Mental Health and Prostate Cancer in the Veterans Population - Zachary Klaassen

June 20, 2024

Alicia Morgans speaks with Zach Klaassen about his research focusing on the intersection of mental health and prostate cancer care in the veterans’ population. Dr. Klaassen shares insights from his extensive study aimed at creating the world's largest prostate cancer mental health database. Initial findings reveal that veterans with mental health issues are less frequently diagnosed with prostate cancer, but when diagnosed, the cancer tends to be more aggressive. Further analysis shows that these patients are more likely to receive definitive therapy but adhere less to follow-up surveillance and have a higher risk of biochemical recurrence. Dr. Klaassen emphasizes the importance of integrating psycho-oncology into prostate cancer care, highlighting the need for multidisciplinary approaches to improve outcomes. His work underscores the necessity of addressing both the cancer and the patient’s mental health to enhance overall care.


Zachary Klaassen, MD, MSc, Urologic Oncologist, Assistant Professor Surgery/Urology at the Medical College of Georgia at Augusta University, Well Star MCG, Georgia Cancer Center, Augusta, GA

Alicia Morgans, MD, MPH, Genitourinary Medical Oncologist, Medical Director of Survivorship Program at Dana-Farber Cancer Institute, Boston, MA

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Alicia Morgans: Hi, I'm so excited to be here at ASCO 2024 with Zach Klaassen, who is joining me to talk about his Department of Defense-funded research, which is so important, looking at mental health and prostate cancer care within the veterans population.

You're presenting here at ASCO 2024. Can you tell me a little bit about it?

Zach Klaassen: Yeah, I'm super excited to be able to present this, and it's really a team effort. I think it's a career development award I received four years ago. We're seeing some fruition of the data. I really have to give credit to Steve Freedland, the sponsoring PI, and his team at the Durham VA, which is just exceptional and really able to generate these huge databases at the granular level. And so, just by way of background, we really were trying to build the biggest prostate cancer mental health database, hopefully in the world, honestly.

When we looked at our aims, we presented aim one as an e-poster last year. We basically asked a simple question: In men that have mental health issues versus those that don't, what's the incidence of prostate cancer?

We basically found that mental health patients are less likely to be diagnosed with prostate cancer, but when they are, it's more aggressive than in men that don't have mental health issues. So that was sort of our first presentation of the data from the grant. Then that kind of comes into the second aim, which we're presenting this weekend.

Alicia Morgans: Wonderful. And just to follow up a little bit about that, and I know I quizzed you on this before we started rolling. It's interesting because one could think that a patient who's involved in mental health care within a VA system may actually have more screening and more opportunities to get a diagnosis of prostate cancer. And you have theories about why this might not be true.

Zach Klaassen: Yeah, it's interesting. I mean, this is all hypothesis-generated. It's a classic epidemiology study, so we don't have any causation that we can talk about, just associations. And I think there are many theories. The VA does a great job with their mental health programs, but they may not actually go see a urologist or even a PCP. So they're in the VA for one reason, it's for mental health treatment or for issues like depression, etc. And so I think that the hypotheses are probably several as to why they're being diagnosed less often, but with more aggressive disease.

Alicia Morgans: Absolutely. And certainly, I remember seeing that when I practiced in the VA setting years ago. So tell us more about the updated data, the aim two of this grant.

Zach Klaassen: Yeah, so we're excited because we went from an e-poster to a regular poster this weekend, which is cool. So aim two is basically the next step. And so we're looking at men who were diagnosed with prostate cancer. They either had mental health issues or did not have mental health issues. And so we're really looking at three aspects in this aim: Did they receive definitive therapy? Did they adhere to surveillance if they had definitive therapy, and what was the risk of biochemical recurrence?

And so what we took was basically a subgroup of our big population, 52,000 men, about 20,000 had mental health issues. And we found that men with mental health issues were treated with definitive therapy actually more commonly than men without mental health issues, 34% more likely. Which sounds good because if they're being diagnosed with more high-risk disease, they're getting definitive therapy. That's good.

When we looked at adherence, these are small changes, it was 8% less likely to adhere to surveillance, and we define that as PSAs three within the year, two within the second year, and so on. So it was sort of a relatively loose definition of surveillance. We found that they were statistically significantly less likely to adhere to surveillance.

And then the third sub-aim of that was are they at risk of biochemical recurrence? And they were, they're 7% more likely to be at risk of biochemical recurrence compared to those that did not have mental health issues. So when we take this all together, there are again, more hypotheses generating reasons for all of these, but we're seeing some statistically significant findings.

Alicia Morgans: It's so important too because so many people, whether they're in a veteran system or outside, have coexisting mental health diagnoses. So as I think about it, just sort of piece by piece, when I see a patient who has a higher mental health burden, I do think that there are times when I am a little more worried about having that person engage in active surveillance and so often counsel the patient, when appropriate, to move forward with definitive therapy. That's just one reason why more may engage in that. And you said, of course, higher risk disease. Are there other reasons you think these veterans may have been advised to have definitive therapy?

Zach Klaassen: It's a good question. I think when we think about this, you're right. I mean, we've had mental health discussions together on UroToday before, and I think there are potentially some patient-specific factors.

Are they going to follow up as often as men that don't have mental health issues? And we don't know the severity of mental health issues. I think that's an important point as well. And from a physician's standpoint, do we just want to treat it so that we don't have to worry about it? I think there's probably a little bit of both. And I think these are certainly great prospective ideas. And I think as we continue to work through the data and see some of these results, it's almost like a separate question that's coming up as to why.

Alicia Morgans: Yeah, yeah.

Zach Klaassen: So I think that's a classic epidemiology study is to figure out what the next steps are from a prospective standpoint.

Alicia Morgans: Absolutely. When it comes to biochemical recurrence and those rates being higher, do you feel like the data gave you a reason for that? Was it because... Did you control for higher risk of disease at diagnosis and other factors that might contribute? And you may not know the answer to this, but do you have thoughts about why?

Zach Klaassen: It's interesting. We are probably going to keep working on that after the grant is done, and we've got some questions. Was this radiotherapy specific? Was this prostatectomy specific? At this point, we don't know, but there are a lot of deep dives to be done. Certainly, Gleason score and whatnot, that's a little harder to tease out of the VA in terms of being able to get that data. But I think from a treatment standpoint, looking at whether there are trends in the treatment and whether these patients are having more recurrence, I think is definitely something we can look at.

Alicia Morgans: Absolutely. And to your point earlier, it's not just the cancer-related factors. There could be mental health-related factors including adherence to mental health treatment that might also be coming into play. So how does this affect your day-to-day in the clinic? Because as I said earlier, so many of our patients have coexisting anxiety, depression, and other mental health concerns.

Zach Klaassen: Yeah, absolutely. I mean, we have a great psycho-oncology team at our cancer center, and I think that's where we really have to partner. We've seen multidisciplinary treatment for obviously metastatic hormone-sensitive, mCRPC, moving into high-risk, biochemical recurrence, and even at the localized setting, there's an opportunity to partner with psycho-oncology social work.

And I think even just having distress thermometers and getting an idea of how we can just judge it from a snapshot, are these patients struggling and they're maybe not telling us, just paying attention to body language. And really, it's a whole team aspect.

If one of my nurses comes in and says, "This guy's not really doing well," boom, they've done their job, they've bumped it up to me, my job's to figure out is this somebody who needs to see psycho-oncology today? Should they see them in a week or so? And I think it's just having an awareness. We're treating the cancer, but we're also treating the patient. And I think that's important. Not that our job is to be the psycho-oncologist or be the psychiatrist, but to get them to the right people.

Alicia Morgans: Absolutely. As you were talking, I was just thinking also about how important caregivers, family members, friends, and support systems must also be, as we continue to move forward to care for these patients.

Zach Klaassen: No question. No question.

Alicia Morgans: So congratulations on this grant.

Zach Klaassen: Thank you.

Alicia Morgans: I mean, this is a hugely important grant, and I hope that those listening to UroToday, of course, recognize that, but also consider applying for the Department of Defense grants as well. They are phenomenal. What would your final word to listeners be on this study?

Zach Klaassen: Yeah, it's interesting. I think, as I just mentioned before, I think you have to just be paying attention to these patients. And we know, we did some previous work when I was a fellow in Toronto, knowing that patients that utilize mental health resources, they're at higher risk of worse cancer-specific outcomes. And we know that this is a high-risk population. It's probably multifactorial, but just paying attention to it, having your team educated on it.

And I'll put a little plug in. We're looking at the last aim, which we're hoping that will come out soon, and really looking at does treatment for the mental health then get these patients back to the same level of outcomes as patients that don't have mental health with prostate cancer? So we've got some more exciting stuff coming and hopefully a big paper down the road.

Alicia Morgans: I love to hear it and always appreciate talking with you. You do such important work, certainly in this area among others, and I appreciate your time and your expertise.

Zach Klaassen: Always a pleasure, Alicia. Thank you.