Why we need to use psychological interventions in medical treatment for prostate cancer (and how to do it)

There are over 230,000 Australian men living with a diagnosis of prostate cancer. Their survival rates are high because of medical advances, but quality of life in survivorship is poor for far too many men.

Being a prostate cancer survivor brings with it a level of psychological distress that can compromise both mental and physical health. Men and their partners must cope with a major life stress that cuts to the very core of their beliefs about themselves and their place in the world. A diagnosis of prostate cancer is almost always accompanied by feelings of fear, shock, anger, deep sadness and confusion. Almost one-third of men with prostate cancer will experience some form of psychological distress across both the treatment spectrum and different stages of the disease. Compared with men in the general population, men with prostate cancer are twice as likely to experience depression and three times more likely to experience anxiety. They have a 70% greater risk of suicide. This risk is greatest within the first year after diagnosis and increases with the severity of the clinical stage of the disease at diagnosis.

If unaddressed, such significant levels of psychological distress result in poorer quality of life and clinical outcomes. They also harm a man’s ability to effectively navigate the complex medical treatment journey required for prostate cancer survivorship, compromising their physical health, decision-making, problem-solving, communication with health professionals, and ability to effectively use patient support networks. Side effects from certain prostate cancer treatments compound the distress. Surgical and radiotherapy treatments may negatively affect sexual, urinary, and bowel function. Men undergoing androgen deprivation therapy (ADT) experience poorer psychosocial outcomes than men receiving other treatments, including depression, anxiety, relationship changes, cognitive and affective symptoms, and sleep disturbances. Regardless of other treatments, receiving ADT is predictive of higher distress and has a threefold greater risk of depression compared to radiation treatment alone.

All this distress also affects partners, families, and colleagues. Yet the level of patient distress is often hidden from healthcare providers. Asking for psychological help does not come naturally to many men. Research has even shown that men who say to their doctor they will take action in the face of dealing with prostate cancer are actually those who are least likely to seek help.
Addressing this significant unmet need to reduce patient psychological distress not only eases suffering for men and their families it will also result in a more effective treatment process and better patient outcomes.

Offering prostate cancer patients access to psychological help and encouraging a focus on wellbeing during treatment is a start but not enough to make a difference. After a prostate cancer diagnosis, the psychological needs of men and their families vary greatly. These needs are influenced by life course, context and gender, and will change over time. Critically, support must be individualised to the level of need and be accessible in a range of settings, spanning community and acute care. Evidence-informed psychological intervention for men undergoing treatment for prostate cancer is as vital as the drugs, surgery and other medical treatments that save their lives.

The Facing the Tiger Psychological Care Approach for men with prostate cancer was developed to help health professionals provide accessible low-intensity psychological intervention early and at a time when it is most needed. Low-intensity interventions aim to democratise psychological care through accessibility and an enhancement of personal agency to encourage mastery of one’s own wellbeing. The strategies used are informed by firm evidence, and the approach allows for a highly accessible, cost-effective intervention.

It was developed out of 30-plus years of research and clinical work by Professor Suzanne Chambers AO, a world leader in the psychology of prostate cancer.

The approach emphasises the use of the Australian-developed Psychosocial Care Model for Men with Prostate Cancer and the Prostate Cancer Survivorship Essential Framework. It can be applied in any prostate cancer treatment setting as either a basic intervention or at a higher tiered care level. It consists of three main components which can be flexibly applied:

  • a patient self-help book entitled Facing the Tiger: A survivorship guide for men with prostate cancer and their partners
  • a healthcare provider manual entitled A Health Professionals Guide to Delivering Psychological Care for Men With Prostate Cancer.
  • a structured professional training workshop.

The patient book is designed to be a first-off support, focusing on the day-to-day worries and concerns men and their partners experience when dealing with the disease. It makes use of cognitive behaviour therapy approaches, psycho-education and lived experience stories. The book can be supplied proactively to all patients no matter what stage of treatment (universal intervention) to help ease current distress and help prevent the development of higher levels of distress or to patients identified as at risk or showing clear signs of distress (targeted intervention). The book is recognised as part of best-practice psychosocial care based on Australian guidelines for multidisciplinary treatment of prostate cancer and is endorsed by the Urological Society of Australia and New Zealand, the Australia and New Zealand Urological Nurses Society, and the Prostate Cancer Foundation of Australia (PCFA).

The healthcare provider manual is designed to be used within practices that currently provide a level of medical, nursing and allied support services to prostate cancer patients. Most commonly, the manual is used by prostate cancer care nurses or urology and oncology nurses, but it can also be used by psychologists, occupational therapists, physiotherapists, exercise physiologists, sex therapists, or general practitioners. The manual allows the healthcare provider to structure tailored men-centred interventions to match the patient’s needs while ensuring consistent distress monitoring and encouraging the use of survivorship care plans. It uses existing information, stories, and activities in the patient book. The manual includes standardised session structure guidelines, flexible delivery options, downloadable and photocopiable session worksheets, a downloadable fill-in PDF patient survivorship care plan, download links to free external forms/tests and an external resource list covering issues such as sex, urinary problems, exercise and complementary medicine. No extra patient materials are required for an intervention to be conducted. All nurses in the PCFA Prostate Cancer Specialist Nursing Program are provided with a copy of the manual and receive training on its use with patients.

The training workshop is for health professionals who have knowledge and experience working with people with cancer. Guidance is provided around vigilance and surveillance of psychological wellbeing by incorporating screening for distress into the care model. The intervention strategies applied are informed by evidence on effective psychological care for men with prostate cancer, applying a cognitive behavioural approach and drawing from three main perspectives: stress and coping; problem-solving; and psychological flexibility. The workshop includes three core study elements that connect sequentially supported by the healthcare provider manual and a reflective learning Participant Training Workbook with set pre-reading. Small group learning cohorts (maximum of 20 participants) are utilised with a focus on connecting theory and evidence to practice. Remote and face-to-face delivery modes are available.

The result is that the Facing the Tiger Psychological Care Approach can be implemented within a medical setting without the need for extra staff or a large capital investment. Initial improvements in patient outcomes can be achieved quickly with universal intervention at a per patient cost of around $20.00 simply by supplying all patients with a copy of the self-help book. Extending that level of care to patients exhibiting higher levels of distress is achieved by equipping selected staff with the provider manual at $135.00 per professional. Optional training to enhance the effectiveness of using the manual and self-help book with patients costs around $500.00 per participant. The minority of patients who exhibit major clinical levels of distress under treatment can then be identified by this extended level of care and appropriately referred to outside psychological treatment.

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