Patients receiving ADT should be counseled to improve mental and emotional well-being

A new study published in the Journal of Urology® reports that prostate cancer patients treated with androgen deprivation therapy (ADT) experienced changes in mental and emotional well-being during treatment, although there was no meaningful decline in emotional quality of life two years after treatment.

Investigators at the University of California-San Francisco recommend counseling men about the potential adverse effects of ADT as well as the interventions to improve mental and emotional health such as exercise programs and diet.

Nearly 240,000 men were expected to be diagnosed with prostate cancer in the United States in 2013, with around 30,000 deaths. Treatment for prostate cancer is associated with significant physical side-effects. Some of these patients are likely to experience more adverse side-effects and complications from the treatment than from the cancer itself. Earlier studies have suggested that treatment may also affect mental and emotional health.

ADT, which suppresses the production of testosterone by either medical or surgical castration, remains the gold standard for treating advanced prostate cancer, either alone or with radiation therapy. Benefits include reduction of tumor burden, delayed cancer progression, and overall improvement in survival in some cases. However, ADT has a number of physical side-effects, including hot flashes, decreased libido, fatigue, decreased bone and muscle mass, increased total body fat content, and possible harmful cardiovascular effects.

Previous studies have reported cognitive and affective symptoms following ADT, particularly in the elderly. Symptoms include emotional upset (tearfulness, irritability, and anger), decreased motivation, hopelessness, and cognitive interruptions in attention, memory, and visual processing. Some studies have linked ADT use to depression, although it is not clear whether such effects are a direct consequence of ADT itself or perhaps associated with age, comorbidities, hot flashes, fatigue, and insomnia.

The current authors evaluated the effects of ADT on mental and emotional well-being in men diagnosed with localized prostate cancer using data from the CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor) registry, which consists of data from largely community-based practices across the United States. Over 3,000 men completed a pretreatment and at least one posttreatment quality of life assessment checklist.

The authors focused on men newly diagnosed with localized (non-metastatic) prostate cancer in 1995-2011 and treated with radical prostatectomy, brachytherapy, radiation therapy, or primary androgen deprivation therapy (PADT). Of men included in the study 75% were treated with local therapy, 20% combination treatment, and five percent PADT. Among men in the PADT group, 84% were treated with luteinizing hormone-releasing hormone agonist monotherapy and 16% received combined androgen blockade.

Approximately 36% of patients reported some type of mental impairment at pretreatment evaluation, including depression, insomnia, confusion, poor concentration, sleep disturbances, nervousness, or poor memory. There were no overall differences in rates of mental health symptoms at diagnosis among treatment groups, although 18% of the PADT group reported poorer memory compared to 12% in the local group and 15% in the combination group.

Analysis demonstrated that exposure to ADT was associated with significant changes in mental and emotional well-being but did not result in clinically meaningful declines at 24 months. “These results could be related to men in the ADT group adapting to their symptoms over time, thus reporting improves scores,” explains lead investigator Clint Cary, MD, MPH, of the Department of Urology at the University of California-San Francisco.

The most pronounced effect of ADT was on vitality. “This result corroborates other studies documenting fatigue among the most commonly reported side effects of ADT,” says Cary. “It is not clear though whether the fatigue is a direct effect of ADT itself or a consequence of the physical side effects of ADT, such as sleep disturbances or hot flashes.”

Cary recommends that patients are counseled on possible ADT-related quality of life changes, as well as ways to minimize these changes before treatment for prostate cancer. “All patients should be well informed about the potential adverse effects of ADT, and interventions to improve mental and emotional health such as exercise programs and dietary/lifestyles changes could be of particular importance,” he concludes.