New Challenges in Psycho-Oncology Research III: A systematic review of psychological interventions for prostate cancer survivors and their partners: clinical and research implications
2017; Wiley; Volume: 26; Issue: 7 Linguagem: Inglês
10.1002/pon.4431
ISSN1099-1611
AutoresSuzanne K. Chambers, Melissa K. Hyde, David P. Smith, Suzanne Hughes, Susan Yuill, Sam Egger, Dianne L. O’Connell, Kevin Stein, Mark Frydenberg, Gary Wittert, Jeff Dunn,
Tópico(s)Global Cancer Incidence and Screening
ResumoThe medical and social context of prostate cancer (PCa) has changed dramatically since the introduction of PSA testing for early detection in the late 1980s,1 leading to a peak in incidence in the developed world in the 1990s and again a decade later.2 Since that time, novel PCa treatments have rapidly emerged in the radiation and medical oncology field, as well as surgical advances.3 The recent emergence of active surveillance for low-risk disease has further expanded possible treatment approaches.4 Market forces from consumers, clinicians, and the therapeutic industry have driven changes in clinical and surgical management and treatment; however, psycho-oncological research and survivorship care arguably has lagged behind. Specifically, although men are surviving longer, they may not be surviving well. In 2012, there were over 1.1 million incident cases of PCa diagnosed and more than 300 000 deaths worldwide.5 Five-year prevalence estimates suggest that there are over 3.8 million PCa survivors globally6 with this expected to increase rapidly in future.7 The challenges we face in meeting the needs of these men and their families into the future are vast. Up to 75% of men treated for localised PCa report severe and persistent treatment side-effects including sexual dysfunction, poor urinary or bowel function.8 Psychosocial concerns are prevalent with 30%-50% of PCa survivors reporting unmet sexuality, psychological, and health system and information needs9, 10 and 10%-23% of men clinically distressed.11 Risk of suicide is increased after PCa diagnosis12, 13 and can persist for a decade or more.14 In the longer term, 30%-40% of PCa survivors report persistent health-related distress, worry, low mood15 and diminished quality of life (QoL).16 Partners of PCa survivors also experience ongoing psychological concerns and changes in their intimate relationships17; with these impacts driven in part by the man's level of distress, sexual concerns and physical QoL.18 In 2011, our group published the first criterion-based systematic review of psychosocial interventions for men with PCa and their partners.19 We concluded that group cognitive-behavioural interventions and psycho-education appeared to be helpful in promoting better psychological adjustment and QoL for men with localised PCa, and coping skills training for female partners may improve their QoL. However, data were limited by inconsistent results and low study quality. In response to the increasing burden of PCa, uncertainties about optimal psychosocial care, and additions to the literature, we updated and extended this review with the intent of determining benefit and acceptability, and considering intervention content and format. In brief, we considered the range of psychosocial and psychosexual interventions that may be optimal, and for whom. Two clinical questions guided the review20: In men diagnosed with PCa (Q1) and/or in their partners/carers (Q2), what is the effectiveness of different psychosocial or psychosexual interventions compared with (i) other psychosocial or psychosexual interventions, or (ii) usual care or no intervention, in maintaining or improving QoL or psychological wellbeing? Psychosocial or psychosexual interventions were included if they had one or more of the following components: education (psycho-education, psycho-sexual education, PCa education), cognitive-behavioural (cognitive restructuring, behaviour change, cognitive-behavioural stress management), relaxation (relaxation techniques, meditation), supportive counselling (counselling/psychotherapy, health professional discussion), peer support (peer support, social support including discussion within a group of peers), communication (skill development to encourage communication with partners, health professionals or generally) and decision support (aids or tools to assist decisions about PCa treatment or use of sexual aids). The review and reporting of results were guided by the PRISMA statement.21 Ethical approval was not required. Our prior review (until December 1, 2009) identified 195 articles that met criteria for the current study.19 Searches were updated from 2009 onwards. Eleven relevant databases were searched (eg, MEDLINE, Embase, PsycINFO, and CINAHL; Figure 1) up to January 9, 2017. Free-text terms and database-specific subject headings for PCa and psychological and QoL outcomes were used (Appendix A shows full search strategies). Reference lists of included articles were also searched. ClinicalTrials.gov (http://clinicaltrials.gov/) (June 2016) and the International Clinical Trials Registry Platform (http://apps.who.int/trialsearch/) (October 2016) were searched for ongoing and completed trials and associated publications. Two authors reviewed titles and abstracts and excluded irrelevant articles and duplicates. Full-text articles that potentially met criteria were then retrieved and reviewed by one author. A random sample of 5% of articles was assessed for inclusion by 2 authors with 100% agreement achieved. One author extracted pre-specified study characteristics (eg, participant demographics, PCa treatments, intervention content, delivery and results) and another checked each extract. To support data extraction, published descriptions of interventions were content analysed to create a framework of common psychosocial or psychosexual intervention components (Appendix B). The Cochrane Collaboration's tool was used to assess risk of bias regarding sequence generation, allocation concealment, blinding of participants and personnel collecting outcome data, incomplete outcome data, selective outcome reporting, and other sources (eg, difference in follow-up between arms).22 Blinding is difficult to achieve in psychological trials where consent mechanisms require participants to understand differences in treatments, which are often clearly discernible to the participant (eg, therapist-delivered intervention vs self-help materials).19 On this basis, blinding was excluded from assessment. Clinical trial registries at https://clinicaltrials.gov/, http://www.isrctn.com/, and http://www.anzctr.org.au/ were searched for protocols of included studies to identify pre-specified outcomes and determine whether there was a risk of bias from selective outcome reporting. Differences in evaluations were resolved by discussion and where necessary adjudication by a third author. The criteria of Yanez et al23 were used to identify and evaluate aspects of interventions that indicate acceptability: ≥40% recruitment rate, ≥70% retention at end of intervention or follow-up (or <30% withdrawal), and ≥70% average intervention attendance. It was anticipated that some trials may be underpowered.19 Thus, an intervention was considered potentially beneficial compared with usual care or better than another intervention if for at least one reported outcome (at the longest reported follow-up), there was in favour of the intervention(s): (i) a statistically significant difference between arms; (ii) a moderate or large standardised effect size (eg, Cohen's d ≥ 0.5, η2 ≥ 0.06); or (iii) a difference in mean score changes from baseline calculated by ANCOVA or multiple linear regression between arms ≥10% of the scale of the differences in means. For a given measurement scale, results from subscales were only considered in the absence of an overall score. In all, 6631 citations were identified of which 161 full-text (including 16 identified from reference lists) were retrieved and evaluated as well as 195 articles from the prior review.19 Of the total 356 full-text articles assessed for inclusion, 68 articles met criteria and reported a total of 57 RCTs. Forty-one RCTs reported in 51 articles (2 publications for 10 studies) included only patients (Q1); 1 RCT included only partners (Q2); 15 RCTs reported in 16 articles (2 publications for 1 study) included patients and partners (Q1 and Q2) (Figure 1). Most studies were excluded because of study design or population not meeting criteria, or results for patients or partners/carers were not reported. Clinical trial registry searches identified 47 trials: 25 completed (16 included in the review); 20 ongoing; 2 terminated (slow accrual, funding unavailable). Risk of bias from sequence generation (61% Q1; 64% Q2) and allocation concealment (71% Q1; 79% Q2), was unclear, and high for incomplete outcome data (43% Q1; 43% Q2) for most studies. Risk of bias from selective outcome reporting was also high for majority of partner studies (43%) and unclear for patient studies (63%). Most studies were low risk for other sources of bias (70% Q1; 86% Q2) (Appendix C). Included trials randomised 8378 men (range 27-740; 48% of trials had <100 participants), and 1313 partners (range 27-263; 57% of trials had 90% partners were female in 14 trials; >80% partners were spouses in 12 trials). Most (67%) trials were conducted in North America. In 10 trials (4 including partners), participation was determined by socio-demographic background (eg, African-American), emotional state (eg, distress), or QoL (eg, urinary or sexual dysfunction, ADT treatment side-effects, fatigue). When reported, mean or median age was below 65 years in 49% of trials for patients and below 65 years in 100% of trials for partners. In approximately half of trials (57% of patient trials, 40% of partner trials) reporting college/university education, >50% of participants were university/college educated. In 25 trials (45%), men were diagnosed with or treated for localised disease in the previous 6 months (14 trials enrolled men prior to treatment or treatment decision). Men with recurrent or metastatic disease and their partners were included in 16% and 21% of trials, respectively. The number of relevant outcomes measured by trials varied from 1 to 16 (patient) and 2 to 12 (partner). Most common outcomes for patients were sexual bother and/or function and mental health; and for partners were relationships, general and cancer-specific distress. Trials reported 41 patient, 1 patient and partner, and 1 partner person-focused (targeted and delivered to the individual or person) interventions and 14 couple-focused interventions (targeted and delivered to the couple as a dyad) (Appendix D). Most interventions were compared with usual or standard care; however, what the comparison group entailed was rarely described. Follow-up ranged from immediately post-intervention to approximately 19 months (person-focused, Median = 3 months) or 12 months (couple-focused, Median = 6 months) post-intervention. Trials comprising interventions that were person-focused were more acceptable than couple-focused interventions (recruitment: 72% vs 29%; retention: 74% vs 64%). Approximately 40% of person and couple interventions indicated acceptable mean attendance (Table 1). Three trials reported couple-focused interventions that, compared with usual care, increased partner distress about sexual function,24 worsened partner challenge appraisal,25 and reduced relationship satisfaction and intimacy for partners who had high levels of these constructs at baseline26 (Appendix D). By contrast, for patients, all intervention effects indicated improvement. Four trials included outcomes of interest27-30 but did not report comparative results and were excluded. The remaining 29 trials (21 person-focused: 20 patients, 1 partner and patient; 8 couple-focused) showed a benefit for psychosocial or psychosexual outcomes (Table 2). Most (80%) person-focused interventions were for men with localised disease. Of the effective interventions, most (95% person-focused, 86% couple-focused) significantly impacted patient outcomes. No person-focused trials had a significant effect on relationship outcomes. No couple-focused trials improved decision-making outcomes or fatigue. No trials had a significant effect on partner QoL or sexuality outcomes regardless of intervention focus. Table 3 reports intervention components. Badger 2011,2013 Patients + partners 1. Interpersonal psychotherapy + cancer education: patient and partner 2. Health education attention: patient and partner 1. E, SC, PS, C 2. E 1. Nurse or social worker 2. Research assistants Depression • Patient • Partner Negative affect • Patient Stress • Patient Fatigue • Patient • Partner Social well-being • Partner Spiritual well-being • Patient • Partner P < 0.001 P < 0.05 P < 0.001 P < 0.001 P < 0.01 P < 0.01 P < 0.01 P < 0.01 P < 0.01 8 (patients) or 4 (partners) individual telephone sessions over 8 weeks Bailey 2004 Uncertainty management: cognitive reframing tailored to patient needs 5 weekly individual telephone sessions UC E, CB, C, DS QoL P = 0.01 Berry 2012,2013 Decision support 1 individual internet session UC E, C, DS Self-admin Decisional uncertainty P = 0.04 Campo 2014 Qigong 24 twice weekly group face-to-face sessions Stretch control R Fatigue Distress P = 0.02 P = 0.002 Carmack-Taylor 2006,2007 1. 30 minutes expert speaker or facilitated discussion 2. 90 minutes expert speaker or facilitated discussion Both interventions 21 group face-to-face sessions over 6 months 1. E, PS 2. E, PS Anxiety Depression Sub-group P = 0.02 Sub-group P = 0.002 Chabrera 2015 Decision aid Individual printed UC Self-admin Chambers 2013 740 Telephone psycho-educational 5 individual sessions: 2 pre-tx, and 3 weeks, 7 weeks and 5 months post-tx UC E, CB, R, DS Cancer-specific distress Mental health Sub-group P < 0.008 Sub-group P = 0.04 Diefenbach 2012 1. Prostate Interactive Educational System with or without tailoring to patient's information seeking style (combined results from arms) 1 individual internet/CD-ROM session 2. Control Read Standard National Cancer Institute booklets on PCa for 45 minutes 1 individual booklet 1. E, DS 2. E Confident about tx choice Prefer more information P = 0.02 P = 0.02 Hacking 2013 Decision navigation 1 individual face-to–face or telephone session, audiotape and written notes UC DS Decisional self-efficacy Decisional regret P = 0.009 P = 0.04 Lepore 2003; Helgeson 2006 250 1. Education + group discussion (with family member/friend) 2. Education Both 6 weekly face-to-face group sessions Standard medical care 1. E, PS 2. E Mental health Depression Sexual bother Sub-group P < 0.05 Sub-group P < 0.05 P < 0.01 Mishel 2009 252 1. Decision navigation: Patient only 2. Decision navigation: Patient and support person Both information + telephone calls to review content, identify/formulate questions and practise skills delivered to patient and/or support person individually (not dyad) Both individual/couple booklet, DVD and 4 telephone calls over 7-10 days Control 1. E, SC, C, DS 2. E, SC, C, DS Decisional regret P = 0.01 Penedo 2006; Molton 2008 191 1. 10-week group CB stress management techniques + relaxation training 10 weekly group face-to-face sessions 2. Half-day stress management seminar (same content) 1 group face-to-face session 1. E, CB, R, SC, PS, C 2. E Cancer-related QoL Sexual function P < 0.05 Sub-group P < 0.05 Penedo 2007 1. 10-week group CB stress management techniques + relaxation training 10 weekly group face-to-face sessions 2. Half-day stress management seminar (same content) 1 group face-to-face session 1. E, CB, R, SC, PS, C 2. E Cancer-related QoL P = 0.006 Petersson 2002 Group rehabilitation programme (only or + individual support) including psychosocial components + physical activity 8 group face-to-face sessions over 8 weeks + booster group session after 2 months + written information E, CB, R Sub-group P < 0.01 Schofield 2016 Nurse-led group psycho-educational consultation 4 x group face-to-face sessions (beginning, mid, completion, and 6 weeks post-radiotherapy) + 1 individual session after 1st group consultation UC E, PS, C Depression P = 0.0009 Siddons 2013 60 CB group intervention 8 group face-to-face sessions over 8 weeks Wait-list E, CB, R, C 8 weeks (end of intervention) Masculine self-esteem Sexual confidence Sexual QoL Orgasm satisfaction P = 0.037 P = 0.001 P = 0.046 P = 0.047 Traeger 2013 257 1. 10-week group CB stress management techniques + relaxation training 10 weekly group face-to-face sessions 2. Half-day stress management seminar (same content) 1 group face-to-face session 1. E, CB, R, SC, PS, C 2. E Emotional well-being P < 0.05 Weber 2004 Peer support 8 individual face-to-face sessions over 8 weeks UC PS Sexual bother P = 0.014 Weber 2007 a,b 72 Peer support 8 individual face-to-face sessions over 8 weeks UC Depression Self-efficacy P = 0.03 P = 0.005 Wootten 2015, 2016 1. Online psycho-education + moderated peer online forum (PsychE + F) 6 individual sessions over 10 weeks 2. Moderated peer online forum (F) Individually accessed over 10 weeks 1. E, CB, PS, C 2. PS Distress Decisional regret Sexual satisfaction P = 0.02 P = 0.046 Sig level NR, Difference 1.24 (95%CI 0.25-2.22) Yanez 2015 1. CB stress management + relaxation/stress reduction techniques 10 weekly group online sessions 2. Health promotion attention-control 10 weekly group online sessions 1. E, CB, R, PS, C 2. E Depression Cohen's d 0.5 Campbell 2007 Partner assisted coping skills training 6 ~weekly dyadic telephone sessions UC E, CB, R, C Sexual bother •Patient Depression • Partner Cohen's d 0.5 0.5 Chambers 2015 1. Peer-delivered telephone support 2. Nurse-delivered telephone counselling 8 (recruited pre-surgery) or 6 (recruited post-surgery) dyadic telephone sessions: 2 pre-surgery and/or 6 post-surgery over 22 weeks 1. E, CB, PS, C 2. E, CB, SC, C, DS Use of ED tx Patient p < 0.01 Couper 2015 Cognitive-existential couple therapy 6 weekly dyadic face-to-face sessions Relationship function Partner P = 0.009 Giesler 2005 Patient data only Post-tx nursing support 6 monthly dyadic sessions; 2 face-to-face and 4 telephone sessions Sexual limitation Cancer worry P = 0.02 P = 0.03 Manne 2011 Intimacy-Enhancing Therapy 5 dyadic face-to-face sessions over 8 weeks E, CB, SC, C Cancer concern • Patient Cancer-related distress • Partner Relationship satisfaction • Partner Intimacy • Partner Sub-group P = 0.02 Sub-group P = 0.02 Sub-group P = 0.0002 Sub-group P = 0.001 Thornton 2004 Pre-surgical communication enhancement 1 dyadic face-to-face session SC, C Stress Partner partial η2 = 0.12 Titta 2006 Patient data only Intracavernous injection-focused sexual counselling for couples following patient training in PGE1-intracavernous injections Six 3-monthly dyadic face-to-face sessions Control (partner invited to follow-up visits every 3 months) Erectile function Sexual satisfaction Sexual desire P < 0.05 P < 0.05 P < 0.05 Walker 2013 Educational intervention for couples to maintain intimacy 1 dyadic face-to-face session + booklet Intimacy •Patient Dyadic adjustment • Patient • Partner Cohen's d 0.6 1.0 0.5 Six trials improved patient decision-making mostly for men diagnosed with early stage disease and/or recruited prior to treatment. Decision support, aid, or navigation reduced patient uncertainty,31, 32 conflict,33 and regret34, 35 about their treatment decision, and a combined online psycho-educational intervention and moderated peer forum also reduced regret.36, 37 Patient self-efficacy or confidence in their decision-making was increased by decision navigation34 and interactive education interventions.38 An uncertainty management intervention improved QoL for patients on watchful waiting.39 In 2 trials, a 10-week cognitive-behavioural stress management intervention improved cancer-specific QoL for patients with early stage disease.40-42 Participants who received Qigong43 or a health education intervention44, 45 experienced reduced fatigue. Five trials reported better sexuality outcomes (80% of trials included majority of men who had radical prostatectomy). Combined education and group discussion,46, 47 and peer support,48 decreased sexual bother. A 10-week group cognitive-behavioural stress management intervention improved sexual function for men treated with prostatectomy (88% erectile dysfunction (ED)) who had high interpersonal sensitivity.40, 41 Sexual satisfaction improved for patients in a combined online psycho-educational intervention and moderated peer support forum.36, 7 Only one trial improved multiple sexual outcomes; in addition to increased sexual QoL and orgasm satisfaction, Siddons et al49 reported increased masculine self-esteem and sexual confidence for men treated with radical prostatectomy (90% ED) and who received a cognitive-behavioural group intervention. Overall, 60% of trials reported follow-up immediately following or close to intervention delivery. Eleven trials improved patient mental health outcomes. Patients receiving a combined online psycho-educational intervention and moderated peer forum had less distress.36, 37 Qigong also decreased distress43; and a nurse-led psycho-education intervention50 and peer support51, 52 reduced depression. In 2 trials, a 10-week cognitive-behavioural stress management intervention improved emotional well-being53 and depression.23 Mental health and cancer-specific distress improved in younger, more highly educated patients who received a tele-based psycho-educational intervention.54 A multi-modal intervention including cognitive-behavioural therapy also reduced cancer-related distress (avoidance) in patients with a monitor (cognitive scanning) coping style.55 Patients with high-baseline depression or anxiety showed improvement in these constructs if they were allocated to either a multi-modal intervention including either 30 or 90 minutes of an expert speaker/facilitated discussion.56, 57 In another trial, patients with lower baseline depression were less depressed if they received a combined education and group discussion intervention.46, 47 In this same study, patients with lower self-esteem at baseline had less depression and better mental health if they participated in either a combined education and group discussion or education only intervention. One trial improved patient and partner mental health outcomes.44, 45 Patients in the health education attention intervention had less depression, negative affect, stress, and greater spiritual well-being. Effects on stress were more pronounced for men who were less educated, and greater reductions in depression were experienced if men were older, had lower PCa-specific QoL, active chemotherapy, less social support or cancer knowledge. Patients receiving combined psychotherapy and education had more positive affect if they were more highly educated, had higher PCa-specific QoL, or more social support. Partners in the health education intervention had improved depression, social, and spiritual well-being.44, 45 Intimacy-enhancing therapy increased cancer-specific QoL for patients with early stage disease and higher symptom-related concerns at baseline.26 Four trials improved sexuality outcomes for patients only. Coping skills training reduced sexual bother,58 and intracavernous injection-focused sexual counselling increased patient sexual function, sexual satisfaction, and desire.59 Post-treatment nursing support lessened the extent to which sexual dysfunction interfered with spousal role activities.60 Prostate cancer nurse-delivered and peer-delivered telephone counselling interventions uniquely reported increased use of ED treatment at 12-month post-recruitment follow-up for men with localised disease who had prostatectomy.61 Mental health was improved in 5 trials, predominantly for partners. Coping skills training reduced partner's depressed mood.58 Pre-surgical communication enhancement intervention reduced partner stress.62 Cancer-related distress lessened in younger women receiving cognitive-existential couple therapy,63 and partners with high levels of baseline distress receiving intimacy enhancing therapy.26 Cancer-related worry also reduced for patients receiving post-treatment nursing support.60 Three trials improved relationship outcomes, mostly for partners. Cognitive-existential couple therapy enhanced relationship function for female spouses.63 Intimacy enhancing therapy was associated with improved partner relationship satisfaction and intimacy for partners with lower baseline scores on these variables.26 Education to maintain intimacy also improved intimacy for patients starting ADT, and dyadic adjustment for patients and their female partners.64 Effective person-focused interventions were most commonly delivered in an individual (53%) or group (47%) setting; face-to-face (50%), via telephone (26%) or online (26%); by a psychologist/counsellor (41%), nurse (29%) or self-administered (26%). Couple-focused interventions were delivered to dyads most commonly face-to-face (67%) or by telephone (44%); by a psychologist/counsellor (44%) or nurse (22%). Psychosocial and psychosexual intervention can improve decision-related distress, mental health, domain-specific, and health-related QOL in men with PCa. Combinations of educational, cognitive behavioural, communication, and peer support have been most commonly applied and found effective; followed by decision support and relaxation; and to a much lesser extent supportive counselling. These components were often used in a multi-modal approach, and delivered through both face-to-face and remote technologies, with therapist, nurse or peer support. In sum, multi-modal psychosocial and psychosexual care for men with PCa, particularly localised disease, is both acceptable and effective. The evidence is less clear for the female partners of these men and couples as a dyadic unit. Couple-focused interventions were the least acceptable approach and almost half of the couple interventions produced poorer outcomes for partners. When couple interventions were effective, they improved relationship outcomes for the partner but not the man; had a positive effect on the partner's mental health but conversely; improved sexuality outcomes for the man but not the partner. No interventions improved sexuality outcomes for female partners. Based on these results, effective and acceptable interventions for female partners and couples remain an area of uncertainty. It may be that couples interventions have been primarily focused on the PCa survivor's needs, leaving the partner's concerns poorly managed. This is an area where significant further work is required to understand the needs and preferences of couples, and to determine approaches to improve sexual and relationship satisfaction for both partners. Limitations of the research to date include small sample sizes; low statistical power; suboptimal statistical methods in some studies; inconsistency in measurement approaches; a lack of diversity in participants—particularly with regards to gay and bisexual men; men with advanced PCa; and men from socio-economically deprived; and non-Anglo-Saxon backgrounds. Long-term survivorship outcomes (>2 years) are yet to be addressed. In addition, intervention components were often described in a vague way such that it was not always clear what was actually delivered; and treatment fidelity and therapist adherence was in most studies not well described. Strengths of the current review by comparison with previous reviews include a departure from a narrow focus on specific intervention type(s), single outcomes, or sub-groups; a consideration of acceptability as well as statistical significance; and examination of not only intervention effectiveness but also who benefits by considering the influences of socio-demographic and medical characteristics of men and their partners; intervention format and delivery; and acceptability. Standards for psychosocial care with regards to screening for distress are now widely accepted,65 and the validity of the distress thermometer for men with PCa is well established with clear cut-offs for caseness.11 In this review, approximately one-quarter of interventions reported effects moderated by socio-demographic or psychosocial variables; with age, educational level, domain-specific QOL, baseline mental health, and social support important considerations in designing care. Hence, as well as taking into account levels of distress, it is also important to consider factors that both moderate intervention effectiveness and place men at risk of greater psychosocial distress and poorer QOL (such as age, domain-specific QOL, socio-economic deprivation) over the longer term.16 Survivorship care plans for PCa will need to be stepped according to the type and depth of need.66, 67 In conclusion, there is sufficient evidence to recommend multi-modal psychosocial and psychosexual interventions for men with PCa; with distress screening and risk and need assessment built in to tailor support to the individual. As yet, there is insufficient evidence to confirm the optimal approach for female partners and couples. We note that in this review education and communication support was commonly applied effectively across both person and couples-focused interventions. By contrast, supportive counselling was often used for couples, whereas for patients peer support was more common. This may reflect in part what support methods are acceptable to men. Care approaches also need to consider the impact of PCa on men's masculine identities and embed sensitivity to these masculinities in psychosocial and psychosexual interventions in a way that extends beyond a reductionist focus on erectile dysfunction.65 There is a need for improvement in the field in study quality, especially with regard to treatment fidelity. Where interventions are multimodal better clarity about therapy components would assist application by clinicians. There remain gaps in knowledge about effective intervention
Referência(s)