For this study, the authors use the Shared Equal Access Regional Cancer Hospital (SEARCH) database to identify all men with prostate cancer who underwent radical prostatectomy between 2000-2017 at eight high-volume VA centers. A pre-cancer diagnosis of PTSD or depression was identified using ICD-9 and ICD-10 codes ascertained using a three-year look-back window. The primary outcome was biochemical recurrence, defined as PSA >0.2 ng/ml, 2 values at 0.2 ng/ml, or salvage treatment (radiation or hormonal therapy). The secondary outcome was all-cause mortality. The authors used univariable and multivariable Cox proportional hazards models, adjusting for baseline patient characteristics (age, body mass index, race), year of surgery, surgical center, pathologic variables (grade group, extracapsular extension, seminal vesicle invasion, lymph node status) and comorbidity burden quantified using the Charlson comorbidity index, to evaluate the association between PTSD and depression, separately, with biochemical recurrence and all-cause mortality.
After the appropriate exclusion of patients, the final cohort included 4,950 men. There were 735 (14.8%) men with a known pre-prostate cancer diagnosis of PTSD, and 398 (8.0%) patients with a known pre-prostate cancer diagnosis of depression. Men with PTSD or depression were younger (61 vs. 62 years, p<0.001), had lower pre-radical prostatectomy PSA values (6.0 vs. 6.3 ng/mL, p=0.022), and had a lower comorbidity burden. Patients with PTSD were more likely to be African American (36% vs. 32%, p=0.022) and to have served in the Army (62% vs. 52%, p<0.001) or Marines (19% vs. 10%, p<0.001). Importantly, there were no significant differences with regards to final pathologic variables or number of PSA checks between radical prostatectomy and biochemical recurrence, suggesting that follow-up regimens were similar between the groups. On both univariable and multivariable analyses, both PTSD (adjusted HR 0.99, 95% CI 0.85-1.15, p=0.87) and depression (adjusted HR 0.89, 95% CI 0.72-1.09, p=0.25) diagnoses were not associated with rates of BCR. The time from radical prostatectomy to biochemical recurrence for men with and without PTSD, as well as men with and without depression, are as follows:
Similarly, PTSD (HR 1.07, 95% CI 0.76-1.19, p=0.54) and depression (HR 0.96, 0.70-1.31, p=0.78) were not associated with all-cause mortality. Sensitivity analyses with one- and five-year lookback windows for pre-radical prostatectomy diagnoses of PTSD and depression likewise demonstrated no associations with biochemical recurrence or all-cause mortality. The strength of this study is the granular data with appropriate follow-up to be able to adequately assess these associations. A limitation of this study is that the findings may not be generalizable to other patients with localized prostate cancer, such as those undergoing radiation therapy.
Dr. Sayyid concluded this study with several take-home points:
- Within the confines of an equal-access VA health system, pre-radical prostatectomy diagnosis of PTSD or depression does not impact biochemical recurrence or all-cause mortality
- These results suggest that differences in oncologic outcomes previously seen amongst patients with significant psychological burden in different healthcare systems may be related to disparities in access to care
- These findings also highlight the quality of care received by veterans at the VA, which actively targets these patient populations in order to minimize health outcome discrepancies
Presented by: Rashid K. Sayyid, MD, Augusta University/Medical College of Georgia, Augusta, Georgia
Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia, @zklaassen_md, at the 20th Annual Meeting of the Society of Urologic Oncology (SUO), December 4 - 6, 2019, Washington, DC
References:
1. Jazzar U, Yong S, Klaassen Z, et al. Impact of psychiatric illness on decreased survival in elderly patients with bladder cancer in the United States. Cancer 2018;124(15):3127-3135.
2. Klaassen Z, Wallis CJD, Goldberg H, et al. The impact of psychiatric utilization prior to cancer diagnosis on survival of solid organ malignancies. Br J Cancer 2019;120(8):840-847.