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Ruchika Talwar: Hi everyone, and welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar. And I'm really excited to bring you two researchers today who will be discussing a very important topic, The implications of Mental Health Disorders on the Care of Prostate Cancer Patients. Today we have Dr. Joshua Cabral, who is a urology resident at the University of Chicago. And Dr. Nyame, who is a urologic oncologist at the University of Washington. Thank you both so much for joining us today.

Yaw Nyame: It's a pleasure to be here, and thank you for the invitation.

Joshua Cabral: Pleasure, same. Thanks for having us. All righty. So as mentioned, we did a study titled Inequities in Definitive Treatment for Localized Prostate Cancer Among Those With Clinically Significant Mental Health Disorders. I have no disclosures. So just a little background on the topic. Approximately 50% of US adults will meet the criteria for a DSM-IV disorder at some point in their lifetime. And what we suspected was that mental health disorders are associated with significant stigma and bias around them, that may ultimately lead to healthcare services inequity. And we wanted to take some time to just shine some light on this topic. There is the intersection of mental health, social factors such as race, socioeconomic status. And prostate cancer-related treatment and outcomes is not a well-researched field and we wanted to just try and tackle this.

So the objective of this study, we aim to one, evaluate the relationship between mental health disorders and types of prostate cancer received, as well as determine the association between definitive treatment of prostate cancer and mental health disorders. We used the same Medicare database from 2004 to 2015 to look at patients with clinically localized prostate cancer. Essentially meaning grade group two through five, any clinical stage N0, M0 disease and patients with a history of a mental health disorder, which we define as having two encounters with predetermined CPT codes associated with that encounter on two separate occasions in two years prior to our diagnosis of prostate cancer. And we excluded any patients with a PSA greater than 50.

Our findings, demographics, we overall identified 101,000 individuals who met our inclusion criteria for clinically significant localized prostate cancer. Of those, we identified 7,945 men who had a mental health diagnosis prior to being diagnosed with prostate cancer. Among those men, the most common mental health diagnosis was depression. About 86.2% of the cohort had a diagnosis of depression followed by bipolar disorder in 9.3% of the cohort. The least common diagnosis was PTSD, about 0.22% of the cohort. A very small number, and they were ultimately excluded from the final analysis. The mean age of patients was 74. The cohort was predominantly married non-Hispanic white and lived in urban settings. Individuals with a mental health disorder were more likely to be unpartnered, reside in a census tract with a higher proportion of individuals in poverty and found to have severe co-morbidities based on the Charleston co-morbidity index.


So our findings, so to look at our first objective, just the distribution of treatments among patients with mental health disorders. We see that patients with a history of a mental health disorder were more likely to receive radiation with or without ADT in about 46.1% of the cohort followed by radical prostatectomy in about 22% of them. And you'll also note that individuals with a diagnosis of mental health were more likely to receive ADT alone. And patients with schizophrenia, we see that they were the most likely to receive ADT alone compared to the rest of the cohort. And least likely to undergo radical prostatectomy showing a pretty significant disparity between receiving definitive treatment and what we deemed as non-definitive treatments.


When we further stratified data, we found that individuals with a history of a mental health disorder had 26% lower odds of receiving definitive treatment when compared to those individuals without a diagnosis. Individuals with a history of schizophrenia among those patients were the least likely to receive definitive treatment. And among those who did receive definitive treatment, individuals were less likely to undergo surgery if they were diagnosed with a mental health disorder, unpartnered or were Black. I'll say patients with mental health disorders such as schizophrenia, PTSD, and substance use disorder, more commonly received non-definitive treatment, meaning primary ADT or observation. And among these patients, these are some of the patients with the most functional disabilities. Thank you. Those were the main findings of our study.


Ruchika Talwar: Thank you so much for that comprehensive presentation. This is such an important topic, and I want to just start out our discussion by inquiring about what got you interested in exploring inequities and potential disparities in this population?

Joshua Cabral: Thank you. So this project was initiated while I was a medical student at Howard University College of Medicine. And in the process of developing my interest in urology and my own interest in research, I had connected with Dr. Nyame through the R. Frank Jones Society. And we were initiating talking about what I can begin to do. And at that time, one, I was I think finishing up my psychiatric ward rotation in medical school and how it is the hospital in the DC area that dealt with a lot of the homeless and the patients that suffered from pretty significant mental health disorders. And I was really interested in it and we were just kind of brainstorming what intersection of mental health and urology existed out there. And we began talking about prostate cancer. And then we came up with a question, how do patients with these mental health disorders, how do they receive treatment and what kind of inequities exist there?


And Howard University, it's a predominantly historically Black college, one of the educated, the most African-American doctors in this country. And a lot of the emphasis there is on the inequities because of the patient population and what differs between us and different institutions. So it was a really good intersection based on my clinical interests, my research interests, and then my real life experience at Howard.


Yaw Nyame: Yeah, and I'll just say, here at the University of Washington within the Department of Urology, we had a real interest in finding ways to support students that didn't have home urology programs that were underrepresented in medicine. And as this was occurring, I get an email out of the blue from Josh just asking if there's an opportunity to meet via Zoom. And that's really one of the incredible things about this time that we are in, is that we can connect with people who are far away. So we had an east coast to west coast collaboration, and what Josh doesn't realize is he's telling me about his psych rotation and mental health disorders and University of Washington is a safety net hospital in our region. And so we do take care of a wide range of patients who have mental health disorders and diagnoses that might also have competing social situations that make their care complex.


And so for me, coming from my training background to here and suddenly treating people for prostate cancer, for instance, who are houseless, this topic really resonated with me. What was fun was to see Josh who like every medical student has limited urology knowledge, bring a good idea to the table, and then have our entire research team figure out ways to support him in finalizing a research project idea. And then John Gore and I talk about this all the time, one of the really fantastic things that we try to do in our mentorship program, both in this program for underrepresented in medicine students and for University of Washington students and residents, is this idea of helping people develop an idea from conception to a publication. And really proud of Josh for being able to complete that in this work.


Ruchika Talwar: Well, kudos to you, Josh, because it takes a lot of initiative and I think this is truly a testament also to the value of groups such as our R. Frank Jones that help to strengthen and diversify our workforce. So really a two-layered story here, but this is such an important question and I think you don't realize that your clinical experience at Howard as a medical student is really going to shape the way we treat our prostate cancer patients through some of this data. So huge congratulations to both of you, to you Dr. Cabral for really carrying this project, but also to you, Dr. Nyame, for being a great mentor clearly. Moving a little bit into some of the interesting results from your analysis, I get the feeling that your analysis perhaps may actually be an underestimate of the degree of the problem because there's so much stigma that is still associated with mental health disorders and seeking and obtaining treatment.


Now, your inclusion criteria required a code that told us the patient sought mental health care in the prior two years before being diagnosed with clinically localized prostate cancer. Tell me a bit about your thoughts. Are we truly under characterizing the problem here? And what about your experiences for both of you in environments that treat at risk populations?


Yaw Nyame: Yeah, I will say this is a SEER-Medicare analysis, and so there is a richness of data that's available to analyze in SEER-Medicare. But it is a very pre-specified population, one that is over the age of 66 actually in these analyses because we want at least one year of data preceding their cancer diagnosis and one that's insured. And so those things really impact the conclusions and our lenses from which we should view these conclusions. I think there's no doubt that if you think of the potential for non-coding of diagnoses and the restrictions that we have around who our patient population is, that we are very likely underestimating the severity of inequities in patients with mental health disorders, especially those who have more severe mental health diagnoses that are complicated by social factors. And if they're under the age of 65 and uninsured, you can imagine that there's only more layers of complexity in this particular problem.

One thing I will highlight is that we were talking about people who have diagnoses, localized diagnoses. And so we're excluding people who had delayed diagnoses that developed metastatic disease, but we're also excluding what is likely to be a fairly large unscreened population. And so there's no doubt from our perspective that we're not capturing the full story. But it's still an important story to tell because this is in a way an idealized situation for a patient with a mental health diagnosis that they are insured, that they have enough episodes of care in a medical home to have a diagnosis. And in this study, what we see is that the more severe your diagnosis, the less likely you are to get treatment, which is really an important message to put out there. Given how long patients can live with complex mental health disorders now, and given the benefit of treatment and well-selected patients, those are the things that we really need to be thoughtful about.


Ruchika Talwar: Yeah, I could not agree more. I think no story is perfect. This study certainly has its limitations, but it is such an important question to be exploring. And these sorts of conversations will move the field forward because although not every clinician will be collecting data and measuring their performance in this population, it at least gets urologists to think when they see a patient who might have an underlying diagnosis of a mental health disorder. And actually will help us as clinicians be a bit more aware of our treatment recommendations. So along those lines, very concerningly, as you mentioned, even in an ideal state there was a significant proportion of patients who were undertreated or treated inappropriately with ADT only. From a health policy or QI perspective, can you share a bit about your thoughts on how as a field we can try to improve the care in this population?


Yaw Nyame: Yeah. Not to dominate the conversation, but I will say historically as a mental health diagnosis and especially a severe one was associated with worse lifetime expectancy, that we didn't have the same successful therapies that we have now. And we certainly didn't have systems for support in the ways that some health institutions and systems have to support those patients. And the most important thing for me in doing this project is just highlighting that yes, someone with severe mental disorder like schizophrenia that is debilitating, can still live a really long time and they could still die from prostate cancer. So I think it's important that we check our biases and make sure as clinicians at the very least when we have these encounters, that we do a very honest and critical assessment of life expectancy and the risk and benefits of treatment, goals of care. And those encounters take time.

So you asked about what are some potential solutions here? Well, for those that might have multidisciplinary clinics, for instance, this might be a great patient to slot into a clinic setting where you might have more time and more resources available to really understand... And all of the different providers in the same space to discuss why maybe prostatectomy or radiation might be a better treatment modality. And I think we think about multidisciplinary clinics and care really in the setting of complex oncology, but I think complex social and comorbid conditions such as this could be a really fantastic way to think about reinventing or rethinking the application of a multidisciplinary setting. And then obviously I think from a policy standpoint, these are populations that are at risk. We don't have a lot of well codified and collected data at the population level on outcomes and we should.

We should collect that data to better understand how we're serving those that are vulnerable, that have the cancers that we treat. And then we should be providing support, whether it be through insurance or other social means for these patients, either through the funds that exist in our institutions for those that are fortunate enough to have surplus. But certainly that's what the government, local and federal is here for us to support vulnerable populations. And I think there's tremendous opportunity to extend services to make sure that cancer care and aging population of individuals with mental health disorders is available and being supported adequately.


Ruchika Talwar: Yes. Great points. Dr. Cabral, anything to add?

Joshua Cabral: Yeah, I think the one thing that I would add is in our study it showed that over the study period, so in 2004 through 2016, the rate of primary ADT at least in the population with mental health disorders did decrease. It was much higher in 2004 than it was in 2016, which is reassuring and reflects changes in practice over that time period. But even in 2016, it still was disproportionately skewed towards individuals with mental health disorders. So it is an area that we can continue to do better in and implement and think about what it is Dr. Nyame mentioned.

Ruchika Talwar: Yes, another great point. At least we are seeing improvement in your data. Well, thank you both so much for spending time with us today. I really look forward to more literature in this space and I'm excited to be able to share some of your important research findings with our UroToday community.

Yaw Nyame: Thank you so much, Dr. Talwar, for the invitation and to the UroToday team for highlighting Josh's fantastic work and giving us an opportunity to share.


Joshua Cabral: Thank you doctors.

Ruchika Talwar: Yes, kudos to you, Josh. Thanks to our audience. And we'll see you next time.