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Transcript of Vol. 102_05 Interview


Molly Wetterschneider: Welcome to the JNCI Podcast, a production of the Journal of the National Cancer Institute. I'm Molly Wetterschneider.


Molly Wetterschneider: In 2009, in the United States, 192,280 men received the diagnosis of prostate cancer, devastating news that would rattle the nerves of even the most easygoing of men. And while the cancer alone can be fatal, researchers have found that for some, just the stress of diagnosis and not the cancer itself can lead to death, either through suicide or through a fatal cardiovascular event. I spoke with Meir Stampfer, a professor of medicine at Hartford Medical School, and Lorelei Mucci, an assistant professor of medicine, also at Harvard Medical School. In Issue 5 of JNCI, they present a paper that explores the risks of suicide and cardiovascular death in patients that have been diagnosed with prostate cancer. Thank you for speaking with me, Dr. Stampfer, Dr. Mucci.

Lorelei Mucci: Thank you. Our pleasure.

Meir Stampfer: Nice to be here.

Molly Wetterschneider: You’ve just published a study in which you assess the risk of suicide and cardiovascular death after patients have been diagnosed with prostate cancer. Tell me a little bit about the study. I’ll start with you, Dr. Stampfer.

Meir Stampfer: Well, the study was based in the SEER program, the Surveillance, Epidemiology and End Results program, which encompasses over 300,000 patients diagnosed with prostate cancer. And we tried to determine what the risk of suicide and death from cardiovascular disease was at various time points after the initial diagnosis. We know that diagnosis of cancer is a stressful event. So our hypothesis was that the risk of both outcomes, suicide and cardiovascular disease, would be increased immediately after the diagnosis, and then over time, that would risk would decline.

Molly Wittershneider: And so suicide and cardiovascular death are both-- they were chosen specifically because they are clearly linked to stress.

Meir Stampfer: Correct.

Molly Wittershneider: And then why did you choose prostate cancer, specifically?

Meir Stampfer: Prostate cancer, first of all, is an area of research interest for our group, but it also poses a very interesting, unique situation for cancer because of the huge increase in diagnosis of prostate cancer, due to widespread PSA screening. So the nature of the disease which is diagnosed has changed dramatically over the last couple of decades. Years ago, most cases of prostate cancer were diagnosed because of the symptoms of the disease. But nowadays, after establishment of PSA screening, most cases are diagnosed based on the screening. So this change, we thought, would be very interesting to assess vis-à-vis its impact on stress and these particular outcomes.

Molly Wittershneider: Okay. Well, can you tell me what PSA screening is?

Meir Stampfer: PSA stands for prostate specific antigen, and it’s produced only in the prostate, and levels go up in the blood when either the prostate is enlarged or there’s prostate cancer present. And this blood test can point to a higher risk of the presence of prostate cancer years before any symptoms arise. PSA screening has become very common in the U.S., so most cases of prostate cancer are now found as a result of a PSA screening. Once the PSA levels go up, there’s a increased chance for a biopsy and therefore, an increased chance to find a prostate cancer.

Molly Wittershneider: So you found then that there was a difference in the risk for suicide and cardiovascular death, based on the difference in this PSA screening.

Lorelei Mucci: Well, our project didn’t directly look at PSA screening in the influence on cardiovascular mortality and suicide. What our project did look at was different time periods since 1979 and through 2004. So we looked at cases that were diagnosed many years ago and then cases that have been diagnosed more recently, since PSA screening has become much more common. But we didn’t directly have information about whether our cases were diagnosed because of PSA or not.

Molly Wittershneider: That was just insight that you had discovered that perhaps there could be a link between the two, based on the kind of data that you received from both time periods. That was the change in the environment.

Lorelei Mucci: Exactly, exactly. So prior to around 1990-- so PSA screening, as Dr. Stampfer mentioned, was introduced around 1987, 1988. Its frequency-- screening has become very common and it became very common quite quickly. So really, around 1993, screening was very common in the population. But still, for these cases diagnosed in the study, we don’t have information specifically about whether they were a cancer that was discovered as a result of screening or if it was discovered because of clinical symptoms or other symptoms.

Molly Wittershneider: So what kind of numbers are you looking at for these risks of death in suicide and cardiovascular disease? I mean, what numbers are we looking at the differences between, before and after, or between the patients with prostate cancer and the control group?

Lorelei Mucci: So we specifically looked at the year following a cancer diagnosis. And so among all 300,000 patients in our study, we had 148 men who died of suicide and 6,845 who died of cardiovascular disease. And for the suicide, we found this number of suicides was about 40 percent higher than what we would have expected among men in general. So if men hadn’t had prostate cancer, among these patients diagnosed with prostate cancer, there was a 40 percent increased risk during the first year. And in particular, if you look really within that first three months after cancer diagnosis, there was about a 90 percent greater risk of suicide, compared to men who had not been diagnosed with prostate cancer.

Molly Wittershneider: And that was overall, or simply during the pre-PSA screening time?

Lorelei Mucci: That was overall, so for all 300,000 of our patients, if you look across the whole study period. And so what we saw was, when you looked at for suicide risk now during this more recent

timeframe where a lot of PSA screening has been going on, there was no increased risk of suicide at all, either during the first year or during-- even when you look at the first three months, we saw no increased risks for suicide.

Molly Wittershneider: Tell me a little bit about prostate cancer, specifically. How does the prognosis for prostate cancer compare to other cancers? Is it more stressful to get a diagnosis of prostate cancer than other cancers? Or is it simply this cancer was chosen based on the data that you had?

Meir Stampfer: The prognosis for prostate cancer has improved very dramatically in the last few years. This is only partly due to improvement in treatment. It’s mainly due to the effects of widespread PSA screening, which picks up the diagnosis of prostate cancers that otherwise never would come to light. So through screening, many cases are being diagnosed that never would cause symptoms and never would cause death. So at this point, the five-year survival for prostate cancer, taken overall, is 99 percent. We believe that this improved- apparent improved prognosis probably explains why the risk of suicide has declined so much, compared to early years upon diagnosis of prostate cancer, because nowadays it’s so common.

Molly Wittershneider: Is there a sensitive area where the risk of death from stress of diagnosis is greater than the risk of death from the actual diagnosis, or late diagnosed disease? I mean that, obviously, since there was a transition from diagnosis being more of a death sentence at one time than it is now, but then you might assume that death due to stress as a risk would be greater during that time period.

Meir Stampfer: Yeah, you make a good point, that for many men, the value of having a diagnosis of prostate cancer, if the disease would not have any clinical impact anyway, is only going to be negative, not only because of increase in stress, but also because of unnecessary treatment. And we know that prostate cancer is very over-treated and over diagnosed. The big dilemma in the field is you can’t tell at the time of diagnosis exactly which cancers could be safely ignored, compared to those that require treatment. That was the central question in prostate cancer research.

Lorelei Mucci: I think one other interesting finding that relates to your question is the finding around cardiovascular death. Even in this current era of where there’s a lot of cancer screening going on, we actually still saw about a 50 percent increase of cardiovascular deaths during the first months.

Now, that risk is lower than what we saw for our cases diagnosed earlier in the time period of the study. But still, we see this elevated risk for cardiovascular deaths. So I think that goes to the fact that there’s still some stress around the diagnosis, even with this knowledge that prostate cancer does have a very good prognosis. I think, even though there is a lot of information in the public about prostate cancer and its prognosis, I think when a person first hears a cancer diagnosis and until had and his family have had a chance to do some research on what options there are and what this disease is about, there still can be this anxiety and stress. And I think you see this as a result in the findings that we have for cardiovascular mortality.

Molly Wittershneider: So conventional wisdom tells us that cardiovascular disease and suicide are related to stress; and so have you simply shown the obvious? That it’s extremely stressful to get bad news from your doctor? And if that’s what you’re showing, is it important for physicians to see studies such as this?

Meir Stampfer: Well, it is obvious, I think, that receiving a diagnosis of cancer is stressful. No one would dispute that, and certainly suicide and cardiovascular disease reflect stress. I think the point of interest here and my surprise, actually, at the results was that the level of stress induced by a diagnosis of prostate cancer was sufficient to actually increase mortality from these causes. So I think everybody would appreciate there’s some stress. But I don’t know if clinicians would really appreciate that, for some men, that stress would be enough to cause death.

Lorelei Mucci: I agree. And also, to give a sense about the relative increase and, on a relative scale, how significant the diagnosis is in impacting stress. And thinking about this, these are the extreme outcomes that can occur as a result of stress. And I think it makes you aware of even how much bigger impact stress may have on, for example, nonfatal cardiovascular events, as well as other issues around quality of life. And I think it goes to the importance of when the physician sits down with the patient and makes his diagnosis, that it will be important to start thinking not only about treating the cancer, but thinking about the patient as a whole person and how this may be impacting the man’s life.

Molly Wittershneider: Well, thank you both for your insight.

Lorelei Mucci: Thank you so much.

Meir Stampfer: Glad to help.

Molly Wittershneider: That was Dr. Meir Stampfer and Dr. Lorelei Mucci of Harvard Medical School. Look for their paper on the risks of suicide and cardiovascular death in patients that have been diagnosed with prostate cancer in Issue 5 of JNCI. You’ve just enjoyed another edition of the JNCE Podcast. Please check back in two weeks for our next audio update and a new issue of JNCI. Until then, love to hear from you. Send an e-mail to podcasts@oxfordjournals.org and let us know how we’re doing. In the meantime, you can find even more information on today’s topic, as well as news and commentary about cancer research online at jnci.oxfordjournals.org. Also, for the latest cancer news and studies, follow us on Twitter at jnci_now. I’m Molly Wittershneider. Thanks for listening.