Originally published 2/22/2017
We believe this is one of our most important blog updates because it both addresses anxiety associated with PCa diagnosis, and it presents scientific evidence that anxiety itself may actually promote tumor growth.
First, a 2021 paper (Sarchi, et al.) describes the psychological anxiety and depression many patients feel when they are waiting for their biopsy results. Most men are already stressed just at the mere prospect of a needle biopsy. But then comes the period of not knowing while dread builds. Based on a validated questionnaire administered after a biopsy but before results were known, 41% of patients suffered distress, with anxiety as the main component. The authors note that studies have not given psychological distress the recognition it deserves; anxiety is a reality that has been “under-evaluated.”[i]
Second, and perhaps even more significant, is the biochemical role that anxiety may play in actually making a man’s PCa worse! This insight comes from a 2021 laboratory study (Bellinger, et al.) The research team worked with mice ranging in age from young to old. All mice were inoculated with prostate cancer cells that quickly began to develop into tumors. Meanwhile, the mice were isolated and restrained for 2 hours daily in order to create stressful conditions resulting in measurable levels of stress hormones in the blood (norepinephrine and corticosterone). These are the same hormones released in our own bodies when anxiety activates the fight-or-flight response. After two weeks, the tumor-bearing mice were put through a 30-minute maze test to observe their behavior for signs of psychological distress. The team’s findings are noteworthy:
- The tumor-bearing mice demonstrated anxiety-like behavior, including reduced activity
- The old mice manifested more distress signals than the young mice
- Despite similar genomic expression of tumor growth factors in all mice, regardless of age, the older mice developed larger tumors
- Biochemically, the immune systems of the old mice were less effective against tumor activity than in the young mice.
The authors wrote, “Prostate cancer (PCa) prevalence is higher in older men,” and “… poorer coping with psychosocial stressors effect prognosis.” They conclude that stress-triggered anxiety “… interacts to affect PCa outcomes by interfering with neural-immune mechanisms and affecting behavioral responses.”[ii] In other words, since PCa generally affects older men, the anxiety may actually drive inflammatory biochemical factors that accelerate tumor growth.
To return to the idea of increased anxiety while waiting for biopsy results, the Bellinger study raised the question whether this can make an impact, however small, on the prognosis for men who already have PCa but don’t yet know it. It also implies that if the biopsy results come back positive, raising anxiety yet another notch, the patient’s internal biochemistry may now further aggravate tumor activity! At our Center, we believe we help reduce each patient’s anxiety by a) determining if a biopsy is even necessary, thanks to multiparametric MRI tumor profiling, and b) if so, providing a real-time, MRI-guided targeted biopsy using minimal needles. while gaining maximum diagnostic accuracy. Of course, it’s always been important to us to care for each patient at all levels, including his peace of mind, because it’s simply the right way to do medicine. Now, thanks to the Bellinger study, we realize that it’s not just so patients feel better psychologically by lowering anxiety, it’s also in the best interests of his PCa treatment outcome by helping keep the biochemical and genomic brakes on his disease.
A 65 year old healthy man, with no family history of prostate cancer, had a routine PSA of 4.7 ug/L. His digital rectal examination was normal. He became anxious and depressed. A transrectal ultrasound guided biopsy showed a single microfocus of prostatic intraepithelial neoplasia. He remains dispirited. A new disease entity was identified and termed “PSAdynia.”
In 1997, Dr. Laurence Klotz published an article about a new psychological epidemic. His work was early recognition that prostate cancer is not just a physical disease, but also a source of mental and emotional distress—enough to earn its own odd name of PSAdynia. Most healthy men age 55 or older are not concerned about prostate cancer (PCa) until something unusual brings it to their attention. Then, studies show that worry levels increase when a man goes for a PSA blood test, especially if he has a family history of prostate cancer, or at least one previous suspicious result. If this one proves unfavorable, the patient embarks on a journey with peaks of anxiety at certain points:
- Future PSA tests
- Going for a prostate biopsy
- Waiting for biopsy results
- Positive biopsy findings
- Making a treatment decision
- Going through treatment
- Post-treatment follow-up PSA tests
The PSA test launched a roller coaster of worry during the entire “clinical timeline of the disease.”[iii]
A patient’s level of anxiety can predict his treatment preference. A recent study of 1531 patients newly diagnosed with low risk PCa used a “Distress Thermometer” as a way to gauge each person’s anxiety level at the time of diagnosis and at the time of treatment decision. Those who were highly anxious at diagnosis were more likely to choose surgery over Active Surveillance (AS) even though they were qualified for AS. “Similarly, men who were more distressed around the time they made the treatment decision were likely to choose surgery over active surveillance, as well as surgery over radiation.”[iv] Why would they choose a treatment with risks of urinary and sexual side effects? They were seeking the peace of mind they thought surgery would bring. They were willing to go to rather drastic lengths – major surgery – rather than put themselves through what has been called “surveillance fatigue.” They may have learned that 20-50% of patients who seem qualified for AS are found to have higher grade disease on the 1st or 2nd biopsy.[v] This would naturally deter many from committing to AS.
Overcoming anxiety
The biggest source of stress in facing screening, biopsy, and treatment outcome is fear of the unknown.
What will the blood test show? What will the biopsy reveal? How painful will treatment be? What if I come out of it with ED? How do I know they got it all? The energy that goes into trying to anticipate and prepare for unknown bad possibilities sets up a cycle of fear that can pop in and disrupt normal activity. It’s like becoming a little boy who fears there’s a monster lurking under the bed, waiting to pounce.
On the other hand, a clear perception of the situation catalyzes and empowers a patient to get a handle on the true situation, make rational action plans, and implement them with confidence. The Sperling Prostate Center offers multiparametric MRI of the prostate as the most efficient way to dispel fear and anxiety. When you with your own eyes what’s going on in your body, you demystify the unknown and transform it into a manageable, treatable clinical condition with maximum chance for success.
Multiparametric MRI offers mind-easing benefits. If a doctor recommends a biopsy based on suspicious PSA, first have an mpMRI scan done. Our powerful 3T magnet features all the imaging sequences needed to distinguish prostate cancer from benign conditions such as BPH or inflammation, without the use of an endorectal coil. If a biopsy is necessary, we reduce the fear by using real-time MRI to direct a minimum number of needles into the suspected tumor with pinpoint accuracy. In fact, such a targeted biopsy delivers the most accurate diagnosis by sampling areas most likely to harbor aggressive cells. Another advantage is the ability to prioritize and plan treatments based on the known size, shape, location and aggression of the tumor. Finally, our expert staff and 3T magnet offer MRI-guided Focal Laser Ablation (FLA) for which our Center is the recognized pioneer and authority.
As experts in FLA, we provide a reassuring middle ground between whole gland surgery and radiation – with their risks of side effects – and AS with its chance of psychological fatigue and possible tumor growth and/or progression. Our patients who learn they are candidates for FLA almost immediately begin to experience relief from distress. Some of them have said that undergoing FLA is not much different from an in-and-out dental procedure with Novocain. Some have said that if they hadn’t been awake during the procedure, they could not have believed that they actually went through a cancer-killing treatment as they walked out the door and headed for dinner.
If you are worried about being at risk for prostate cancer, contact our Center to learn how we can help put your mind at rest. We are here to help you overcome your prostate cancer anxiety.
Download Our Free Ebook: “How to Manage Prostate Cancer Anxiety”
Don’t let anxiety over prostate cancer run you. Instead, learn how you can take charge and empower yourself to manage stress and boost positive treatment outcomes with our “first aid kit” of practical tips and tools.
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
[i] Sarchi L, Eissa A, Puliatti S, Amato M et al. Psychological distress among patients awaiting histopathologic results after prostate biopsy: An unaddressed concern. Urologia. 2021 Oct 6:3915603211049889.
[ii] Bellinger DL, Dulcich MS, Molinaro C, Gifford P et al. Psychosocial Stress and Age Influence Depression and Anxiety-Related Behavior, Drive Tumor Inflammatory Cytokines and Accelerate Prostate Cancer Growth in Mice. Front Oncol. 2021 Sep 16;11:703848.
[iii] Dale W, Bilir P, Han M, Meltzer D. The role of anxiety in prostate carcinoma. Cancer. 2005 Aug 1;104(3):467-478.
[iv] Leick, Ellie. “Patient Anxiety Influences Prostate Cancer Treatment Decisions.” Cure, Jan. 14, 2017. http://www.curetoday.com/articles/patient-anxiety-influences-prostate-cancer-treatment-decisions
[v] hoyke P, Loeb S. Active surveillance. Oncology Journal, Prostate Cancer. Jan. 15, 2017. http://www.cancernetwork.com/oncology-journal/active-surveillance-prostate-cancer
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
