In men with prostate cancer, do psychological and cognitive interventions improve psychological adjustment?
No studies specifically addressed this question for men with advanced prostate cancer, although one low-quality study recruited men on hormonal manipulation but did not assess disease stage. Only one medium-quality study was identified. While it is reasonable to assume the general approaches utilised in studies with men with localised disease are likely to be acceptable to men with metastatic disease, the problems faced by these two groups of men differ. For example, the side-effect profile of radical prostatectomy differs markedly to that of hormonal ablation; and men who have incurable disease face a different psychological challenge to men receiving treatment with curative intent, as indeed do their spouses. However, while caution should be applied in generalising the outcomes of these studies to men with metastatic prostate cancer, the beneficial effects and clinical importance of psychosocial intervention for all cancer patients and their families is now well established through clinical practice guidelines both in Australia and North America. 
Studies differed in the type of intervention, patient group and outcome measured, nevertheless, four low quality studies were identified that utilised a primarily educational approach to intervention, and of these three investigated men receiving radiation therapy for localised prostate cancer. Johnson et al undertook a randomised controlled trial assessing the effectiveness of an education audiotape about radiation therapy with 84 men scheduled to receive this treatment for localised prostate cancer. Compared with men who received general social contact from research staff, over the course of treatment men who received the audiotape experienced less disruption in recreation and pastime activities (p<0.02), but no differences were found for mood. In a subsequent study Johnson recruited 62 men who were undergoing radiation therapy for prostate cancer and randomised them to one of three different types of audio-taped messages: (i) coping and self-care advice; (ii) treatment-focussed patient education or (iii) non-focussed information (control group). For mood, men who were low in optimism benefited most from treatment-focussed patient education (p<0.05).
Kim et al randomised 152 men receiving radiation therapy for localised prostate cancer to a sensory informational instruction audiotape versus general self-care instruction audiotapes. The sensory informational tape included descriptions of the physical environment during treatment such as sounds heard, the specific side effects expected and when they were most likely to occur. After their last radiotherapy treatment, men who received the sensory informational audiotape reported less fatigue (p<0.06) and better sleep (p<0.03) than men who received general self-care instruction. No differences were observed for mood. In contrast to the three previous studies, Templeton et al recruited 55 men on hormonal manipulation in a randomised controlled trial of an evidence-based education package supplemented with verbal teaching by a urology nurse. Men who received the education package experienced greater improvements in quality of life by comparison to controls at one month post-intervention. It was not possible to ascertain the size of the effect from the data presented.
Lepore and Helgeson utilised a broader intervention approach that combined education with peer support in a low-quality randomised controlled trial with 24 men who had recently completed treatment for localised prostate cancer. The study compared six weekly lectures plus peer discussion jointly facilitated by a nurse and psychologist versus a control group. Two weeks after the intervention, men in the intervention group experienced greater improvements in mental health subscale of the mental functioning domain of the SF36 (p<0.05); less distress about cancer-related thoughts (p<0.05); less conflict with their partners (p<0.01) and family/friends (p<0.05); and greater self-efficacy (p<0.05). In a subsequent larger study of medium quality, Lepore et al and Helgeson et al assessed the effectiveness of group education versus group education plus peer discussion versus control in a randomised controlled trial with 250 men with mixed-stage prostate cancer. In the twelve month follow-up period men who received group education plus peer discussion were more likely to maintain steady employment (p<0.05) compared with the other conditions; and experienced less sexual bother compared with controls. Men with less education, lower self esteem, lower prostate self efficacy, and higher depressive symptoms benefited most.
Scura et al randomised 17 men newly diagnosed with prostate cancer to nurse-delivered telephone support over a 12-month period supplemented with written materials versus written material only. The study was low quality and no significant effects were found. Qualitative data from participants suggested that telephone nurse support was acceptable to these men.
Penedo et alundertook a low-quality study where 92 men treated previously for localised prostate cancer were randomised to either a ten-week group-based cognitive behavioural intervention or a halfday educational seminar. Men who received the ten-week intervention reported post-intervention improvements in quality of life (Functional Assessment of Cancer Therapy–General Module or FACT-G) (p<0.03). In a subsequent study, Penedo et al repeated this trial design with 191 men treated previously for localised prostate cancer. This study was also of low quality. Men who received the cognitive behavioural intervention reported post-intervention improvements in benefit finding (p<0.01) and quality of life (p<0.01). No improvements were observed for men who attended the halfday seminar. Effect sizes were small.
Giesler et a randomised 99 men newly diagnosed with prostate cancer along with their partners to receive a nurse-driven computer-assisted intervention or standard care. The intervention focussed on symptom management and psycho-education and was tailored to men who had received treatment for localised disease. Men were followed for twelve months. At that time men in the intervention group reported less cancer worry (p<0.03) and fewer sexual limitations (p<0.02) compared with men who received standard care.
By contrast, peer support for people with cancer is seldom evaluated in gold-standard intervention designs. This may be due in part to this source of support emerging from a community lay setting rather than as a professionally driven care model. Poole at al in a low-quality study compared 142 men in prostate support groups to 92 non-attenders and found no difference in quality of life between the two groups of men. Steginga et al undertook a survey of 1224 men previously treated for prostate cancer who were members of prostate cancer support groups affiliated with the Prostate Cancer Foundation of Australia. This level IV study found high levels of satisfaction with the support provided by these groups, with no differences in satisfaction between professionally- or peer-led groups. The strongest predictor of satisfaction with support was the man’s perception that his clinician was supportive of the group (p<0.01). Men with more pain (p=0.01), a poorer quality of life and higher distress (p<0.01) were less positive in their endorsement of the groups. In the one peer-support study identified that utilised a randomised controlled design, Weber et al recruited 30 men who had received a radical prostatectomy to compare a series of eight weekly meetings with a supportive peer with usual care. Peers were long-term survivors of prostate cancer who had also been treated with radical prostatectomy. At four weeks, men in the intervention group reported less depression (p<0.02). However this effect was not evident at eight weeks. At eight weeks men who received the peer support reported less sexual bother (p=0.01).
In summary, research into psychosocial interventions for men with prostate cancer is still developing.Despite this, there is good evidence that such care produces a range of positive outcomes for men and work elsewhere underscores the importance of psychosocial support being included in care pathways.  It can be argued that men with advanced disease carry a higher individual disease burden than do men with localised disease. The lack of research activity targeting these men’s needs should be addressed by non-government and government cancer control agencies as a priority.
Evidence summary and recommendations
|There is good evidence that a range of intervention approaches have positive effects on adjustment outcomes such as quality of life, benefit finding, cancer worry, sleep, fatigue, sexual bother, work role, recreational activities, health behaviours and physical functioning. Men who are more depressed, have lower levels of education, have lower self esteem and self-efficacy may benefit more from intervention. Effective approaches include group-based cognitive behavioural interventions, nurse-delivered education and support, sensory patient education, one-to-one peer support and group education with peer discussion. Most studies are on men with localised disease.||II||, , , , , , , , , , , |
Men with advanced prostate cancer should be offered psychosocial interventions to enhance their adjustment.
Effective approaches include group-based cognitive behavioural interventions, nurse delivered education and support, sensory patient education, one-to-one peer support and group education and discussion (support groups).
However, psychosocial intervention research for prostate cancer has predominantly been undertaken with men with localised disease. Research addressing the unique psychosocial needs of men with advanced disease is needed.
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