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Just 2 hours of teaching men with prostate cancer how to self-manage their stress improves their ability to cope with their fears of undergoing radical prostatectomy.
Moreover, the effects of learning how to manage their stress are long-lasting, and could result in less cost to the health care system, according to a poster presented at the annual meeting of the American Society of Clinical Oncology.
Researchers at the University of Texas M.D. Anderson Cancer Center and Baylor College of Medicine, both in Houston, randomized 150 men with early-stage prostate cancer attending their urology clinics to receive stress management, supportive attention, or usual care.
"Our aim was to see whether incorporating presurgical stress management into the treatment plan prior to undergoing radical prostatectomy would help decrease stress and anxiety going into the perioperative environment, as well as help with quality of life afterward," lead investigator Lorenzo Cohen, Ph.D., explained in an interview.
Stress management consisted of two individual sessions, each 45-60 minutes long, with a clinical psychologist 2 weeks before surgery. During those sessions, the men were taught relaxation techniques including diaphragmatic breathing and guided imagery. They also received coaching on what would happen on the day of surgery and were given coping skills to use after their surgery. In addition, they had one brief, 5-10-minute session on the morning of their surgery, and another brief session 2 days after surgery. The men were also given a stress management guide and an audiotape to help them practice deep breathing and guided imagery at home.
Supportive attention consisted of two individual sessions, each 45 to 60-minutes long, with a clinical psychologist 2 weeks before surgery, in which the men discussed their fears but were not taught any relaxation skills. They also had two brief sessions—one on the morning of surgery and one 2 days afterward. The third group received standard medical care, and did not meet with a psychologist.
All men completed psychosocial and quality-of-life measures at baseline and 6 and 12 months after surgery. Most men were Caucasian (78%), married (85%), and highly educated (80% with some college or higher education).
After controlling for age, ethnicity, marital status, disease stage, baseline prostate-specific antigen, Gleason score, and baseline test scores, the researchers found that men who received either stress management or supportive attention had significantly less distress in the week prior to surgery than did the usual-care group.
On the morning of surgery, the men who learned to manage their stress had the least distress, followed by the men who received supportive attention. The men who received usual care had the greatest distress, the researchers found.
"There was a clear dose-response effect, which emphatically showed us that a very brief, two-session encounter can really buffer some of the distress and anxiety about going into surgery," said Dr. Cohen, chief of the integrative medicine section in the department of palliative care and rehabilitation medicine at M.D. Anderson Cancer Center.
Conceding that such a result might have been anticipated, Dr. Cohen said he and his colleagues were astonished to discover that the effects of stress management persisted 1 year later. "These patients had less interference in their ability to engage in physical functioning, reported less bodily pain, and reported better general health scores as far out as 12 months later. That such a brief, two-session intervention would have impacts on patients 12 months later came as quite a surprise, but this was a randomized controlled trial and that's what the data show," he said.
Dr. Cohen noted that other researchers also are finding that relaxation techniques result in fewer complications, faster procedures, and less pain and distress for patients. As an example, he cited Dr. Elvira V. Lang of Harvard University, who is using self-hypnosis to relax patients while they undergo invasive medical procedures such as cardiac catheterization and breast biopsy.
"Such stress reduction interventions should be part of the standard of care. So far, they are not. But these results strongly suggest that one needs to incorporate some form of stress management prior to the acute stress of surgery," he said.
Cohen L. et al. Long-term effects of pre-surgical stress management for men with early stage prostate cancer undergoing radical prostatectomy (RP). Abstract 5148.
Commentary |
As a urologic surgeon and patient advocate, I applaud the authors for their novel and important study. They performed a randomized prospective trial comparing standard care with structured relaxation technique training and surgical education with surgical education without relaxation technique training. Even after 1 year, the patients who had structured relaxation technique training had enduring benefits. While I think this study is great, I am not surprised. Patients who get more education and coaching have better, more satisfying outcomes. Unfortunately, these high-intensity preoperative sessions and coaching are generally "unfunded mandates." Most insurers do not reimburse adequately for these efforts, and ever-more-burdened urologists do not have adequate time to address these issues. Perhaps this study will lead to insurance coverage for preoperative clinical psychology sessions. In our practice, we provide all patients with a preoperative educational packet containing general prostate cancer educational materials and site-specific comprehensive information about surgery (www.dukehealth.org/Services/ProstateCancer/Treatments/Surgery). While this is better than nothing and saves us some time in clinic, the "hands-on" approach employed in this study and a clinical psychologist on the "prostate care team" clearly is preferred if available. Not only should we teach stress management, but we also should coach patients about sexual function rehabilitation and recovery of urinary continence as well. Personally, I feel that the best surgeons are not just those who are master technicians, but also those who take an active role in the coaching and critical support both preoperatively and in the critical 6-12 months after the operation! — Judd W. Moul, M.D.
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