M. D. Anderson study finds pre-surgical stress management improves mood, quality of life

April 06, 2009

HOUSTON - Brief stress management sessions prior to and immediately after surgery may have both short- and long-term benefit for men undergoing a radical prostatectomy for early-stage prostate cancer, according to research from The University of Texas M. D. Anderson Cancer Center.

The study, in the current issue of the Journal of Clinical Oncology, is the first to examine the benefits of psychosocial intervention for prostate cancer patients prior to surgery. It found that men who participated in the sessions experienced less short-term mood disturbance and better long-term quality of life, compared to patients who had the procedure but did not have any behavioral intervention.

Most psychosocial interventions in cancer of any type have been studied after patients have completed surgery, explained Lorenzo Cohen, Ph.D., the study's senior author and professor in M. D. Anderson's Departments of Behavioral Science and General Oncology, and director of the Integrative Medicine Program.

"We know that for men with early-stage prostate cancer, the time when they are making treatment decisions is very stressful," said Cohen. "A radical prostatectomy is not without possible, very personal, consequences, including urinary incontinence and erectile dysfunction. Patients may also be worried about the uncertainty that the surgery will cure their cancer.

"From other areas of research, we know that going into a surgical setting overly stressed may increase a patient's recovery time. With this study, we wanted to intervene in the pre- and post-surgical setting and try to help relieve stress and minimize mood disturbance, such as depression, anxiety and distress, both in the short- and long-term."

For the randomized study, 159 early stage prostate cancer, radical prostatectomy patients were assigned to receive either: two 60-90 minute sessions of pre-surgical stress management intervention and brief booster sessions the morning of, and 48 hours following surgery; two 60-90 minute individual supportive attention sessions and boosters similar to the stress management group; or standard care. Assessments occurred before the sessions, one month before, one week before, and the morning of surgery, as well as six weeks, six and 12 months following surgery.

The stress management was based on aspects of cognitive behavioral therapy. Men in the stress management group met with a clinical psychologist and were taught simple behavioral techniques, including diaphragmatic breathing and relaxing guided imagery and cognitive therapy. Those in the supportive attention groups met with the same psychologist, but sessions were more general, and centered around open discussions. Patients in the standard care group did not receive any behavioral therapy.

For the stress management group, the men were exposed to an imagery experience of the day of surgery - all the sounds and sensations from pre-op, to the recovery room, to coming out of anesthesia - while they were in a relaxed state. They were then taught cognitive skills to work with negative thinking and realistic expectations - so that patients could better manage any unexpected side effects during their recovery or difficulty healing.

The researchers found that in terms of short-term effects, assessed at one week before and the morning of surgery, men in the stress management group had the lowest levels of mood disturbance followed by those in the supportive attention group, with patients in the no therapy group having the highest level, with the difference between the stress management and standard care groups being statistically significant.

During the long-term follow-up, assessed at six weeks, six and 12 months, patients in the stress management group reported a higher level of physical functioning and aspects of quality of life than patients in the other two cohorts; the difference between the stress management and standard care groups was statistically significant.

The largest difference between the groups was at the 12-month follow-up, when the standard care group reported lower levels for physical functioning than those who received the stress management intervention. It's also interesting to note that at no point was there any statistical difference between the supportive attention and the other two groups, said Cohen.

Cohen and his team were surprised to see this level of difference in physical functioning during the long-term follow-up because the interventions in the pre- and peri-operative settings were so brief and mainly focused on aspects of stress management.

"We're trying to understand what is potentially associated with a patient's long-term quality of life and what was it that happened in the stress management group that resulted in a much better quality of life in the year post-surgery," Cohen said.

"Before we can suggest that stress management is useful prior to surgery for all men undergoing a radical prostatectomy, we need to better understand the mechanism behind our findings, as well as understand for whom this type of intervention will be the most useful," Cohen said. "However, that said, all diagnosed with cancer treatment should be encouraged to participate in any stress management program - be it mind-body, or cognitive in nature. We know that they are safe and may improve patients' well-being and help them adjust to a cancer diagnosis."

As a follow up, Cohen and his team are currently analyzing immune function and stress hormone levels from collected blood samples.
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Prostate cancer is the leading cause of cancer in men. According to the American Cancer Society, in 2008, 186,320 were diagnosed with, and 28,660 died from the disease.

The research was supported, in part, by funds from the National Cancer Institute.

In addition to Cohen, other authors on the study include, from M. D. Anderson: Patricia Parker, Ph.D., Adoneca Fortier, Danielle Carr, Ph.D., all of the Department of Behavioral Science; Curtis Pettaway, M.D., Richard Babian, M.D., and Louis Pisters, M.D., all of the Department of Urology; Qi Wei, Department of Palliative Care and Rehabilitation Medicine; and from Baylor College of Medicine, Brian Miles, M.D., of the Department of Urology.

About M. D. Anderson

The University of Texas M. D. Anderson Cancer Center in Houston ranks as one of the world's most respected centers focused on cancer patient care, research, education and prevention. M. D. Anderson is one of only 40 comprehensive cancer centers designated by the National Cancer Institute. For four of the past six years, including 2008, M. D. Anderson has ranked No. 1 in cancer care in "America's Best Hospitals," a survey published annually in U.S. News & World Report.

University of Texas M. D. Anderson Cancer Center

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