Dr. Dan Sperling
There’s a common expression about the elephant in the living room. It refers to a big uncomfortable problem that everyone knows is there but no one is talking about.
The media is bringing to our attention a big problem in men’s health. An unknown but sizable number of men who have depression, anxiety, suicidal thoughts, poor anger management, etc. suffer silently. The Association of American Medical Colleges (AAMC) asks this question: If men die by suicide four times as much as women, why are men with depression and mood disorders diagnosed at a far lower rate?
It’s not because men don’t seek counseling or therapy services. Studies show that 60% of men who took their own lives had sought help from mental health centers or other programs. AAMC theorizes that counselors and therapists may not be equipped to distinguish aspects of a man’s suffering that are unique to men due to societal biases that they “simply need to ‘man up’ and stop showing weakness, or that the symptoms they present are not consistent with diagnostic tools.”
I am not a mental health professional, but as a doctor specializing prostate cancer, I encounter anxiety and depression my patients every day. It’s not because of chronic mental distress. Rather, it’s situational. Their emotional or mental distress is understandable because they have prostate cancer. While any cancer diagnosis would be depressing, this is a man’s disease, and my patients are just as much affected by societal norms of manliness. While I’m here to treat and heal their bodies, I don’t want the elephant in the living room to be their feelings. Patients handle their prostate cancer journey better if given a chance to openly name what troubles them, and have it acknowledged and validated.
It’s not just about the cancer. For many, they’ve heard rumors that the cure may be even worse. If they’ve done online research or joined a support forum, they’ve read about side effect risks like urinary incontinence and erectile dysfunction. Their unspoken questions lurk in the background, affecting the decision-making process. I find that unless I gently ask about their inner feelings and fears, most of my patients keep them under wraps. I suspect that as men raised in a culture of “boys don’t cry,” they won’t express fear and anxiety over being tested, scanned, probed, cut open, radiated—whatever. Experts tell us that it’s healthier to express what’s going on, not “stuffing” feelings, so secret fears don’t hold one back from full freedom of choice when faced with possibly life-changing decisions.
In my experience, if given the chance and a trusted listener, it doesn’t take much for my patients to name the elephant in the examining room: Will I have to wear pads or diapers? Will I be able to perform in the bedroom? For how long? And of course, the biggest fear of all, am I going to die? When depression and anxiety accompany prostate cancer, it’s not mental illness, but the same patterns of communication barriers faced by men in chronic or emotional distress show up in my office.
Again, I’m not professionally qualified to treat men’s mental illness. However, I have a few things going for me to help support and ease patients through their feelings and concerns, and give them hope.
First, I live by every physician’s mandate, “above all do no harm.” I am fortunate that I entered the field of radiology during a period of rapid change in prostate cancer world. Breakthrough treatments at that time brought alternatives to surgical gland removal (prostatectomy) and whole-gland radiation. These new approaches made it possible to destroy a prostate cancer tumor without obliterating the whole gland. I am by nature an empathic man, so I not only understood the clinical good this would do, I could emotionally relate to it. These new approaches meant significantly reducing the risk of urinary and sexual side effects—a great way to do less collateral harm done by whole-gland treatments. What enabled such focal (targeted) treatments was revolutionary imaging called a multiparametric MRI prostate scan. It visually reveals key characteristics of a suspicious tumor, even bore a biopsy.
Second, I was fortunate to be in the vanguard of pioneers who developed a specific method of targeted treatment called Focal Laser Ablation, an effective alternative to whole-gland surgery or radiation. We now know that not every prostate cancer patient needs a whole-gland approach, because nowadays we can detect prostate cancer when it’s small and not very aggressive. For patients with such low-risk disease, Active Surveillance may be recommended as a way to hold off on treatment until triggered by new tumor activity or growth. Or, for a patient who psychologically isn’t comfortable with the idea of cancer growing in their body, we can determine if he’s a good candidate for a focal approach.
Third, I am blessed to have my own practice where my Center is equipped with a state-of-the-art magnet. I use it for tumor identification, to do a minimally invasive MRI-guided targeted prostate biopsy, and to provide MRI-guided focal therapy. In short, under one roof our MRI results enable us to plan, deliver, and verify a focal treatment. This gives me two advantages for diagnosing and treating men:
- With MRI imaging, biopsy and other lab analytics as needed, I’m able to efficiently generate a comprehensive portrait of each patient’s unique disease, since no two prostate cancer cases are identical. I have time to go over with each patient his images and test results so he understands what’s going on in his body. I have thorough information so I can lay out all treatment options (including whole-gland treatments) that are appropriate in his case, and work with him to develop a tailored treatment plant that matches his disease and his lifestyle preferences. Many patients who qualify for Active Surveillance or focal therapy choose to proceed with a focal procedure. They want the tumor gone while having the best hope of preserving potency. If they came in feeling depressed and anxious, they leave re-energized and ready to enjoy life.
- Just as important, in the process of doing all the above, the patient and I get to know each other. If he is going to entrust his fears, hopes, life and lifestyle to me, I have to earn it. I strive to do so with each patient, whether or not he chooses to be treated in my Center.
To return to the topic of men’s mental health, for prostate cancer patients there are published studies on “treatment regret.” Patients who, after treatment, feel that they made the wrong choice or ended up with unanticipated difficult side effects, become depressed and anxious. They are not mentally ill, but now they have a lingering mental health problem. Doctors who treat prostate cancer need full understanding of their patient’s disease. Equally, they need to know if there’s a frightened, depressed, anxious elephant in the waiting room.
