consequences.6 A prospective observational study incorporating different stages of the patient and partner’s journey is needed to guide the development of a focused, coherent psychosocial intervention, which can be tested and, if effective, woven into routine clinical care to improve psychosocial adjustment. Here, we report the findings of such a study and recommend the development of a program of counselling.

Methods
Recruitment

Our multisite study was designed to elicit data from two groups of couples facing PCA: (i) couples where the patient has just learnt he has localised (potentially curable) PCA; and (ii) couples where the patient has been told that he has metastatic (incurable) PCA. Consecutive clinic attendees who met study criteria (Box 1) were recruited between March 2002 and March 2005 by oncologists and urologists working in public hospitals and private practices in metropolitan Melbourne. (The patients were also recruits for a larger, patient only, 18-month longitudinal study.) Interviews took place before the launch of definitive treatments, such as prostatectomy or radiotherapy, or soon after.

Measures

The anxiety and depression modules of the Composite International Diagnostic Interview (CIDI)7 were administered to patients and partners. The CIDI, which derives psychiatric diagnoses according to the Diagnostic and statistical manual of mental disorders 4th edition (DSM-IV),8 has confirmed reliability and validity.7 The CIDI computer software takes account of symptoms arising from physical illness (including cancer and its treatments) to ensure they are not incorrectly ascribed to depression or anxiety diagnoses.7 The CIDI has recency codes that separate past psychiatric disorders from current disorders. For our study, only DSM-IV diagnoses over the 12 months before the interview are reported (12-month prevalence rates).

The Brief Symptom Inventory (BSI)9 is a 53-item self-report psychological symptom scale. It yields a global rating of psychological status called the Global Severity Index (GSI), comprising a grand total of scores divided by the number of valid items. The BSI also provides subscale scores for depression and for anxiety. In each case, a higher score denotes greater psychological distress. The BSI’s ability to discriminate clinically distressed from non-distressed samples has been well established, using structured psychiatric interviews as benchmarks.9 Extensively used in psycho-oncology research, the BSI is sensitive to changes in psychological adjustment and to psychopathology.10 Specific threshold scores of psychiatric “caseness” (where an individual’s levels of symptoms are deemed to correspond to a diagnosable psychiatric disorder) have been established for both men and women.11

The Dyadic Adjustment Scale (DAS)12 is a six-item self-report scale widely used in the context of families experiencing cancer.13 The DAS is designed to measure the quality and level of satisfaction of romantic relationships in cohabiting couples.14 The DAS yields the DAS Full Scale score, comprising the sum of the recoded item scores; a higher score represents greater marital satisfaction (maximum 30).

Results
Psychiatric diagnoses in patients and partners at Time 1

The rates of DSM-IV anxiety and depression for 90 patients and 103 partners at Time 1 are given in Box 4. The partners had rates of major depression more than twice the normal rate for the Australian (Victorian) community;17 patient rates were also higher than the community rate but proportionally not as elevated. A similar pattern emerged for rates of generalised anxiety disorder and other anxiety disorders in patients and partners.

Comparing distress in patients and partners at Time 1

Overall mean psychological distress (GSI) in partners at Time 1 was almost twice as high as in patients (Box 5). Similarly, depressive symptoms and anxiety symptoms at Time 1 (BSI Depression and Anxiety Subscales) were substantially higher in partners compared with patients.

Change in rates of psychiatric caseness in patients and partners at Time 2

At Time 1, 15% of partners (n = 102) exceeded the female GSI threshold for psychiatric caseness;11 at Time 2, 14% of partners (n = 89) met criteria for psychiatric caseness. Ten per cent of patients (n = 103) met criteria for psychiatric caseness at Time 1, but this went up to 15% of patients (n = 82) at Time 2 (Box 7).

Discussion

To our knowledge, this is the first prospective, observational study of couples facing PCA using a sample of this size and gathering information from both patients and partners concurrently.6 Our findings of a change in the psychological status of both partners and patients over a period of 6 months, and of different patterns of change in the two groups, are intriguing. The partners were more distressed at the time of diagnosis, and less so 6 months later; the converse occurred in the patients. With respect to marital satisfaction, there were again different patterns, with patients’ satisfaction levels remaining constant over 6 months but partners’ satisfaction declining.

The diminution in distress in partners supports findings from a previous study that the anxiety of partners of patients with advanced PCA decreased over a period of 6 months.18 That study is the only prospective one, other than our own, that includes partners. The worsening marital satisfaction we identified in partners agrees with the findings of a cross-sectional study of 164 partners, a mean of 4.3 years after initiation of PCA treatment; most reported dissatisfaction with their relationship.19

The elevated rates of diagnosable (DSM-IV) depression and anxiety in the partners we studied, compared with both a community sample of women and the patients diagnosed with cancer, also agree with previous research involving cross-sectional measurement of distress in patients with PCA and their partners.20,21 Contradictory findings in one study22 — lower distress in partners than patients — may be explained by sampling (patients were in remission with no metastatic disease and no hormone therapy and were interviewed many months after completing successful therapy). In the former two studies,20,21 a broader range of patient stages and treatment modalities were sampled.

Our findings suggest that women whose partners are facing a new (or renewed) threat from PCA are initially vulnerable to distress, but their level of distress diminishes somewhat in succeeding months. Paradoxically, it appears they may become increasingly disenchanted with their marital relationship over the same period. Meanwhile, patients appear relatively unaffected psychologically at the outset, but become more distressed over time (although their marital satisfaction appears to remain unchanged).

The prevalence of GSI psychiatric caseness in partners diminished over 6 months. It is possible that this finding is a result of higher attrition of psychiatrically unwell partners, rather than the resolution of disorders. In nine of the 10 instances of partners dropping out of the study, the patient they partnered died during the 6-month period. Thus, this group may have represented partners facing greater psychological challenges than those who remained at Time 2. Patient GSI caseness, by contrast, was lower than that in partners initially, but 6 months later reached the same elevated level found in partners at Time 1.

Comparisons of mean BSI scores between patients and partners (or raw rates of DSM-IV diagnoses) need to be made with caution in the light of the widely established epidemiological finding that women report anxiety and depression symptoms at higher rates than men.23 However, rates of BSI caseness should not be affected by this phenomenon, since separate caseness thresholds have been derived from normative samples for men and women.11

We had expected that the stage of PCA (localised or metastatic) would affect the level of psychological distress reported by patients and partners. We did not find this at the time of diagnosis or 6 months later. The dearth of longitudinal psychosocial research comparing stages of PCA makes it difficult to draw on other work to explain this. Our findings suggest that the psychosocial impact in the two events is similar, but it is possible that our study lacked the power to detect a small difference or that the differences emerge after more than 6 months.

A potential limitation of our study is that recruiting participants via clinics may introduce bias, as not every patient diagnosed with PCA in the community has an equal chance of being recruited into the study. However, it is the only practical way to gain timely access to a sufficient number of patients with PCA at a particular stage of the disease, and gives us access to patients and partners in a real world clinical setting.

Studies that obtain their sample from cancer registries, such as that of Valdimarsdottir et al,24 may enjoy reduced selection bias, but the inevitable delays in registration into databases preclude researcher access to patients (and partners) at the time they are dealing psychologically with the diagnosis and its implications. Studies that seek recruits through advertisements, attendees at information sessions, or self-help group memberships, such as that of Ko et al,25 face considerable potential selection bias as participants are self-selected. Recruitment of consecutive clinic attendees is a favoured form of sampling in psycho-oncology research.5,6,10

Although attrition was a feature of our study, the levels of participation and retention achieved suggest that couples facing PCA represent a motivated and accessible group for psychosocial assessment and, in all likelihood, counselling. The perseverance shown by most of the patients and partners, especially in answering highly personal questions about themselves and their partner at a demanding time, suggests that couples facing PCA construe the situation as a crucial challenge in their lives together.

Our findings suggest the value of a couple-focused counselling program, similar to that devised and applied for couples facing breast cancer.26 A preventive intervention of this type could help the growing number of middle-aged and older men affected by PCA and their partners to, as much as possible, enjoy productive lives together. Such an intervention could buttress the most salient form of social support both patient and partner will need — each other’s — in the months and years that follow the diagnosis of this common cancer.

Received 16 June 2006, accepted 31 August 2006

  • Jeremy W Couper1
  • Sidney Bloch1
  • Anthony Love2
  • Gillian Duchesne3
  • Michelle Macvean4
  • David W Kissane5

  • 1 Department of Psychiatry, University of Melbourne, Melbourne, VIC.
  • 2 School of Psychological Science, La Trobe University, Melbourne, VIC.
  • 3 Peter MacCallum Cancer Centre, Melbourne, VIC.
  • 4 The Cancer Council Victoria, Melbourne, VIC.
  • 5 Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Centre, New York, NY, USA.


Correspondence: couperjw@svhm.org.au

Acknowledgements: 

Our study was supported by grants from the National Health and Medical Research Council and the Bethlehem Griffiths Research Foundation. These funding bodies had no role in study design, data collection, analysis, interpretation or writing of this article. We would like to thank all of the patients and their partners who kindly participated in this study and the clinicians who recruited them, namely: David Angus, Adam Broad, Alex Cato, Michael Chamberlain, Martin Cherk, David Clarke, Laurence Cleeve, Owen Cole, Niall Corcoran, Anthony Costello, Mike Dally, Ian Davis, Anthony Dowling, Gillian Duchesne, Farshad Foroudi, Mark Frydenberg, Jeremy Goad, Bronwyn Matheson, Jeremy Millar, Robin Murray, Justin Peters, Mark Rosenthal, Andrew See, Jeremy Shapiro, Ross Snow, Jo Stewart, and Keen Hun Tai.

Competing interests:

None identified.

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