Mental Health Illness in Patients with Non-Muscle Invasive Bladder Cancer. Does BCG Play a Role? - Valentina Grajales

July 28, 2023

In this discussion, Ruchika Talwar spotlights the crucial research of Valentina Grajales. Driven by a personal experience with her father's prostate cancer diagnosis and consequent depression, Dr. Grajales explores the incidence of mental health illness in non-muscle invasive bladder cancer patients. Her research, using the SEER-Medicare dataset, found a reduced incidence of mental health issues in patients receiving BCG, a type of bladder cancer treatment. She further discovered certain demographic factors linked with increased mental health incidence, including older age, unmarried status, female sex, higher comorbidities, and higher pathological stage and grade. The discussion highlights the significance of screening patients for mental health conditions in urologic oncology clinics and emphasizes the importance of conversations around mental health from the initial diagnosis phase.


Valentina Grajales, MD, MS, Urologic Oncology Fellow, MD Anderson Cancer Center, Camden, NJ

Ruchika Talwar, MD, Urologic Oncology Fellow, Department of Urology, Vanderbilt University Medical Center, Nashville, TN

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Ruchika Talwar: Hi everyone. My name is Ruchika Talwar and I'm honored to be joined here today by Dr. Valentina Grajales, who is a urologic oncology fellow at MD Anderson. We'll be spotlighting her research in today's Health Policy Center for Excellence discussion. Thank you again, Dr. Grajales, for being here with us today.

Valentina Grajales: No, thank you for having me. I'm really excited to be here.

Ruchika Talwar: So we'll be discussing your research that has to do with mental health illness in patients who have non-muscle invasive bladder cancer. Does BCG play a role? Why don't we start by you giving us a little bit of background on what got you interested in this topic?

Valentina Grajales: Yeah, absolutely. I am very passionate about mental health, actually it's very close to me, very personal to me because my father passed away from prostate cancer and during his treatment he developed depression. And so I know firsthand what cancer diagnosis and treatment and really what an impact it can have in a patient's life and mental health. So that's why I've been really excited with this research and really bringing it into our field of bladder cancer.

Ruchika Talwar: Well, thank you for sharing that. And I'm really sorry for your loss, but I do think that so many of us have these personal experiences that we use to drive us forward. And it's amazing that hopefully your important research can now play an important role for so many patients, bringing your personal experience into how you treat cancer patients. So thank you. What has been done so far in this space?

Valentina Grajales: Yes, so we have seen, what got us interested in this question of BCG, whether it has a protective effect on the incidence of mental health illness was that there were a few studies that showed that there was a decreased incidence of neurodegenerative disorders such as Alzheimer's disease and Parkinson's disease with those patients receiving BCG. So we were interested to see if we saw the same effect or the same association in non-neurodegenerative mental health conditions. And so that's what started this whole study.

Ruchika Talwar: Interesting. What patient population did you explore this question in?

Valentina Grajales: So we focused mainly on the non muscle invasive bladder cancer population and patients who were receiving BCG versus those who were not receiving BCG. Unfortunately, we could not compare to patients receiving intravesical chemotherapy because the numbers were so low, but we did adjust for multiple co-factors and confounding variables to try to see the effect.

Ruchika Talwar: Got it. Got it. And this was within the SEER-Medicare dataset, right?

Valentina Grajales: That's right.

Ruchika Talwar: Okay, great. So tell me more about what you found.

Valentina Grajales: Yeah, so we saw actually that there was a decreased incidence in mental health in patients receiving BCG compared to those who were not receiving BCG. We also found important demographic factors associated with increased incidence of mental health, and I think that's important because for us, when we're seeing patients in clinic, we can take note of these risk factors and screen patients for mental health issues. So those patients were older, they were unmarried, female sex, they had higher comorbidities and higher pathological stage and grade. And so it's important for us to keep that in mind because we can easily screen patients in clinic for any new mental health conditions.

Ruchika Talwar: Yeah, you bring up a great point in that a cancer diagnosis and mental health illness sometimes do certainly go hand in hand, and this is a unique population in that generally these patients are managed without any major invasive issues. Like they won't need cystectomy, a lot of times they don't need systemic therapy, although obviously that's changing now with all of the alternatives to BCG, but it is a unique patient population. So how can we as urologists actually screen these patients or tackle some of these discussions in our encounters?

Valentina Grajales: Yeah, and that's right. I think you bring up a good point, and I think that's why we focus on the non muscle invasive bladder cancer patients. Because when we think about muscle invasive bladder cancer, we do know that they are at higher risk for suicide and for mental health illness because of the severity of disease and the invasive treatment modalities. And when we think about non muscle invasive, we think they have excellent prognosis, but they do have a big burden in surveillance and in treatment over the years. And so that also has an impact in mental health.

I know that as urologists, we have very limited resources and we have busy practices. So I understand that it would be difficult to implement surveys or have dedicated mental health staff in the clinics, but I think that even just a few screening questions like how has your mood been in the past two weeks or how are you coping with the disease or with the treatments? I think that that can give us an idea of where the patients are. And if you are concerned about the patient, then you can refer them to our mental health colleagues.

Our study showed a very high incidence of mental health, of new mental health diagnosis. About two out of five patients developed a new mental health diagnosis after bladder cancer diagnosis throughout their treatment. So I think it is important for us to keep in mind that even though we think of non muscle invasive as a more mild form of the disease, that there are still factors that impact their mental health. There's also the cost toxicity associated with the surveillance and treatment too.

Ruchika Talwar: Yeah, absolutely. I mean, 40%, that's staggering. And in addition to financial considerations and burdens of long-term surveillance, I think that intravesical therapies and cystoscopy can be really tough on patients. Those symptoms are very bothersome; hematuria, lower urinary tract symptoms, irritated voiding symptoms, those all really impact someone's quality of life. So I definitely can see the overlap there. And again, I want to thank you for taking on this important work.

We talked about screening, but tell me a little bit about your discussion at initial diagnosis. Is this something that you think we should be addressing at that time as well? Since like you said, you all measured a 40% incidence.

Valentina Grajales: I think it's important for patients to know that they can talk to us about their mental health and what they're going through. So I do think it's important to start a conversation early, especially because we know that there is a high incidence of mental health illness during treatment.

Ruchika Talwar: Yeah, and I hope people see work like what you're doing and are a little more encouraged to tackle on these often taboo and difficult conversations. So thanks again for taking this important topic on and for joining us today.

Valentina Grajales: Oh, thank you so much. I was really fortunate to be here today with you guys.

Ruchika Talwar: Thanks to our audience for tuning in, and we look forward to having you at our next Health Policy Center of Excellence video.