AUA 2018: Impact of Post-Treatment Psychiatric Illness on Survival Outcomes Following Treatment for Patients with Muscle-Invasive Bladder Cancer

San Francisco, CA ( For people with new cancer diagnoses, initial psychological stress can be related to several factors including medical, patient-related, societal, and cultural factors [1]. Over 30 years ago, the Psychological Collaborative Oncology Group found that 53% of adult patients with cancer adjusted normally to the crisis of illness, however the remainder of patients met diagnostic criteria for a psychiatric disorder, most commonly adjustment disorder with depressed and/or anxious mood [2]. More contemporary studies suggest that major depression, delirium, adjustment disorder and anxiety disorders are prevalent in 10-34% of cancer patients. 

The treatment of muscle-invasive bladder cancer (MIBC) is multimodal, complex and often carries significant physical and psychological morbidity risks. At the invasive bladder cancer session at AUA 2018, Dr. Williams from UT-Galveston presented their group’s population-level assessment of the incidence and types of psychiatric illnesses diagnosed following treatment of MIBC and determining the impact on survival outcomes. 

For this study, the authors identified 3,709 patients in the Surveillance, Epidemiology, and End Results (SEER)-Medicare database diagnosed with clinical stage T2-T4a bladder cancer from January 1, 2001 to December 31, 2011. Covariates assessed included patient age, sex, race/ethnicity, marital status, and SEER region (Northeast, South, Midwest, and West). Socioeconomic characteristics were determined from SEER-Medicare: county-level education was defined according to the percentage of residents with at least 4 years of college education, and county-level median household income was acquired through linkage to the area health resource file and then divided into quartiles. Comorbidity was assessed using the Klabunde modification of the Charlson index during the year before cancer diagnosis. The incidence of psychiatric diagnosis for each treatment was assessed and multivariable analyses were used to determine predictors associated with psychiatric diagnoses. Cox proportional hazards models were used to determine the impact of post-treatment psychiatric diagnosis on cancer specific survival and overall survival. 
Among the 3,709 patients included, 1,870 (50.4%) were diagnosed with post-treatment psychiatric disorders with the most common diagnoses being mental and behavioral disorder due to psychoactive substance use and depressive disorders, respectively. Patients who underwent radical cystectomy were found to be at a significantly greater risk of having a post-treatment psychiatric illness in comparison to patients who underwent radiotherapy and/or chemotherapy (HR 1.19, 95%CI 1.08-1.32). In adjusted analyses, patients with a post-treatment psychiatric diagnosis had a worse overall survival (HR 2.80, 95%CI 2.47-3.17) and cancer-specific survival (HR 2.39, 95%CI 2.05-2.78). Furthermore, increasing number of psychiatric diagnoses was associated with worse overall survival (3 vs none: HR, 2.21; 95% CI, 1.85-2.66; P<.001) and cancer-specific survival (3 vs none: HR 2.14, 95%CI 1.73-2.65). 

This study elegantly confirms what prior oncology studies in general have shown: bladder cancer patients are at significant risk of post-treatment psychiatric comorbidities, which in fact leads to not only inferior overall survival outcomes, but also worse cancer-specific survival. However, several limitations of the study include the fact that SEER-Medicare studies are limited to patients ≥65 years of age and thus may not be generalizable to younger patients with bladder cancer. Furthermore, the diagnosis of psychiatric comorbidities was derived from administrative claims data, which has inherent limitations. Dr. Williams concluded noting that half of MIBC patients who underwent treatment were diagnosed with a psychiatric disorder which resulted in worse survival outcomes as compared to patients without a post-treatment psychiatric diagnosis. Furthermore, Dr. Williams conjectures that in order to optimize the benefit of MIBC treatments, we must address the non-oncologic needs of patients, including depression screening, treatment, and survivorship clinics, which are needed to improve survival outcomes. 

Presented By: Stephen B. Williams, University of Texas Medical Branch, Galveston, TX 
Co-Authors: Christopher Kosarek, Usama Jazzar, Yong Shan, Galveston, TX, Zachary Klaassen, Augusta, GA, Jinhai Huo, Gainesville, FL, Edgar Esparza, Hemalkumar Mehta, Yong-Fang Kuo, Galveston, TX, Simon Kim, Cleveland, OH, Douglas Tyler, Galveston, TX, Stephen Freedland, Los Angeles, CA, Ashish Kamat, Houston, TX, Dwight Wolf, Galveston, TX 

1. Mehta RD, Roth AJ. Psychiatric considerations in the oncology setting. CA Cancer J Clin. 2015;65(4):300-314. 
2. Derogatis LR, Morrow GR, Fetting J, et al. The prevalence of psychiatric disorders among cancer patients. JAMA. 1983;249(6):751-757. 

Written by:  Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre Twitter: @zklaassen_md at the 2018 AUA Annual Meeting - May 18 - 21, 2018 – San Francisco, CA USA

Watch Stephen Williams and Ashish Kamat discuss “Helping Patients Cope after Major Interventions for Bladder Cancer Therapy”

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