Alicia Morgans: Hi, I'm so excited to be here at AUA 2022, where we have Dr. Zach Klaassen, who is joining us from the Georgia Cancer Center. Thank you so much for being here.

Zach Klaassen: Great chatting with you, Alicia.

Alicia Morgans: Wonderful. So I wanted to talk with you about something that's been so important in our patient population, but not necessarily so really investigated and communicated, its mental health and its effects on patients with GU cancers of course, including men with prostate cancer. Can you tell us a little bit about the scope of this issue?

Zach Klaassen: Yeah, it's interesting. I always get kind of funny looks when I talk about mental health as a urologist, I'm not a psychologist or a psychiatrist, but we see it in our patient population, if you look at our prostate cancer patients, for example, they're all elderly and by definition in the US, that's 25 to 30% of just anybody that walks through the door. So I think if you pair that with the prostate cancer population going through diagnosis and treatment, I think the prevalence is huge in my opinion.

Alicia Morgans: Yeah. And it also of course affects our patients with bladder cancer, as well. Can you describe for the listeners, the issue there?

Zach Klaassen: Yeah. For bladder cancer. This is a comorbid population, as we know, and I think the biggest thing is these patients come in, you're talking about surgery, life changing surgery. So if they come in, most of them are smokers. Most of them are elderly white males. And again, that profile of depression and mental health. So if you tack on, life threatening illness, you're going to do a huge life changing operation. And just that process of getting up to the operation to three, four months afterwards, while they're learning to fix their stoma, things aren't working quite as well as they used to. And so you get that recovery process, which goes on for months. And I think, we've really underestimated in the bladder cancer population, I think by definition, most of those patients have a degree of depression if not other mental health issues as well.

Alicia Morgans: Well, thank you. Now I know you and your team have actually investigated mental health, mental illness in the GU cancer population. Can you share with us a little bit of your work?

Zach Klaassen: Yeah. So back in 2019, when I was doing my master's up in Toronto, at the University of Toronto at the Princess Margaret Cancer Center, we looked at some population level data in Canada and probably the most important finding we had, so we looked at the 10 most common malignancies. So we had bladder, kidney, prostate, breast cancer, lung cancer, et cetera, and across the board for the most part, amongst those 10 most prevalent malignancies, patients that had mental health utilization of resources before their cancer diagnosis, had worse cancer specific mortality. And so obviously this is population level, it's hypothesis generating. It's not correlative, but we see these associations. And so, the discussions of these papers are always interesting because it's sort of, how is this happening? How can we fix it?

I think really it comes down to probably three things. There's certainly a patient specific aspect to it. So if you have somebody who's been hospitalized for psychiatric issues, they're most likely going to be less likely to come to their follow up appointments. But also I think the fact as physicians, these are not the easiest patients that take care of at times. And I think probably subconsciously our biases may sort of drift away from these patients a little bit.

And then I think the other thing that we can really help with getting these patients in is just having a strong team. And I see this in my clinic with my testes cancer patients, in terms of getting them in, having a team, they all have my email address. They have my cell phone number because these are the patients, going to a very specific population of patients, I think those ones are the ones, young men, that really can struggle with this. And I think, taking that whole process together, knowing that these patients have worse, not just other problems, but actual cancer specific mortality disparities is actually quite surprising and something we need to work on over the next several years.

Alicia Morgans: Yeah. To that point, I think it was really interesting. We learned at the APCCC 2022, that there are patients who seem to make different decisions when they have depression, including men with localized prostate cancer, are choosing definitive local therapies that would be curative at a lower rate when they have depression, so really so important. So just operationalizing this, how do you ask these questions in clinic? How do you think about supporting these patients beyond giving them your cell phone number, which may not be tenable for everybody?

Zach Klaassen: Sure. And I think the main thing is just having an intuition. I'm not, like I said at the top, I'm not a psychologist or a psychiatrist, and my job's not to treat their mental health, to treat their prostate cancer, their bladder cancer, but my job is to have that intuition to send them to the people like our psycho-oncology team that we have at the Georgia Cancer Center, which is phenomenal. So to answer your question, I think its clinical intuition and just knowing. It's also asking how they're doing with the diagnosis, how they're doing with treatment. Do they want to talk to somebody?

And oftentimes, you get a little bit of a distant day's response, but then it starts to click that this is not a sign of weakness. This is a sign of, there's somebody here to help you, sort of process and go through this from a nonphysical standpoint. I'll take care of the prostatectomy or the ADT, but it's the rest of it that, I think needs to be at the forefront when we're talking to these patients in the clinic.

Alicia Morgans: That's such a good point. I love the way you describe it. The clinical intuition, because you can ask a question and like you said, people will sometimes give you a day's sort of a response. I think it is up to us then to ask the follow up questions and dig into the day's response, because you could just let it go there, but that's your opportunity in your window to really investigate.

Zach Klaassen: I think another point on this sort of same topic is looking at the family social situation. So if somebody comes in by themselves, there's another risk factor. They don't have the social structure that maybe other patients do or talking to the significant other and saying, "How's he really doing?" Or, "How's she really doing?" Because they'll give you the straight answer. The patient might not, but she'll say, "Ah, he's laying in bed for 18 hours a day. He's on ADT. He's not working out. You told him to go for a walk twice a day. He's not doing any of that." And so you go back to him and you say, "Now, why are you not doing that? Is it because you're tired? Is it because you're depressed? Is it because you're sick?" This is where you sort of take the cues from everybody in the room and I think that's a huge, important aspect as well.

Alicia Morgans: Well thank you so much for going through this because it is underestimated and you are making a difference as a urologic oncologist who prioritizes mental health. And I think we as a field really need to move in that direction.

Zach Klaassen: It's important. I think we all have to do a little bit and I think the structure with survivorship programs, I think it's built in, we just have to utilize it.

Alicia Morgans: Well, thank you very much for your time and your expertise.

Zach Klaassen: Thanks Alicia.