Depression may keep some men from fighting prostate cancer

NEW YORK (Reuters Health) - Depression may be source of disparities in the treatment men get for prostate cancer, according to a new study.

In the analysis, older men who were depressed before they got a prostate cancer diagnosis were more likely to have aggressive cancer, less likely to undergo the recommended treatment for their stage and type of disease and more likely to die.

“We traditionally think of disparities in healthcare by race and socioeconomic status, but our research demonstrates that mental illness can also be a significant driver of treatment choice and outcomes in terms of prostate cancer,” Dr. Jim Hu told Reuters Health in an email.

Hu is director of robotic and minimally invasive surgery at the David Geffen School of Medicine at UCLA. He led the new study that was published in Journal of Clinical Oncology.

According to the Centers for Disease Control and Prevention, almost 200,000 men were diagnosed with prostate cancer in the U.S. in 2010, and just under 30,000 men died from the disease that year.

Past research has linked depression to a greater likelihood of getting less-aggressive treatment and to poorer survival in other cancers, including breast and liver cancers. But little is known about how depression might affect men’s diagnosis and treatment for prostate cancer, Hu and his colleagues write.

The researchers analyzed information from a large national database of Medicare patients, focusing on more than 40,000 men diagnosed with localized prostate cancer between 2004 and 2007 and observed through 2009.

Of those, 1,894 men were also diagnosed with depression during the two years before their cancer was detected.

“First, we found that men with prostate cancer who were older, lower income, with more medical (conditions), white or Hispanic (versus Black and Asian), unmarried, residing in nonmetropolitan areas were more likely to be depressed,” Hu said.

“In addition, depressed men were less likely to seek out definitive therapy (surgery or radiation) in contrast to non-depressed men,” he said, which goes against the current guidelines for treating intermediate- and high-risk disease.

After adjusting for differences in the men’s tumor characteristics and the treatment they chose, the researchers found that depressed men had worse overall survival compared to men who were not depressed, Hu noted.

Hu said he was surprised by the results because depressed men were more likely to see physicians in the two years before their prostate cancer diagnosis compared to non-depressed men - an average of 43 times versus 27 times, respectively.

The team also found that depressed men were more likely to get so-called expectant management, which includes the use of hormones to decrease the aggressiveness of prostate cancer or no treatment at all, which is called “watchful waiting” or active surveillance.

It’s possible, Hu and his colleagues write, that depression makes men less interested in screening, leading to their cancers being diagnosed at a later stage, and makes them choose less aggressive treatment. The greater number of doctor visits might be focused on mental illness, leading to less attention toward cancer screening.

These findings cannot prove there’s a cause and effect at work, the authors caution. However, they suggest that physicians should take care to ensure prostate cancer patients are getting the mental health treatment they need so depression doesn’t bias a patient’s treatment choices and chances for survival.

Dr. Behfar Ehdaie, a surgeon who specializes in prostate cancer at Memorial-Sloan Kettering Cancer Center in New York, said that mental health is an important aspect of prostate cancer care.

Given the prevalence of depression in these men, survivorship in that light has been underreported in the literature, said Ehdaie, who was not involved in the study.

“We know that men who are diagnosed with prostate cancer have an increased risk of suicide – this was shown in a Swedish study looking at men from Sweden,” he told Reuters Health.

“This adds more data from the United States, specifically looking at men age 67 and older, that also demonstrates that mental health should be assessed and be part of our prostate cancer care,” he said.

But Ehdaie emphasized that this study does not suggest the less aggressive approach of expectant management is associated with poor outcomes, or that depression increases the risk of dying from prostate cancer.

“The endpoint evaluated is overall survival, and we do know that from previous studies, depression is associated with cardiovascular events, for example, which are also associated with increased risk of mortality,” Ehdaie said.

That distinction between deaths from prostate cancer or progression of the disease, and overall deaths from any cause is important, he added.

Ehdaie said that future studies are needed to determine the impact of mental health issues on treatment decision making, especially in men with intermediate- or high-risk disease who appear not to be receiving the appropriate treatment.

“As healthcare providers, we need to be aware of the greater risk for aggressive prostate cancer in depressed men,” Hu said. “Additionally, depressed men may require special attention in light of the lower initiative to follow through with physician recommendations.”

Hu added that encouraging depressed men with prostate cancer to join prostate cancer support groups may help spur them to pursue recommended treatments.

SOURCE: Journal of Clinical Oncology, online July 7, 2014.