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Authors Donovan KA, Walker LM, Wassersug RJ, et al.
Review Date October 2015
Citation Cancer 2015; Epub ahead of print (15 Sep 2015): DOI: 10.1002/cncr.29672
Androgen deprivation therapy (ADT) reduces the levels of androgens — the hormones responsible for stimulating prostate cancer (PC) cell growth — extending the lives of men with PC. However, ADT is associated with a range of significant side-effects such as increased risk of cardiovascular disease, hot flashes and sexual dysfunction. Many studies have considered these physical side-effects but few have been devoted to the psychological effects of ADT.
To present evidence of the psychological effects of ADT on men with PC and their partners, and to make recommendations for the management of these effects.
A literature review was conducted; no further details are provided.
SEXUAL FUNCTION AND RELATIONSHIP
• 58-94% men on ADT report loss of sexual desire
• 60% report negative changes in body image
• 73-95% report erectile dysfunction (ED)
• 80-93% report ceasing sexual activity altogether
• Despite loss of sexual desire many couples maintain sexual relationship, important to maintaining normality/intimacy
• Commonly report loss of masculinity due to physical changes (e.g. breast growth), social and psychological factors (e.g. body image).
• Easier to adjust to sexual relationship changes than emotional intimacy
• Improving communication between partners shown to improve mental health of partner
• Little research on same-sex relationships.
• Only one intervention targeting couples dealing with ADT – a self-directed program to manage all side-effects of ADT currently being evaluated in Canada
• Exercise may promote sexual activity maintenance
• Couples should receive counselling to help relational intimacy
• Encourage men to increase sexual repertoire including activities less focused on intercourse.
EMOTIONAL WELL-BEING AND DEPRESSION
• Extreme and frequent changes in mood often reported
• Changing emotional expression may affect interpersonal interactions and self-perception (perceived as ‘unmanly’)
• More research needed on ADT and mental illness/depression.
• Research specific to men receiving ADT not reported
• In men with PC, risk of depression lower in a committed, long-term relationship
• Partners of men with PC also at risk of depression
• No studies on same-sex couples were reported
• Recent research – ignoring impact of ADT on partner may also adversely affect the patient.
• Men/partners should be informed of possible adverse impact on mental health before ADT starts
• Screen men receiving ADT for depression
• More research needed to support role of exercise in reducing risk of depression improve quality of life.
• ADT may impair memory/other cognitive processes due to effect on ligands binding to androgen & estrogen receptors
• One review: 47-69% of men who receive ADT have some degree of impairment in 1+ cognitive domain (e.g. memory, problem-solving skills)
No studies on partners and cognitive effects were found.
• Specific cognitive benefits of exercise for men receiving ADT currently under investigation
• Beginning exercise program before treatment may be more effective than commencing after when side-effects of ADT present.
While ADT increases the lifespan of men with PC it reduces their quality of life during this time. The strongest evidence for the psychological effects of ADT are on men’s sexual function and the sexual relationship. Clinicians have an ethical responsibility to alert men to the possible side effects of ADT when gaining their consent for treatment. Physical exercise appears to have the greatest potential to address the psychological effects of ADT on men with PC and possibly their partners.
Points to Note
- ADT increases the lifespan of men with PC but is associated with significant physical and psychological side effects; few studies have considered the latter.
- The strongest evidence exists for the adverse effects of ADT on sexual function and the sexual relationship. Evidence increasingly suggests there are ADT-associated impairments in multiple cognitive domains and that men who receive ADT are at risk of depression.
- Many of the reviewed studies on sexual function were limited by the measurement of penetrative intercourse only rather than the broader context of sexual activity.
- Few studies have considered same-sex relationships and many studies appear to have been influenced by social assumptions of men and women’s cognitive capabilities (known as ‘neurosexism’).
- Through complex biopsychosocial mechanisms, physical exercise appears to have the greatest potential to mitigate the psychological effects of ADT in men with PC and their partners.