Supportive care intervention in prostate cancer: recent advances and future challenges

Prostate cancer is the most common invasive cancer among males, with 16,349 men diagnosed in Australia in 2005, more than twice as many than with colorectal cancer.1 Prostate cancer incidence trends are highlighted by the rapid rise in incidence soon after the introduction of prostate specific antigen (PSA) testing in the early 1990s, followed by a sharp reduction in rates, and then a gradual increase since 2000.2 Mortality rates due to prostate cancer in Australia started to decrease from 1993 onwards, with these reductions in mortality also being seen internationally.2 The implications of these trends for supportive care services are that the cohort of men in our community who are living with the consequences of prostate cancer is increasing. In 2004, there were about 100,000 Australian men estimated to be living with a diagnosis of prostate cancer,3 with prevalence increasing due to current incidence and survival patterns. Hence, an understanding of effective approaches to psychosocial care for these men and their families, and the challenges to be faced in delivering this care in an approach that is both equitable and evidence-based, is crucial for public health in Australia.

Issues with equity

There are important geographical and socio-economic differences in prostate cancer outcomes in Australia. Prostate cancer survival is highest for men living in more affluent areas and decreases with reducing area-level socio-economic status, and is highest in major cities compared to inner and outer regional areas.3 Consistent with this survival differential, prostate cancer mortality is also reported to be higher in non-metropolitan areas, with the mortality differential increasing over time.4 While the cause of this differential could not be established using these ecological data, fewer radical prostatectomies in regional and rural areas, along with lower rates of PSA testing in these areas, remain among the several competing explanations.4 Given these differences in survival outcomes, that are likely related to access to health care services, it can be expected that there will be differences in access to post-treatment care and support and that this will impact on adjustment outcomes in men.  

Supportive care intervention targets

The diagnosis and subsequent treatment of any cancer is, for most people and their families, a major life stress that is followed by a range of distressing psychosocial effects. Accordingly, clinical practice guidelines have been produced both in Australia and North America that detail evidence-based approaches to ameliorating this distress.5 Effective approaches include cognitive behavioural therapies, relaxation techniques, psycho-education, supportive psychotherapy, peer support and family and couples therapy. They may be delivered in a range of ways, including group and individual formats and face to face and tele-based delivery systems. It remains the case however, that there has not been widespread translation of psychosocial care into standard clinical practice. This has been variously attributed to the low value placed on such care in a disease focused health system, challenges with up-skilling health professionals in this area of practice and patient and family reluctance to seek help, even when distressed.6,7 One approach to psychosocial care translation that has been widely discussed is where patients and family members are regularly screened for psychosocial distress, and those with elevated distress are referred to appropriate evidence-based care services.6 In a stepped care model such as this, all patients and family members receive a standard level of psychosocial care. However, further care is targeted to the area of need and the depth of distress, such that more costly and time intensive interventions are utilised for those experiencing or at greatest risk of unremitting distress. This approach is currently being evaluated in Queensland and New South Wales in a Helpline setting for all cancer types, however to our knowledge has not yet been trialled elsewhere in a controlled design.8 This approach would be expected to also be efficacious for people affected by prostate or any genitourinary cancer, with the proviso that treatment concerns relevant to those specific cancers and gender-appropriate approaches would be addressed.

Making interventions relevant

While it is reasonable to propose psychological distress as a therapy target for all cancer types, it is also the case that adjustment outcomes are heterogeneous both within and across cancer types. Put simply, some patients and carers will do better or worse than others due to pre-existing factors. These include socio-economic status, gender, age, family type and social support, co-morbid mental health conditions, extent of disease and treatment severity, as well as factors that may be amenable to change such as threat appraisal, coping approach and self-efficacy. Risk factors for distress that are not amenable to change remain part of the intervention model or approach, in order to identify ‘at risk’ for distress target groups and factors that may hinder uptake of services. For example, people who have lower levels of education may be at risk for poorer adjustment outcomes, but also less likely to uptake educational programs to mitigate that risk, unless these programs are tailored to address low literacy. Patients who reside in regional and rural areas may experience difficulties not only in accessing medical treatments, but also psychosocial care services, unless those services can be remotely delivered. Men who typically do not utilise mental health services to the extent that women do may be unlikely to access such services, unless these services are sensitive to gender issues and masculine approaches to help seeking. Finally, people are less likely to seek services that do not, at face value, resonate with their own cancer experience. On this view, unless psychosocial care services are integrated with symptom management, they will be less relevant for patients whose immediate concern in the case of genitourinary cancer may be urinary or bowel incontinence, or sexual dysfunction. Figure 1 is a diagrammatic representation of how environment, context and individual variables should be considered when developing interventions.