Men who receive androgen deprivation therapy (ADT) following radical prostatectomy for prostate cancer (PCa) are at higher risk for depression, according to investigators.

Using data from the Danish Prostate Cancer Registry, Anne Sofie Friberg, MD, from the University Hospital of Copenhagen Rigshospitalet, Denmark, and colleagues conducted a retrospective review of 5570 men treated for PCa from 1998 to 2011. The team examined the effect of subsequent treatment with ADT or salvage radiation or both on the risk of depression after radical prostatectomy (RP). During 40,681 person-years of follow-up, 773 first events of depression occurred.

Men treated with ADT after surgery had a significant 1.8-fold increased risk of depression compared with those who received no subsequent treatment, after adjusting for age group at the time of surgery, year of surgery, income quintile, and cohabitation status, the investigators reported at the 34th Annual European Association of Urology Congress in Barcelona, Spain. Depression risk was increased 2.2-fold among men who received salvage radiation in addition to ADT. Salvage radiation without ADT did not significantly increase the risk of depression.

“Clinicians should thus be aware of depressive symptoms in patients with postsurgical relapse and subsequent treatment with ADT,” the authors concluded in a poster presentation.

The study also found that low income, comorbidities, living alone at PCa diagnosis, and earlier period of surgery were associated with an increased risk of depression.

Dr Friberg’s team noted that lower urinary tract symptoms (LUTS) and erectile dysfunction (ED) are associated with an increased risk of depressive symptoms,

Following RP, 25% to 50% of men experience erectile dysfunction (ED) and up to 80% report urinary incontinence, Dr Friberg’s team noted. ED and lower urinary tract symptoms are associated with the prevalence of depressive symptoms.

“Subsequent treatments may introduce further problems with urinary continence, bowel and sexual function on top of the psychological effect of experiencing failure upon surgery with curative intent,” the investigators concluded.

“Increased risk of depression among patients treated with ADT is an important issue,” said Grace Lu-Yao, PhD, MPH, associate director of population science at the Sidney Kimmel Cancer Center–Jefferson Health and vice-chair of population science in the Department of Medical Oncology at Thomas Jefferson University in Philadelphia. “ADT is widely used for the management of prostate cancer and is associated with many side effects such as hot flashes, fatigue, fractures, weight gain, and increased risk of cardiac adverse events.”

Data suggest depression can increase mortality in men with PCa.  Sandip M. Prasad, MD, from the Medical University of South Carolina in Charleston, and colleagues performed a population-based observational cohort study using SEER (Surveillance, Epidemiology, and End Results)-Medicare linked data of 41,275 men diagnosed from 2004 to 2007 with clinically localized PCa.2 The investigators identified 1894 men with a depressive disorder in the 24 months prior to their PCa diagnosis. Depressed men experienced worse overall survival across risk strata.

Treatment with ADT can adversely affect quality of life, and can affect a man’s self-image. “Given the impact of depression on mortality, morbidity, and the quality of life, it is important that a multi-disciplinary team approach be used to provide optimal prostate cancer care,” Dr Lu-Yao told Renal & Urology News.

Michelle B. Riba, MD, director of the PsychOncology Program at the University of Michigan Rogel Cancer Center in Ann Arbor, said the findings from the Danish researchers are intriguing although highly limited. A prospective is warranted, she said. “To really discuss depression, you have to measure depression and it would be done at baseline and at pivotal times,” Dr Riba said.

Distress issues need to be discussed with men who have PCa, said Dr Riba, past president of the American Psychiatric Association. Men who require ADT for PCa are faced with a unique set of circumstances that possibly contribute to high levels of distress. “The other part of this issue is that these individuals have sleep problems, libido issues, stress, and all those can be contributing factors for depression,” Dr. Riba said. “You need to screen at pivotal times, and that may not be in the first visit. You need to screen for distress and further problems with cognitive issues, sleep issues, and sexual issues.”

She chaired a National Comprehensive Cancer Network panel on distress in cancer patients and how best to treat it.3 According to the panel, distress management is a standard of quality cancer care and patients should expect it and ask for it from their cancer care team.

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References

  1. Friberg AS, Dalton SO, Larsen SB, et al. Risk of depression after radical prostatectomy – a nationwide registry-based study. Data presented at the 34th Annual European Association of Urology Congress in Barcelona, Spain. Poster 1171.
  2. Prasad SM, Eggener SE, Lipsitz SR, et al. Effect of depression on diagnosis, treatment, and mortality of men with clinically localized prostate cancer. J Clin Oncol. 2014;32:2471-2478.
  3. National Comprehensive Cancer Network. Distress.