SUO 2022: Addressing Mental Illness and Suicidality in Men With Prostate Cancer

( At the second Prostate Cancer Session of the Annual Meeting of the Society of Urologic Oncology, Dr. Zachary Klaassen discussed the very important topic of mental illness and suicidality in men with prostate cancer.

Dr. Klaassen began by providing an overview of the prevalence of mental health concerns in patients with prostate cancer. Based on more than 50 thousand men in SEER-Medicare datasets, he noted that more than one in 5 men with localized prostate cancer will develop mental illness in the four to five years following diagnosis. Importantly, the causes of this are potentially multitudinous and may vary between men. However, the direct effects of the cancer diagnosis, the side effects of local therapy (including urinary incontinence, erectile dysfunction, and bowel dysfunction), and the side effects of systemic therapy (including androgen deprivation therapy [ADT], novel hormonal therapies, and chemotherapy) contribute significantly.

Importantly, he highlighted that a recent analysis from the CEASAR cohort led by Dr. Amy Luckenbaugh showed that, among 2700 men with localized disease, longitudinally assessed rates of depression did not vary significantly between men who received active surveillance, those who underwent surgery, those who were treated with radiotherapy alone, and those who received radiotherapy with ADT.

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However, the authors found that older men, those in poorer overall health, unmarried men, and those with higher baseline depression scores were more likely to have a decline in their mental health following prostate cancer diagnosis. Given these differences between patient groups, Dr. Klaassen emphasized the potential for mental health issues to represent a disparity issue among our cancer patients. Beyond those features identified by Dr. Luckenbaugh and colleagues, Parikh et al. recently demonstrated, using data from the Veterans Affairs cohort, that African American men were more likely to be diagnosed with depression following prostate cancer diagnosis (Aor 1.15, 95% CI 1.09-1.21) but were less likely to be prescribed an anti-depressant (aOR 0.85, 95% CI 0.77-0.93). Further, the association between depression and all-cause mortality was stronger among these African American men (aHR 1.32, 95% CI 1.26-1.38) than among white men (aHR 1.15, 95% CI 1.07-1.24).

While Luckenbaugh and colleagues didn’t find differences in longitudinally assessed mental health among patients with localized prostate cancer who received radiotherapy with or without ADT, other analysis, including of the SEER-Medicare dataset have shown that the incidence of depression increases with increasing cumulative ADT exposure: 12% among those who received 6 months or less of ADT, 26% among those who received 7-11 months, and 37% among those who received 12 months or more.

Considering the actionability of these data, Dr. Klaassen highlighted that recent work utilizing the Optum database showed that the median time from ADT initiation to diagnosis of depression or anxiety was 9.3 months. However, among those diagnosed, nearly half (47.7%) did not receive treatment. Thus, there is a large unmet need.

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Transitioning from a discussion primarily focused on depression to suicidality, Dr. Klaassen noted that population-based studies have shown an increased risk of mortality due to suicide among prostate cancer patients, compared to the general population. In particular, at 15-years or more after diagnosis the mortality rate is increased by 84% (SMR 1.84, 95% CI 1.39-2.41). Further, older, Caucasian men and those with distant disease appeared to be at higher risk in this analysis. Updated analyses focusing on men with local-regional prostate cancer showed that, reassuringly, suicide-related mortality in this population may not be elevated (SMRs 0.85-1.07, all non-statistically significantly different from 1). However, among those men with distant disease, suicide related mortality is significantly elevated, beginning as early as the first year following diagnosis.

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Dr. Klaassen emphasized that there are, in total, 26 population-level studies assessing suicide among cancer patients. However, the vast majority of these fail to account for psychiatric comorbidity prior to cancer diagnosis. To address this, Dr. Klaassen highlighted work that he and colleagues performed which specifically looks at the effect of cancer diagnosis on the risk of suicidal death, while accounting for pre-diagnosis psychiatric health.

In this analysis, there was an increased risk of suicide-related mortality for cancer patients in the early period following diagnosis (HR 1.60, 95% CI 1.42, 1.81), however, this diminished over increasing follow-up.

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Addressing prostate cancer specifically, subgroup analyses of this study did not show an elevated risk of suicidal death among prostate cancer patients (HR 1.07, 95% CI 0.90-1.27), though this analysis was not stratified by disease stage.

As we look to move these data into our clinical care, Dr. Klaassen emphasized that mental illness is an important aspect of prostate cancer survivorship. However, there are many potential barriers. In a study of 61 oncology health care professionals, the majority had interacted with at least one patient with suicidal ideation, and most had at least one patient commit suicide during their carriers. Numerous barriers were identified in terms of identifying these patients including the fact that many patients give no warning that is perceptible to their health care team, patients concealing their suicidality, patients failing to attend scheduled follow-up, difficulty on the part of the health care team to differentiate suicidality for mental health distress, a lack of time with patients, a fear of asking about suicidality, a lack of coping resources to deal with patients with suicidality, and a lack of training and awareness. However, these professionals were able to identify potential strategies to identify patients at risk of suicide. These included paying attention to patient verbal indicators or explicit actions, being aware of a prior history of mental health disorders, and identifying mental health distress. One practical way to assess this is the NCCN distress thermometer. In addition to a visual-analogue distress thermometer, this tool allows patients to identify sources of problems, including practical issues, family problems, emotional problems, spiritual/religious concerns, and physical problems.

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In the context of his own practice at the Georgia Cancer Center, he emphasized the importance of the multi-disciplinary team including psycho-oncologists and urologists specializing in sexual medicine and reconstruction.

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In closing, Dr. Klaassen emphasized the importance of collaboration and appropriate referrals to specialists who can assist with the survivorship care of our patients with prostate cancer. Use of a tool such as the NCCN distress thermometer can provide a good screening tool to identify patients with mental health concerns.

Presented by: Zachary Klaassen, MD, MSc – Urologic Oncologist, Assistant Professor of Urology, Georgia Cancer Center, Augusta University/Medical College of Georgia