Studies Bring Focus to Impact of Urologic Disease on Mental, Emotional Health

San Francisco, CA ( -- The burden of urologic disease can affect not only a patients’ physical health, but also their emotional and mental health. Five new studies being presented this year at the AUA Annual Meeting in Chicago demonstrate the impact of male-factor infertility, as well as treatments for benign prostatic hyperplasia (BPH) and prostate cancer on emotional and mental health. These studies will be presented during a special session for media on Sunday, May 5 at 11:00 a.m. Mayo Clinic urologist Dr. Tobias Kohler, chair of the AUA Public Media Committee, will moderate this session. 

Abstracts presented include: 

Publication # PD29-04 Qualitative Assessment of Male Partner Needs Among Infertile Couples 
Male partners react to an infertility diagnosis differently if male-factor infertility is the cause, and could benefit from specific support services geared to them, according to this study. Using focus groups of male and female participants affected by infertility, researchers collected information about individual experiences and the availability and quality of patient resources available to patients. 

Key findings include: 
  • In cases of male-factor infertility, men reported self-blame, feelings of guilt and isolation, and loss of manhood, compared to cases of female-factor infertility, in which men saw their primary role as that of a problem-solver.
  • All participants reported frustration with a lack of information available on male infertility and difficultly finding reputable websites pertaining to male reproductive health. Both men and women voiced a need for mental health resources geared toward couples. 
  • Men seek easy-to-understand, centralized information, whereas women had a need for more comprehensive, detailed materials. 
Publication # PD19-03 Correlation Of Alpha Blocker With Dementia In Patients With Benign Prostate Hyperplasia: A Nationwide Population-Based Study Using The National Health Insurance Service Database 
Alpha-blocker medications are not associated with an increased risk of dementia, according to this review of 65,481 patients in Korea. Using data from the National Health Insurance Service database, researchers identified patients with no record of cognitive dysfunction or dementia who were taking alpha-blocker medications in 2011,followed them until September 2017 and tested the effect of different alpha blockers on the risk of dementia. 

Key findings include: 
  • After a mean follow up of 1,496 days, the incidence of dementia was 18.5 percent in the tamsulosin cohort, 19.1 percent in the doxazosin cohort, 21.2 percent in the terazosin cohort, 18 percent in the alfuzosin cohort and 21.3 percent in patients not taking medication.
  • The risk of dementia did not significantly differ between the tamsulosin, doxazosin and alfuzosin cohorts.
  • While the risk of dementia was higher in the terazosin and no-medication cohorts, patients taking terazosin had a significantly lower risk of dementia than patients taking no BPH medication. 
Publication # PD25-08 Body Image Issues And Attitudes Towards Exercise In Men Diagnosed With Prostate Cancer Undergoing Androgen Deprivation Therapy
Androgen-deprivation therapy (ADT) is an established treatment for prostate cancer, but side effects – such as weight gain and decreased sexual function – can significantly impact a man’s body image and attitudes toward exercise. Researchers interviewed men with prostate cancer after ADT to explore a number of key topics, including ADT-induced body changes, body image issues and exercise. Findings suggest men on ADT could benefit from additional support to overcome these body issues.  

Key findings include: 
  • Participants on ADT were concerned about body feminization, including breast enlargement, sexual function (impacting feelings of masculinity), weight gain and physical limitations (functionality loss).
  • Men felt exercise counterbalanced some ADT side effects, particularly weight gain, while simultaneously enabling them to have control over their bodies in spite of a cancer diagnosis.
  •  In spite of this, men still identified barriers to exercise, including fatigue, time and a concern about being judged for their physical appearance or performance when exercising in groups. 
Publication # MP22-15 Depression In Prostate Cancer Patients Starting Androgen Deprivation Therapy 
Men taking androgen deprivation therapy (ADT) for prostate cancer may be at an increased risk of depression, particularly if depressive symptoms were present prior to treatment, according to data from the multi-center RADICAL PC study. Researchers identified 407 men starting ADT treatment and evaluated depressive symptoms using the Patient Health Questionnaire (PHQ-9) and, using biological, psychological and social predictor variables, evaluated symptom predictors. 

Key findings include: 
  • Men with poor functional status had an increased risk of depression with ADT.
  • Retired men had a decreased risk of depression. 
  • Indicators of advanced disease was not associated with depression
Publication # PD30-12 Risk Of Dementia Following Androgen Deprivation Therapy For Treatment Of Prostate Cancer 
Androgen deprivation therapy (ADT) has an effect on cognitive health, and pharmacologic ADT may be associated with an increased risk of dementia or Alzheimer’s disease, as well as an increased use of psychiatric services by men with localized or locally advanced prostate cancer. In this retrospective cohort study using Medicare data from the 

Surveillance, Epidemiology, and End Results (SEER) database, researchers identified more than 100,400 men (aged 66 and older) with no prior history of stroke, dementia or use of psychiatric serves, who were diagnosed with prostate cancer between January 1992 and December 2009. Cox regression models were used to estimate risks of Alzheimer’s, all-cause dementia and whether psychiatric services were utilized following different doses of pharmacologic ADT. 

Key findings include: 
  • Pharmacologic ADT was associated with a 22 percent increased risk of all-cause dementia, a 29 percent increased risk of Alzheimer’s and a 15 percent increased risk of psychiatric services use.
  • ADT showed a dose-responsive relationship for a duration of seven months with all-cause dementia and Alzheimer’s, with an increased risk of 30 percent and 41 percent, respectively. 
  • Use of ADT for longer than seven months was associated with a greater risk of all-cause dementia, Alzheimer’s and an increased use of psychiatric services. 
“The interplay of mental health and disease pathophysiology is an area of unmet need,” Dr. Kohler said. “These four studies elegantly remind us that medications and medical interventions can affect our emotional wellness and we must be on the lookout for both negative and positive impacts.” 


Qualitative Assessment of Male Partner Needs Among Infertile Couples
Akanksha Mehta, Brent Hanson, Louisa Stark, Camille Hawkins, James Hotaling

Information and support related to reproductive health and infertility services is primarily geared toward female partners. The goal of this study was to assess the experience and needs of male partners faced with either male- or female-factor infertility. 

Methods: Exploratory focus groups involving 13 male and 14 female participants affected by infertility were conducted by trained facilitators, and documented via audio recordings and written summaries. The focus groups discussed 1) individual experiences with male- and female-factor infertility, and 2) availability and quality of education materials pertaining to the diagnosis and treatment of male factor infertility. Data transcription and coding was performed in duplicate to ensure accuracy, and qualitative thematic analysis was performed using
NVivo v10 software.  

Feelings of grief and loss related to the inability to have a family were common. Men also reported problems communicating with their partners, leading to emotional isolation. With female-factor infertility, men viewed their primary role as problem solvers while with male-factor infertility, men reported frequent self-blame, loss of manhood, and feelings of guilt and isolation. Men frequently experienced barriers to treatment. All participants reported frustration with the lack of information about male infertility, difficulty finding reputable websites pertaining to male reproductive health, and scarcity of male reproductive health specialists. Men wanted easy-to-understand, centralized information about male infertility while women valued comprehensive, detailed materials with links to additional resources. Both men and women voiced a need for mental health resources geared towards couples with infertility. 

Conclusions: Male partners of infertile couples experience substantial emotional and psychological distress, which is often unrecognized. Men experience female-factor infertility differently from male-factor infertility, which highlights the need for specific support services geared toward the male partner. Normalizing the experience, improving access to care for men, and developing easily-understood educational materials will better serve patients and allow them to become informed participants in their care. 

American Society of Reproductive Medicine Research Grant. 

Body image issues and attitudes towards exercise in men diagnosed with prostate cancer undergoing Androgen Deprivation Therapy. 
Caterina Gentili, Stuart McClean, Lucy Hackshaw-McGeagh, Amit Bahl, Raj Persad, Diana Harcourt 

Introduction: Androgen Deprivation Therapy (ADT) is a well-established treatment for prostate cancer (PCa). ADT side effects can impact on body composition and functioning. Some patients might experience feelings of body feminization that can be detrimental to their body and appearance satisfaction. ADT side effects are well known, but only a limited amount of research explored their psychological impact on men&[prime]s body image. A potential strategy to counterbalance ADT side effects, promote mental health and reduce appearance-related concerns could be exercise. However, adherence to exercise recommendations is very low. Therefore, this qualitative exploratory study aimed to: &[middot]Explore the impact of ADT-induced appearance and functionality changes on patients&[prime] body image. &[middot]Investigate patients&[prime] attitudes towards exercise and potential exercise barriers. 

We conducted 22 semi-structured interviews with PCa patients following ADT (Mage = 67.9 yo, SD = 9.99 ). The interviews touched upon ADT-induced bodily changes, body image issues, and exercise. Each interview lasted around 45 minutes, was audio-recorded and transcribed word-by-word. Thematic content analysis was conducted with NVivo. 

We extracted 4 main themes and 14 sub-themes. 1) Body Image concept. For some patients body image concerns represented either a novel topic or a problem they never felt able to talk about. Body image was also often conceived as &[Prime]what other people can see&[Prime] rather than one&[prime]s judging of his own body. 2) Bodily changes. Participants expressed appearance dissatisfaction focusing on body feminization. In particular, breasts enlargement, weight gain, functionality loss, and sexual issues had an impact on their sense of masculinity. 3) Exercise benefits. Participants reported to exercise to counterbalance ADT side effects, weight gain in particular. Moreover, exercise gave them a sense of achievement and control over their bodies despite cancer, and a renovated sense of physical self-efficacy. 4) Exercise barriers. Participants reported time management and fatigue as main exercise barriers. Moreover, they expressed the concern to be judged for their physical appearance and performance when exercising in groups. 

These findings highlight not only the need to further investigate body image concerns and exercise barriers in PCa patients undergoing ADT, but also underline the necessity to provide information and support for those PCa patients who might be struggling with body image issues. 

Funding: This project is funded by the charity Above and Beyond, Bristol (UK) 


Depression in prostate cancer patients starting androgen deprivation therapy 
Gagan Fervaha, Jason Izard, Dean Tripp, Selina Rajan, Sarah Karampatos, Bobby Shayegan , Edward Matsumoto, Tamim Niazi , Annabel Chen-Tournoux, Vincent Fradet , Yves Fradet , Emmanuelle Duceppe , Luke Lavallee, Christopher Johnson, Joseph Chin, Da 

Introduction: Androgen deprivation therapy (ADT) for the treatment of prostate cancer has been shown, albeit not consistently, to be related to specific consequences such as incident depression. The presence of depressive symptoms in patients with advanced disease eligible for ADT is less well understood. The current study was undertaken to estimate the prevalence and predictors of depression in a contemporary sample of patients beginning ADT. 

Data from the current study were drawn from the RADICAL PC study, a parent prospective cohort study conducted across 13 sites in Canada. Men with prostate cancer initiating ADT for the first time were recruited. Depressive symptoms were evaluated using the 9 item version of the Patient Health Questionnaire (PHQ-9). A score of 8 or higher on this scale represents clinically relevant depressive symptoms. To evaluate predictors of depressive symptoms, a logistic regression model was constructed including biological, psychological, and social predictor variables. 

Data from 407 patients were available at the time of this analysis. Of these, 43 (10.6%) endorsed clinically significant burden of depressive symptoms. Two variables were identified as independent predictors of depression - poor functional status (OR=5.18, p<0.001) increased depression risk, whereas being retired was found to be protective (OR=0.37, p=0.03). Indicators of advanced disease (e.g. presence of metastatic disease) were not associated with depression in either univariate or multivariate models. 

Our multi-centre study of depressive symptoms among prostate cancer patients starting ADT shows that these symptoms are already present in a sizeable sample of men. These do not seem to be affected by disease-related indicators, but rather are better predicted by psychosocial variables. Clinicians should be suspicious of poor psychological functioning especially among those prostate cancer patients with poorer functional status. Moving forward, it will be important to document the incidence and change in depressive symptoms as these patients begin ADT and are followed prospectively. 

Funding: Prostate Cancer Canada 


Risk Of Dementia Following Androgen Deprivation Therapy For Treatment Of Prostate Cancer 
Anna Krasnova, Karl Heinrich Tully, Matthew Epstein, Maya Marchese, Barbra A. Dickermann, Alexander Putnam Cole, Stuart R. Lipsitz, Paul L. Nguyen, Adam S. Kibel, Toni K. Choueiri, Shehzad Sultan Basaria, Lorelei A. Mucci, Maxine Sun, Quoc-Dien Trinh 

There is limited epidemiological evidence for the association between androgen deprivation therapy (ADT) and the risk of incident dementia, yet several studies show no such association. Consequently, we aim to assess if receipt of ADT increases the risk of dementia among men with localized and locally advanced prostate cancer and if it does so in a dose-dependent manner. 

We conducted a retrospective cohort study using Surveillance, Epidemiology, and End Results (SEER)-Medicare linked data among 100414 men aged 66 years and older who were diagnosed with localized and locally advanced prostate cancer (cT1 - cT4) between January 1992 and December 2009 and followed until administrative end of follow-up at 36 months or death. Men were excluded if they had a prior history of stroke, dementia or use of psychiatric services reported in Medicare claims. Propensity weighted competing risk Cox regression models were utilized to estimate hazard ratios (HR) and 95% confidence intervals for the risk of Alzheimer&[prime]s, all-cause dementia, and use of psychiatric services following different doses of pharmacologic ADT (0, 1-6, and &[ge]7 months). 

Of the 100,414 men with prostate cancer (median age 73 [IQR: 69-77] years; 84% white, 10% black), 38% (n= 37,911) received ADT within 6 months of diagnosis. Receipt of any pharmacologic ADT was associated with 22% increased risk of all-cause dementia (HR 1.22, 95% CI 1.12-1.33, p<0.001), 29% increased risk of Alzheimer&[prime]s (HR 1.29, 95% CI 1.16-1.43, p<0.001), and 15% increased risk of psychiatric services use (HR 1.15, 95% CI 1.04-1.28, p=0.008). Additionally, ADT showed a dose-response relationship for the duration of &[ge]7 months with all-cause dementia and Alzheimer’s, where there was an increased risk of 30% and 41%, respectively, in comparison to no ADT. A dose-response relationship was not seen for ADT and use of psychiatric services (ptrend=0.07). 

Our study supports an association between pharmacologic ADT and increased risk of developing all-cause dementia, Alzheimer&[prime]s, and use of psychiatric services in men with localized and locally advanced prostate cancer. Longer duration of ADT ≥7 months corresponded with greater risk of these events. These data provide additional evidence supporting an effect of ADT on cognitive health. 

Funding: Brigham Research Institute, Bruce A. Beal and Robert L. Beal Surgical Fellowship, Conquer Cancer Foundation, Defense Health Agency, Intuitive Surgical, Prostate Cancer Foundation, Vattikuti Urology Institute. Maxine Sun is supported by an American Urological Association data grant. 

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