There are a number of therapeutic psychological approaches that have been found to be effective for men with prostate cancer, that are likely to be broadly applicable to other genitourinary cancers. Lepore trialled a group based psycho-education, plus peer support program for men with prostate cancer, finding that men in the intervention were more likely to maintain steady employment and experience less sexual bother.9 Men who initially had lower levels of education, lower self-esteem, lower self-efficacy and higher depression, benefitted more. In a recent randomised control trial with 159 men undergoing radical prostatectomy for prostate cancer, Parker et al found that a pre-surgical stress management intervention improved mood and physical functioning, although the effects were modest and prostate specific quality of life was not improved.10 A group based cognitive behavioural stress management with men previously treated surgically for prostate cancer, found improvements in sexual functioning, with the effect moderated by interpersonal sensitivity,11 as well as increased benefit finding and quality of life,12 with the latter mediated by the development of stress management skills.
More recently the Australian Cancer Network has released draft Clinical Practice Guidelines for Advanced Prostate Cancer, where an in-depth systematic review of the evidence for psychosocial intervention for men with advanced prostate cancer was undertaken.13 This review was widened to include men with prostate cancer of any stage, due to the paucity of research on men with advanced disease. A number of limitations in the research to date were noted, including the use of small convenience samples, cross-sectional designs, limited follow-up and a general failure to adhere to Consolidated Standards of Reporting Trials guidelines.14 In addition, the economic benefits of interventions have also generally failed to be assessed. This may, at least in part, be hampering efforts to have these care models introduced into standard practice within cash strapped health care systems.
Case for peer support
It is notable that the one support model that has been widely introduced in Australia for men with prostate cancer is peer support. To date there are 92 prostate cancer support groups that are affiliated nationally with the Prostate Cancer Foundation of Australia, with individual membership approaching 10,000. Peer support models do not typically lend themselves to control designs due to their community based nature, with one ongoing randomised controlled study a recent exception.15 However, despite the lack of high level evidence, the growth of these groups across the country and elsewhere internationally speaks to their face validity and suggests that health professionals and researchers working in this area should consider ways to incorporate peer support into care models and research designs.
Internet: are we there yet?
The internet is a medium that offers opportunities for delivering new types of psychosocial interventions and social support. To date, internet based peer support groups and mailing lists have been the most common type of intervention and have been reported to provide both informational and emotional support. Internet use has been associated with improving self-efficacy variables (confidence in actively participating in treatment decisions, asking physicians questions and sharing feelings of concern) in one large, cross-sectional study. Preferred features of cancer support websites are that they provide: a range of supports; cancer related information;16 ability to chat to others with cancer; to ask questions of a clinician17 and; in the case of young adult users, offer some sort of game.18 Even after a decade of expanding internet use, internet support is not sought as commonly by some groups as others. Less frequent users include ethnic minorities, males and lower socio-economic status men and women.19 Women may use internet support in different ways to men. A content analysis of messages posted to a breast cancer and a prostate cancer mailing list found that messages posted by breast cancer patients were more frequent and emotion focused. Those from prostate cancer patients were more cancer information focused and less likely to seek emotional support.20 There are surprisingly few trials of web based time limited psychosocial interventions, despite the many advantages (including limited cost) of this type of intervention, and its emerging success in other health areas. The internet can be particularly useful to provide support for those who are time poor, geographically isolated or disinclined to face to face interactions. We are only at the beginning of the exploration of possibilities using this medium.
A ‘one size fits all’ approach to education and support for cancer patients cannot address the known inequalities in cancer outcomes. We need more precise quantitative evidence of where the greatest needs are, not only from the perspective of the individual patient, but also the characteristics and services of the areas in which they live and then evidence-based investigations on how best to meet these needs. This applies not only to people with genitourinary cancer, but to all cancer types. Finally, cross-disciplinary collaboration between clinicians, epidemiologists, psycho-oncologists, nursing and allied health professionals to underpin this is essential.
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13. Australian Cancer Network Management of Metastatic Prostate Cancer Working Party. Clinical Practice Guidelines for the Management of Locally Advanced and Metastatic Prostate Cancer [draft]. Sydney: Cancer Council Australia, Australian Cancer Network; 2009.
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