Dr. David E. Victorson is a clinical psychologist and Associate Professor at Northwestern University’s Feinberg School of Medicine in Chicago, Illinois.
Prostatepedia spoke with him about a trial he’s running on mindfulness meditation and active surveillance for prostate cancer.
Why did you become a clinical psychologist? How did you end up working with cancer patients?
Dr. David E. Victorson: My training was in clinical health psychology and behavioral medicine. A lot of my early training experiences were in cancer, and in some of those, I had the opportunity to work with men with prostate cancer and their spouses in a clinical capacity.
The reasons why I went into this area are multifaceted, but I would say one of the primary reasons is that there is so much that we can do with our own behaviors and lifestyle practices. There is so much good that we can do for our own health by ourselves without needing any heavy equipment or extreme intervention. A lot of times, it just takes a little nudge in a different direction to get people going on a path that will be incrementally better for them.
How do you usually work with patients?
Dr. Victorson: I don’t work with patients in a clinical therapeutic capacity today. I do 100% research. In 85-95% of our research studies, however, we deliver psychosocial and behavioral clinical interventions. Sometimes you might call them self-management interventions. A lot of them are prostate cancer-focused.
Usually, we involve spouses. We help men and their spouses learn skills that can support their health and well-being in different ways.
Most of those studies are group-based, bringing groups of men and their spouses together for classroom skills.
I’m sure that the skills you teach are useful beyond a cancer diagnosis.
Dr. Victorson: They are. A lot of the things we do are applicable across a whole range of different diseases and conditions. People who don’t have a disease can still benefit. But when you get a prostate cancer diagnosis, modifiable health behavior comes into the picture quickly in terms of diet and exercise.
What we’re trying to do with our meditation study is along the lines of mood management, which can be really important in the context of cancer. There’s nothing like a cancer diagnosis to motivate a person to make that kind of lifestyle change. I’ve heard that before, especially when it comes to exercise and prostate cancer.
Dr. Rob Newton told me that cancer patients tend to be more motivated than cardiovascular disease patients, for example. (See Prostatepedia December 2017.)
Dr. Victorson: Right.
What will you be doing in this particular trial? Why mindfulness education in an active surveillance population?
Dr. Victorson: We are comparing our eight-week mindfulness intervention with a matched attention control program. We anticipate that the attention control program is also going to lead to positive health changes, but we hypothesize it will be different than the mindfulness program.
This is a blinded trial, and men and their partners won’t know what group they’ll be put into outside of the fact that it’s a health promotion intervention. This can be challenging for recruitment when you don’t know what you’re signing up for.
All the men will know is that we are testing two different health promotion and wellness interventions that have been shown to be good for men with prostate cancer. That’s about as far as we go.
Most people who sign up really like it, but they don’t even know that they’re signing up for a mindfulness intervention. We’re not trying to deceive anyone, but we need it to be blinded like this to increase the rigor of our results.
Why mindfulness? As we’re doing a better job of prostate cancer screening, we’re finding more indolent or lower grade prostate cancers. Many of these cancers don’t need to be surgically removed or radiated. Active surveillance is becoming a more possible management paradigm. We know that trend is only going to continue.
Many patients are happy with active surveillance. But there are others who, because of how they grew up or because of what cancer means to them, equate cancer with death. When they’re told they have a tumor, they just want it out.
We’re dealing a specific demographic. Older men might be used to the idea of just wanting to get the situation fixed. That’s how they may cope. We’re also dealing with a treatment culture in which active surveillance hasn’t totally caught on. There are still quite a few urologists who recommend what they were trained to recommend: surgery or radiation even for a very low-grade tumor.
There is a certain type of man who will leave active surveillance after one to three years for definitive therapy even when it may not be medically warranted. This shift may be more connected to them wanting peace of mind and just wanting the cancer out.
I always try to say to patients, “If that’s what it’s going to take for you to get peace of mind, more power to you. You know better than me. I don’t have prostate cancer.” But at the same time, as a health psychologist involved in behavioral medicine, I know that there are other ways to help men manage their anxiety than through surgery.
Therefore, we’re exploring which behavioral approaches can be delivered to keep men on active surveillance longer when it is medically warranted. If their physicians say that they can stay on active surveillance longer, we try to support that. You’re hoping that with mindfulness meditation you’ll be able to help men stay on active surveillance longer.
Could mindfulness ultimately be a routine part of active surveillance programs?
Dr. Victorson: Yes. That is the 30-year career goal. We’re not going to be able to answer that question from this five-year trial, though. One of the biggest indicators of peace-of-mind-related departure from active surveillance is uncertainty intolerance and fear of progression. Those two things can form a powerful cocktail that might drive a man to leave active surveillance prematurely. Some men are able to tolerate uncertainty and fear of progression more than others.
We know that mindfulness training can be very useful in helping someone learn to tolerate uncertainty to a greater extent. We can help build that muscle, if you will, in tolerating uncertainties and with sitting with the discomfort of not having your tumor taken out. We are looking at mindfulness training to help reduce fear of progression and increase tolerance to uncertainty. We think those are two important mechanisms toward this goal.
The psycho-educational health promotion group of men and their partners will learn how to integrate positive health behaviors into their lifestyles—things like eating more vegetables, getting more physical activity, and being more aware of their patterns and behaviors. The program doesn’t have anything to do with mindfulness, regulating emotion, or tolerating uncertainty.