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
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.
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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
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
“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
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
Hu added that encouraging depressed men with prostate cancer to join
prostate cancer support groups may help spur them to pursue
Journal of Clinical Oncology, online July 7, 2014.
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