Prostate news article, February 2010

SUPPORTING THE SUPPORTER: HELPING THE PARTNER OF PATIENTS NEWLY DIAGNOSED WITH PROSTATE CANCER   Article by:   Professor Roger Kirby, Chairman, Prostate UK, Kate Holmes and Dr Peter Amoroso

Prostate Prostate cancer will be diagnosed in more than 35,000 men this year in the UK, and unfortunately almost 10,000 men will die from it. Although the early identification of this tumour can potentially save lives^1,2 the shock of receiving the bad news about the diagnosis, the difficulty selecting the optimum treatment option for that individual, and the problems associated with coming to terms with the effects of treatment may pose an enormous emotional challenge to the individual concerned. Nor is that individual solely impacted when prostate cancer strikes, his entire family are likely to be affected. In particular, his partner is likely to take the brunt of the emotional perturbation that frequently ensues from this anxiety-provoking and potentially life-changing diagnosis and from the effects of the treatment that is required.

The active support of the partner, not only to help the man afflicted through this difficult process, but also to help the supporter to make the necessary emotional adjustments, can make an enormous difference. It also needs to be appreciated that some partners need more support than others. A study by Manne et al examined the cognitive and social processes predicting partner psychological adaption to early stage breast cancer³. It seems likely that very similar processes would apply to the partners of men with prostate cancer. It should be the mission of all urologists to do what they can to ease this process and reduce stress and anxiety levels to a minimum.

Self-evidently, there are several phases of the prostate cancer journey that the patient and his family have to travel: The shock of the initial prostate cancer diagnosis can be devastating, and one that many men, and also their partners, find great difficulty coming to terms with. Part of the problem stems from the reluctance of many men to share their feelings and emotions, even with their closest partner or relatives. The manner in which the bad news about the cancer diagnosis is delivered by the clinician can be critical. It is usually better if the partner is present at this crucial interview, providing the patient himself has agreed to this shared approach. From an ethical viewpoint, the patient's own view about whether or not the partner should be involved in this process should always be respected⁴. It has sagely been stated that if bad news is broken sympathetically, the patient will never forget you, done clumsily, and he will never forgive you. Lucid and sympathetic counselling support not only of the patient, but also of his partner, can mitigate the negative impact of this most difficult time^5,6.

It is sometimes assumed that patients and their supporters may not want to know all the facts about the cancer that afflicts them. Several surveys confirm in fact that the reverse is true⁷. In the age of the Internet many patients in whom this diagnosis is made immediately surf the web and download a considerable amount of often alarming and sometimes misleading information. The availability of well- balanced and non-alarmist information and support for both the patient and their partner during this perturbing juncture can therefore be crucial.

As in many aspects of life, anxiety levels tend to diminish once a definitive decision about a specific course of action has been decided upon. But how can a man and his partner decide between the various treatment options available to them? These include active surveillance, radical prostatectomy (open, laparoscopic or robotic), brachytherapy or external beam radiotherapy, with or without hormone therapy. Each of these has its advantages and disadvantages, as well as prominent advocates and detractors. Educating and informing both the patient and his partner about the pros and cons of the various treatment options in an unbiased fashion can considerably ease the burden of the decision making process by facilitating the process of sharing.

Once a decision has been arrived at for a given treatment option, emotional and psychological support from the partner can be crucial during the preparation process, during the treatment itself, as well as during the recovery period. Prior to surgery for example a fitness and weight reduction process is often beneficial, and active partner participation in this can considerably enhance compliance. If radiotherapy is the treatment option of choice, empathic partner support during the later weeks of treatment when side effects are most troublesome can most beneficial, thereby easing the emotional burden when morale is at its lowest ebb. There is also a tendency during therapy for the patient's partner to become depressed or anxious. Clearly if this can be avoided the patient journey itself will be an easier one to navigate.

Partner and family support for the patient can also be vital during the process of rehabilitation after surgery or radiotherapy. Side-effects of stress urinary incontinence and erectile dysfunction after surgery, urinary frequency and poor flow after brachytherapy and lower bowel disturbance following external beam radiotherapy in particular can be undermining and demoralising, but all tend to improve in the fullness of time, aided by the positive interaction of the family and the clinical team. Hormonal therapy has an inevitable impact on sexuality and this needs to be carefully explained.

Not only the lives, but also the quality of live, of patients, their partners and their wider family can all be substantially affected by prostate cancer, however, some of these changes can be positive as well as negative. Although erectile function may often be compromised, at least initially, other forms of emotional closeness can be fostered, and are often enhanced. Erectile dysfunction can now be treated effectively, and there is evidence that this works more effectively using a couples-based approach⁸. The role of the partner can be critically important in maintaining the morale, self esteem and confidence of the individual affected and maintaining the closeness of the relationship. Careful nurturing and ongoing development of this supporting role by the partner – that is to say “supporting the supporter” – and of the immediate family, by the medical and nursing team involved seems an obvious and rather economical way to improve the quality of the patient journey in this most frequently diagnosed cancer of men.

 

References

1. Schroder F, Hugosson J, Roobol M, et al Screening and prostate cancer mortality in a randomized European study N Engl J Med 2009;360:1320–8.
2. Bill-Axelson A, Holmberg L, Ruutu M, et al. Radical prostatectomy versus watchful waiting in early prostate cancer. N Engl J Med 2005;352:1977–84.
3. Manne S, Ostroff J, Fox K, et al. Cognitive and Social Processes Predicting Partner Psychological Adaptation to Early Stage Breast Cancer. Br J Health Psychol. 2009 February; 14: 49–68.
4. Benson J, Britten N, How much truth and to whom? Respecting the autonomy of cancer patients when talking to their families – ethical theory and the patients' view. BMJ, 1996;313:729–31.
5. Buckman R, Kason Y, How to break bad news – a practical guide for health care professionals London, Macmillan 1993 6. Fallowfield L, Giving sad and bad news. Lancet,1993; 341:476–8.
7. Meredith C, Symonds P, Webster L et al Information needs of cancer patients in the west of Scotland BMJ 1996;313:724–6.
8. Chambers, SK Schover, L, Halford K, ProsCan for Couples: Randomised controlled trial of a couples-based sexuality intervention for men with localised prostate cancer who receive radical prostatectomy. BMC Cancer. 2008; 8: 226.