Originally published 2/16/2017
“Limited attention has been given to the psychological impact of primary treatments in patients with prostate cancer.”[i] We want to update our original post (below) about dementia/cognitive decline in relation to radical prostatectomy, by broadening it out to psychological distress generally related to prostate cancer treatment. Two critical reviews were recently published that address this:
a) Maggi, et al. (2019)[ii] suggest that the major conventional treatments (prostatectomy, radiation and Active Surveillance) are well-tolerated in terms of post treatment anxiety and depression. However, “A mutual influence between functional and psychological modifications induced by treatments has been demonstrated.” By functional modifications, they are referring to the urinary, sexual and bowel after effects that can occur, especially with surgery and radiation. When post-treatment incontinence, erectile dysfunction and bowel problems occur, they “induce psychological distress worsening.” The authors recommend that doctors discuss with patients the functional and psychological aspects of each treatment before making a decision. Patients might wish to know how functional and psychological aspects may differently be influenced by treatment choice.
b) Yiannopoulou, et al. (2020)[iii] note that “Psychological morbidity as well as cognitive impairment are increasingly reported in prostate cancer (PCa) patients.” Therefore, they reviewed published literature on cognitive impairment and emotional burdens associated with each treatment: psychological distress, anxiety, depression, cognitive decline or dementia. As in the Maggi paper, most studies found that the three major treatments are well-tolerated with regard to psychological modifications. “However, many of these patients may require additional emotional support.” There were also findings that “androgen deprivation therapy may be associated with depression, while controversy surrounding the association between cognitive dysfunction, dementia and androgen deprivation therapy remains ambivalent.” In short, emotional distress and cognitive decline may accompany every PCa treatment option to different degrees, say the authors. Again, they recommend that patients and doctors discuss accurate information and manage expectations before treatment decisions. “There is also a need to develop well-targeted psychological and neurological interventions that could help those experiencing ongoing post-treatment difficulties.”
Some PCa patients are more prone to detrimental after effects of treatment, especially those who are frail at the time of therapy. Rosiello, et al. note, “On average, every seventh RP patient is frail and that proportion is on the rise. Frail individuals are at higher risk of adverse short-term postoperative outcomes, that cannot be predicted by other risk factors, such as obesity or comorbidities.”[iv] Thus, while much attention has been paid to physical and functional side effect risks of treatment, the less tangible but no less distressing psychological, cognitive and emotional pain that burdens many post-treatment PCa patients, especially those more vulnerable, should be of equal concern to physicians and patients.
Prostate cancer is a slow-growing disease associated with aging, though younger men may develop more aggressive forms. Another process also associated with aging is dementia, which means declining mental and cognitive function. The incidence of both conditions begins to increase from age 65 onward.
The most common treatment recommended for men with low-to-intermediate risk prostate cancer is complete surgical prostate removal, or radical prostatectomy (RP). As with many cancers, the idea of being “cured” by removing the affected organ has a certain psychological reassurance: “Don’t worry, we can get it all out and you never have to think about it again.” The problem is that RP is major surgery, which can include pain, inflammation, numerous medications, psychological stress, and the aftereffects of anesthesia. In other words, surgery is traumatic on the mind and the body, even though it is being done to save life. There is longstanding evidence that surgery and recovery are especially hard on people whose mental function has begun to decline. On the other hand, a 65-year old man who is in otherwise good health may have early signs of declining mental function that have not yet been recognized. One author wrote, “Studies show as many as 81% of patients who meet the criteria for dementia have never had a formal diagnosis, and families may overlook symptoms as just natural age-related memory loss. Patients with dementia are at higher risk for a complication known as postoperative delirium, and are more likely to have worse surgical outcomes, longer hospital stays, functional declines and death.”[i]
New guidelines strongly recommend that every person over age 65 be evaluated for mental fitness. This is not only to assess that the patient understands and agrees to the risks involved with surgery, but also to ensure that he is able to cooperate and participate fully in his recovery. In some cases, the effects of surgery can actually accelerate mental deterioration. Post-surgery patients who are forgetful or prone to confusion may skip or bungle important care instructions. For example, after RP improper catheter care can lead to serious complications at home. A standard, easy to administer mental evaluation can help doctors and family members anticipate how well a patient will be able to participate in his follow-up protocol.
Early signs of dementia
As people age, a certain amount of mental fuzziness is expected. There is often a very fine line between being a little “batty” and manifesting senile dementia. Unless symptoms are frequent or aggravated, it is easy to excuse away forgetfulness or fogginess as the result of stress, fatigue, etc. The early warning signs of dementia include:
- Changes in short-term memory
- Difficulty finding the right words
- Mood changes
- Listlessness (lack of interest in normal activities)
- Difficulty completing normal tasks
- Decline in sense of direction
- Repeating questions or statements
- Difficulty following storylines
- Becoming less adaptable to change
As hospitals embrace evolving standards of care, it is to be hoped that radical prostatectomy is recognized as “medically traumatic” as much as heart or abdominal surgery. Even robotic assisted RP is not a walk in the park; it involves major anesthesia, physical trauma to the urethra and neurovascular bundles, and going home with a catheter. The practice of cognitive evaluation before surgery should be extended to RP patients. And patients should be informed before RP that, as with any surgery, the after effects may include some impact – however temporary – on mental function.
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] Maggi M, Gentilucci A, Salciccia S, Gatto A et al. Psychological impact of different primary treatments for prostate cancer: A critical analysis. Andrologia. 2019 Feb;51(1):e13157.
[iii] Yiannopoulou KG, Anastasiou AI, Kontoangelos K et al. Cognitive and Psychological Impacts of Different Treatment Options for Prostate Cancer: A Critical Analysis. Curr Urol. 2020 Dec;14(4):169-177
[iv] Rosiello, G., Palumbo, C., Knipper, S. et al. Preoperative frailty predicts adverse short-term postoperative outcomes in patients treated with radical prostatectomy. Prostate Cancer Prostatic Dis 23, 573–580 (2020).
[v] Landro, Laura. “A Mental Test Before Surgery.” Wall Street Journal, Nov. 28, 2016. http://www.wsj.com/articles/a-mental-test-before-surgery-1480352395