BUFFALO, N.Y. — A new study published in The Journal of Urology reports that men with prostate cancer who had worse urinary, bowel and sexual function after surgery or radiotherapy than others experienced more emotional distress.

Interestingly, the reverse was also true as experiencing more distress led to worse function. The likelihood of this reciprocal relationship highlights the importance of greater investment in psychosocial care to mitigate treatment side effects in prostate cancer survivors.

Patients with cancer frequently experience emotional distress, not only when they are diagnosed and during treatment, but also into long-term survivorship. Studies have shown that interventions to reduce the emotional burden of disease in patients with cancer can promote recovery and reduce associated costs.

Most of the 2.8 million survivors of prostate cancer in the United States have been treated with definitive therapy, typically surgery and/or radiotherapy, and have a favorable prognosis.

Men treated surgically often experience some degree of urinary incontinence, especially in the first year following treatment, and most experience erectile dysfunction even two years after surgery. While emotional distress decreases in most prostate cancer survivors, some have high emotional distress that does not decline over time to a level consistent with the general population.

“There is growing appreciation for the need to support cancer survivors’ emotional well-being during survivorship, and for prostate cancer patients a key concern is mitigating the influence of treatment side effects on quality of life, including psychological well-being,” explained the study’s lead author Heather Orom, PhD, associate professor of community health and health behavior in the University at Buffalo’s School of Public Health and Health Professions.

Orom and her colleagues investigated whether urinary, sexual and bowel dysfunction contributes to emotional distress during the first two years after treatment, and whether distress may in turn further decrease function.

They assessed more than 1,100 men diagnosed with clinically localized prostate cancer who were treated with surgery (63 percent) or radiotherapy (37 percent). Urinary, sexual and bowel function was assessed using the Expanded Prostate Cancer Index Composite and emotional distress was assessed using the National Comprehensive Cancer Network Distress Thermometer.

Patients were evaluated before treatment and six weeks thereafter, with follow-up at six, 12, 18 and 24 months. The investigators analyzed how function at one time point influenced distress at a subsequent time point and vice versa, taking into account differences in men’s pretreatment function and distress.

Results highlight the likelihood of a reciprocal relationship between treatment side effects and emotional distress. Because the researchers followed the men over time, they were able to establish strong evidence of a causal relationship between urinary, sexual, and bowel function after definitive treatment and emotional distress. While men on active surveillance were not included in the analyses, the bidirectional relationship between function and distress applied to this group as well.

“These findings indicate that in addition to meeting an important need among some survivors, providing psychosocial support may help mitigate side effects,” Orom said. “It is not simply adequate to monitor patients with cancer for distress and physical quality of life issues. Intervention must be accessible.”

“As urologists, we want men who are treated for prostate cancer to return to their way of life,” adds study co-author Willie Underwood III, MD, associate professor of urologic oncology at Roswell Park Comprehensive Cancer Center. “In order to do so, we must determine better ways to assist men through their emotional distress. Curing their cancer is only the beginning to making them whole.”

The investigators propose two health policy changes that could improve survivor well-being: increased access to healthcare coverage for treatments of erectile dysfunction and better access to psycho-oncologic care at diagnosis and after treatment in men who experience a high level of distress.

“Given the likely bidirectional nature of the relationship between side effects and emotional distress, it makes sense for facilities that have traditionally not incorporated psychosocial care into practice to consider doing so,” they advise.

Paper co-authors include Caitlin Biddle, who received her doctorate in community health and health behavior from UB, and Christian J. Nelson, clinical psychologist at Memorial Sloan Kettering Cancer Center.