Alicia Morgans: Hi, I'm so excited to be here today with Dr. Brian Gonzalez, who's an Associate Member at Moffitt Cancer Center. Thank you so much for being here with me today.

Brian Gonzalez: I'm happy to do it.

Alicia Morgans: Wonderful. Well, Brian, you are giving a wonderfully exciting talk at ASCO 2024. This is a preview to that, and if you're watching after ASCO, it'll be a post view to ASCO and it's really on behavioral interventions to mitigate the adverse effects of ADT, which we know can be really cumbersome and difficult for patients to deal with. I would love for you to go through some of the aspects of that presentation and share with us some of the things we should learn.

Brian Gonzalez: Thank you, Alicia. I'm excited to chat today about behavioral interventions to mitigate the adverse effects of ADT, or androgen deprivation therapy, for prostate cancer. Here's a brief outline describing the two types of behavioral interventions that we'll describe. One of them is cognitive behavioral therapy and another is a category of physical activity interventions. I'll end with some barriers and solutions related to implementing some of these behavioral interventions. As you know, ADT has many different types of side effects that are both common and distressing for prostate cancer patients. And fortunately, the behavioral interventions that I'll talk about today have been adapted and have been shown in empirical studies to improve multiple different types of adverse effects like the ones you see listed here, fatigue and sleep and vasomotor issues, and many others. And a particular benefit of these kinds of behavioral interventions is that they often will improve more than one adverse effect at a time.

So many of these will address issues like distress or stress as well as another target of their intervention. Some of the additional benefits of behavioral interventions include that they have relatively few toxicities including financial toxicity. So the challenge of cost for some of these interventions is very minimal, and the idea is that patients are often taught skills during the course of the behavioral intervention that they're going to keep with them for a long time, and they often have long-lasting effects even past the time when the intervention itself is over. And so, therefore, the cost-effectiveness is usually pretty good. They often also have downstream impacts on quality of life, which is critically important. And generally, these can enhance the degree to which the clinic is providing patient-centered and personalized care to prostate cancer patients.

One of the examples we'll talk about today is cognitive behavioral therapy. This is a type of therapy where patients are empowered to come up with solution-focused strategies that generally fall into the categories of either A, cognitive restructuring that is generally focused on helping patients better cope with some of the symptoms and issues that they're dealing with. And secondly, another category is behavioral strategies that involve changing the way that they plan their day and follow through with some of their behavioral patterns that can be impactful for addressing some of these side effects. One of the citations towards the bottom is an example from years ago of a cognitive behavioral stress management intervention that both addressed stress management skills and improved other outcomes like quality of life among prostate cancer survivors. And it was notable here that the self-efficacy, that is, my perception of my ability to manage my stress in that study, was a significant predictor or mediator of the benefits of that intervention.

And so this speaks to the importance of not only changing behavior but also skill building and enhancing patients' perception of their ability to manage these kinds of issues in their lives. Another category of interventions I'll talk about is physical activity interventions. As you may know, the guidelines from the American Cancer Society generally recommend 150 to 300 minutes of moderate-intensity physical activity, including two to three sessions of resistance training, because of the many benefits of resistance training specifically. And the clear benefits of physical activity interventions, not only among prostate cancer survivors but also in this population, include improved overall fitness, maintaining or preventing loss of muscle mass or muscle strength, improving balance, which can reduce the risk of falls later, generally improving body composition and things like fatigue, mood, and quality of life. And so these are generally found to be very impactful in all kinds of cancer populations, but particularly for prostate cancer patients, those dealing with ADT who are particularly vulnerable to losses in muscle mass and strength.

Although these interventions are very strongly supported by the empirical literature and they're part of NCCN and other guidelines, there are some challenges to implementing these kinds of behavioral interventions. One of the barriers that comes to mind is awareness. So there are many providers that may just be unaware of the importance of some of these interventions and the impact they can have on their patients. Another challenge is that there is some burden to patients. I mentioned financial toxicity may be low, it's not zero, but then also there's some burden sometimes if there's an intervention that is intended to be delivered by a specific provider, be it a nurse or a social worker or some other trained professional to provide that intervention, that just means that then suddenly the patient needs to align their schedule with their ability to get into the clinic to receive this intervention. Although some of that has been easing lately due to the ability to do some of these interventions via video conferencing software.

There are still barriers to access to treatment for some patients as it relates to being able to take time off of work, for example, or to pay for whatever costs are associated with some of these treatments. And then, of course, there's clinic burden. Clinics are very busy, and they may not have figured out how to work into their workflow, how to identify which patients might be most interested or eligible for some of the benefits of these interventions, and how to get them connected with the providers that can support this. But there's some good news, which is that there are solutions for these kinds of behavioral interventions. An example is in the citation listed below, where the solutions in that clinic, focused on a distress management intervention, began by engaging closely with relevant stakeholders.

That includes not only patients and providers, oncologists, and nurses but also caregivers and others who can talk through and think through how best to adapt a given intervention for the patient population that you serve. In that study, they also followed through by, after developing that adaptation, testing it and further refining it as needed to make sure that the intervention met the needs and addressed some of the additional barriers that may have been identified during the course of that project.

Lastly, during the implementation, of course, there are going to be other hiccups that come through or opportunities to make this a little smoother. Those will come up, and that's expected. And so they continue to refine that iteratively. But fortunately, at the end of the day, they had an empirically supported intervention implemented in real-world practice for their patients to provide them with really high-quality care and address a very important and distressing issue for patients.

So our take-home message is that behavioral interventions can address very common adverse effects of androgen deprivation therapy, including some of the very distressing issues that ADT recipients are often most concerned about. In addition, implementing these kinds of interventions can enhance the level of patient-centered and personalized care that your clinic can provide, and that's why we strongly encourage clinics to take a look at implementing these behavioral interventions.

Alicia Morgans: Wonderful. Thank you so much for going through that, Brian. I think many of the clinicians who engage with UroToday are oncology-focused, and so it's just really nice to hear you as a behavioral health clinician go through some of these things. And when I think about implementing some of these behavioral interventions in a clinical practice, certainly the barriers that you mentioned are there, but probably the biggest one that I imagine is having access to somebody like you, or to a social worker, or somebody who can do these methods of behavioral interventions and approaches, whether it's cognitive behavioral therapy or some other psychotherapy, or whether it is referring out to get those resources elsewhere. And I wonder, are there strategies or ways for folks who do not have behavioral health specialists in their practices, are there things that they could look for, or refer to, or how do you come up with this, because we are not all so lucky as to have people like you in our clinical space?

Brian Gonzalez: Thank you, Alicia, for that question. It's a great point that there's certainly a shortage of the kinds of providers who can oversee or administer these services in some oncology clinics. And then it comes to the question of how to best incorporate these opportunities for your patients. One option is to recruit individuals who can provide these services. They might be social workers, psychologists, nurses, or other providers who have these skill sets and have been trained in how to administer some of these interventions themselves or to provide the training to some of the folks who are in your clinic so that they can attend workshops or other training opportunities to administer these themselves. And so either of those poses some challenges, of course.

There are some limitations and trade-offs, but those are some of the clear opportunities for having an individual who can provide some of these services. A third option is referring out to third-party services that might help facilitate some of this. In cases where a patient is dealing with difficulty with sleep, let's say, there are sleep clinics around the community that might be able to provide that service themselves directly while taking into account the unique characteristics of the disease that the patient is dealing with and some of the symptoms they're associated with.

Alicia Morgans: Great. Well, thank you for giving us those options. I am just curious to dig in a little bit into cognitive behavioral therapy or other therapeutic approaches to things like cognitive decline. And I know you've done a lot of work in this particular area, and I have talked to folks who deal more with people who are developing early cognitive decline just with age or perhaps because of stroke or in whatever general medical way they are developing it. And there are all kinds of strategies that can help people not necessarily reverse the cognitive decline but have coping strategies around and solution-focused strategies. I love the way you say that, but around finding ways to cope with this decline and still function in life and still get along in interpersonal interactions as well as whatever other potentially professional roles they play.

I wonder if you could mention a strategy or two that might be of value to people just so they have some take-home opportunities to acknowledge and use when they're talking about this in clinic and can say, "Hey, I learned about this strategy and that strategy, and these are things that you might learn and more when you engage in some of these approaches to resolving or improving your situation."

Brian Gonzalez: Sure. Thank you. And you're right, like you say, it's a very solution-focused approach where you're developing a very tailored and personalized plan with the patient that empowers them to, first of all, begin with interpreting what's happening and understanding their situation in ways that are productive and kind of forward-looking and try to be realistic about what their situation is without too much negativity or positivity really at the end of the day. And that kind of approach is helpful for taking stock of the situation and then also identifying what are likely solutions to, at the very least, help the patient cope with the challenges they're facing. Even if, like you say, we may not be able to reverse the problem, helping empower the patient to better prepare their day and their routine. In the case of somebody who might have cognitive decline, let's say memory is a barrier, it'd be a conversation with the patient to better find out in what kinds of scenarios does this problem most exhibit itself.

And if it's scenarios where they're driving or they're trying to determine what their shopping list is or they may be in conversation with somebody, there're going to be a lot of options and scenarios where these kinds of things can be most impactful. Then it becomes a dialogue about what issues or what things that a patient can do to help compensate for the problem that they're dealing with. And so some of that becomes keeping lists rather than relying on one's memory or reducing the risk of being in a situation that can enhance or make some of these challenges more dangerous. And so just in terms of that planning phase that helps the patient think through what are some of the things that they can do or circulate to strategize around their day to mitigate the challenges they're facing. And then when it comes to the behavioral part of a cognitive-behavioral intervention, it becomes an issue of not only executing on that plan but also increasing their just overall physical activity level. So it kind of becomes a combination of cognitive and behavioral where that physical activity can have benefits in and of itself as well.

Alicia Morgans: Absolutely. I love the idea of, like you said, making lists, but I remember thinking that the suggestion to even just slow down, focus, and try to take stock of what's going on and actively form a memory, and that is not possible for many people, but for people with early cognitive decline, if there's an ability to maintain that attention, have the focus and actively consider, "I'm going to try to form this memory," they can be more successful than if they're just going through life. And sometimes if we're not focused and aware, we are not as able to get that memory formed. And in our day-to-day lives without cognitive decline, we often miss things and forget things. And so it actually, I think, is helpful even for me as I'm trying to make sure that I know when to do this and how to ensure that I meet that deadline or do this, taking that mental moment and trying to form that memory can be really helpful. And I rely like no one else on lists. I love lists.

Brian Gonzalez: Yeah. And it's a reminder, like you say, of trying to create that memory can be helpful. But as you say, there's some benefit too of relying on digital devices, for example, that may be able to assist us in jotting down things that are important to remember just in case we can't rely on the memory later on. So there are lots of opportunities to help patients compensate or cope with cognitive decline, for example.

Alicia Morgans: Absolutely. And it's all important, I think it's a spectrum. It's not from going a hundred miles an hour to going zero. There's a change over time, and these strategies can be helpful now, but also as things change over time and you need more and more support. So if you had to give a final message to the listeners, what would that be?

Brian Gonzalez: It'd be to explore what, from your conversations with patients, what are some of the issues that they tell you are most impactful, and distressing, and interfering in their lives. And try to identify what interventions, NCCN guidelines, or other guidelines might recommend for those issues as ideally first-line behavioral interventions for those issues. And try to incorporate them into your clinic so that you're being most responsive to the patients that you treat.

Alicia Morgans: Absolutely. And if you can't do that yourself, having the support team around you, your nursing staff, your physician's assistants, your nurse practitioners, and your behavioral health specialists, your social workers, we can all work together as a team and try to support these things. But it's wonderful that the NCCN guidelines are recommending these behavioral interventions to try to resolve and relieve some of the stress and challenge that comes with a prostate cancer diagnosis, particularly in the setting of hormonal deprivation therapy. So thank you so much for your time and your expertise. I really, really appreciate it.

Brian Gonzalez: Thank you.