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Zach Klaassen: Hello, and thank you for joining us on UroToday. My name is Dr. Zach Klaassen, I'm an associate professor at the Georgia Cancer Center in Augusta, Georgia. I'm a urologic oncologist. I am pleased to be joined today by Dr. Cristiane Bergerot, who's the Director of the Department of Psycho-Oncology at Grupo Oncoclínicas in Brasilia, Brazil. Welcome, Dr. Bergerot.

Cristiane Bergerot: Hi. Thank you so much. It was a great pleasure to be here. Thank you Zach, and also to UroToday for this special invitation.

Zach Klaassen: Oh, we're delighted to talk to you today about basically the importance of psycho-oncology, particularly as it pertains to prostate cancer patients. I know this is a topic that's both clearly dear to your heart, but also dear to mine. So I know we've collaborated on several projects together, so I'm excited to have you share with the listeners and the viewers today about basically, why this is a passion for you, and sort of your background, and how you implement psycho-oncology into your practice. So let's just start with how does one define prostate cancer survivorship?

Cristiane Bergerot: I would say that prostate cancer survivorship can be defined as the process of living with, through and beyond cancer. And for sure it will include physical, emotional, social, spiritual, and financial aspects of cancer care.

Zach Klaassen: Yeah. I tend to, when I see my patients in the clinic, "You've been diagnosed with prostate cancer, and the survivorship starts right now even before we decide on treatment." Is that an accurate statement? Is that a good way to go about how we discuss this?

Cristiane Bergerot: That's perfect. Perfect. Mm-hmm.

Zach Klaassen: Yeah. And so let's go back to it. So you're obviously the director of a huge consortium down in Brazil, and so, how did you get into the clinic, getting into psycho-oncology, and why are you so passionate about it?

Cristiane Bergerot: I think I'm working in oncology for almost 20 years. And I first started with general oncology, and I've implemented the distress screening program in our institution. And then I moved to different other institutions trying to also see how we can implement this type of research for our patients. When I met Monty, Monty Pal, and we were invited to do a postdoctoral fellowship at his institution. So in 2017, I moved to the United States, and it was when I worked more with GU patients, and especially with patients diagnosed with renal cell carcinoma, prostate cancer, and bladder cancer. And it has been really fantastic since then. I think I'm really passionate about this, because it allow us to address, not only the long-term effect of cancer treatment, but also to improve patients' quality of life, and also to help improve the quality of life of their families.

Zach Klaassen: Yeah, absolutely. Perhaps you can delve a little more into your time that you spent in California. And I mean, the experience there obviously, was fantastic, I'd imagine. And the decision to go back to Brazil, go back home, and rather than stay in the US. How did that all come about?

Cristiane Bergerot: Oh, it was a really hard decision. I think it's two different realities. But I think we were really passionate about the challenge that the proposal here in Brazil was in front of us. So we have the opportunity to work in this huge organization. In which we are trying to standardize the survivorship care program, and also, how we can translate, implement, some of the standards we have in the United States, or also in other developed countries, to improve the care for our patients, and for sure, to improve their outcomes. And I think this is what really moved us to decide to come back to Brazil, and to start this new journey.

Zach Klaassen: That's great. So is there still some collaboration going on with Dr. Pal's group, and how does that sort of fit into your day-to-day?

Cristiane Bergerot: Yeah, so we kept all our collaboration. I'm still having some research running there. And we are also establishing other collaborations with other researchers. Right now, I have one set in collaboration with Dr. Thomas Powles, in which we are trying to develop a new approach to screen our patients with kidney cancer. And we also have another, I have also another collaboration with Dr. Powles and yeah, it has been really powerful. Because this is really opening up for new ideas for us to translate, and to bring back some of this knowledge to improve the cancer care for our patients.

Zach Klaassen: How do you integrate in a clinical workflow? How do you integrate the research into your practice and your colleague's practice in Brazil?

Cristiane Bergerot: Usually we run some feasibility studies, trying to see if it's feasible, or even the efficacy of this program. For example, right now, we have a remote physical activity program for patients on immunotherapy, in which we are trying to see exactly the effect of this kind of intervention, and trying to offer this type of research for patients. That it's not only localized in our center, but also, that are living very far away from the place that they receive the cancer treatment.

We also have the remote geriatric assessment program. This also includes some patients with prostate cancer. In which we are trying to determine exactly their unmet needs, and trying to determine the best way to approach, and to improve their outcomes, and also to improve their adherence to the treatment. And we have another, an app based mindfulness program, that it has been really powerful, because we are seeing some great results. Especially for fatigue and emotional symptoms, and also, quality of life among patients with renal cell carcinoma. For this one, we are also running a partnership with City of Hope, which really brings us some attention exactly to which areas we should work to improve. Yeah.

Zach Klaassen: That's great.

Cristiane Bergerot: I think it's some of the way we are translating all this knowledge.

Zach Klaassen: That's fantastic. So you kind of touched on a little bit about how things are for survivorship in Brazil. Can you talk to us a little bit about how maybe it's different than your experience in the US? Some of the challenges. How it may be a bit easier than in the US. And what are the unique challenges to the Brazilians that maybe we don't understand maybe in the US?

Cristiane Bergerot: I would say that our main challenge is to have the supportive care team to work together with us, and to offer this kind of support for our patients. So right now, we have a survivorship program that includes  multidisciplinary care and supportive services. So specifically, in one of our programs that I'm responsible for, we have a psychologist and nutritionist in each of these centers, to screen our patients at various time points of treatment and disease trajectory. So it is a way for us to follow the standard guidelines, in which we should assess distress, depression. And in the case of prostate cancer to PSA, anxiety at the initial visit, and also at appropriate intervals, it also helps us to monitor their symptoms and to treat them promptly. Other than that, we also provide some survivorship care plans, and access to research and such as support groups or rehab service, and also, trying to include the psychosocial nutrition counseling, whenever we see that it's necessary to improve our patient's outcomes.

Zach Klaassen: So I guess, you obviously have a huge, huge department down in Brazil, and I'm fortunate to have a great psycho-oncology team here. So perhaps for the listeners that maybe don't have that set up, either at their institution or their cancer center, how do you recommend patients getting the kind of help that you provide?

Cristiane Bergerot: I would say that the screening program is one of the best strategies. So even because we know that, I would say that 60% of our patients with prostate cancer, we report on this throughout the disease continuum. So for sure, if we have this type of programming, it will be easier to identify these patients.

And if we think on a disease specific, for example, if you consider just patients with prostate cancer, we can also be aware of the risk factors for emotional disorders, including younger age, lower level of education, low income, unmarried status. And also some clinical characteristics. For example, patients diagnosed at Gleason 8-10, or even patients who had early biochemical recurrence, or the time since the radical prostatectomy, and also, how healthy and physical function, how is the health of our patient and their physical function? I think this is all types of information that can cause our patients that we probably need, or to refer this type of patients to a psychologist, or even to a social worker. Or even if we should deliver some specific type of information to the patients and to the caregivers, in order to better identify when these patients will need some type of support.

Zach Klaassen: Yeah, excellent. One thing, I serve a pretty underserved population in Georgia, and I often try to get an idea of what the family situation is like. And often, it ranges from very involved to not involved at all. How do you see that in Brazil, and how do you incorporate the family into the survivorship programs for these prostate cancer patients?

Cristiane Bergerot: Yeah, it's really interesting, because here in Brazil, we have two different types of healthcare service. So we have the public one and then we have the private one. And in the public service, we find a better type of support for this patient. And in the private one, we also see that some patients have this type of support, but there are a huge number of patients who do not have this type of support. So usually, we try to include their family or their caregiver into the discussion, also to have these patients to make treatment decisions. And also to let them know which type of physical symptoms or emotional symptoms they should be aware, in order to call for the healthcare providers or to get some assistance. So trying to involve them, at least trying to mitigate some of their anxiety and some of their worries with all this new information that they are facing as soon as they receive the diagnosis.

Zach Klaassen: No, that's great. So I know you'll probably say that it's a combination of all of these factors, but we know that prostate cancer patients are at increased risk for depression, suicidal ideation, financial toxicity, anxiety, and certainly, all of these factors may be involved for an individual patient. But in your practice for prostate cancer patients, is there one of these aspects that you see that may be more important, or one that is more prevalent than the others?

Cristiane Bergerot: I would say the younger age, for sure we'll have more patients facing some emotional issues. And I will also highlight the married status. I think this will also impact. And for sure, the disease aggressiveness, or even the late delayed side effects that these patients will face after the treatment. So specifically the sexual function, and also if they have any other issues with the urinary tract or something like that. So these are patients who we should definitely be atentive to. So that we should try to offer some kind of support, or even that we should screen them at least every visit in our institution.

Zach Klaassen: Yeah, absolutely. I know one thing that's come to light in the last probably 5 to 10 years is financial toxicity, and certainly what, depending on the study they rated, maybe one in five or one in three men with advanced prostate cancer may suffer from financial toxicity. So perhaps you can comment on if you see that in Brazil, and how it's tough to mitigate this. These are expensive medications, perhaps insurance isn't covering it. How do you address that from a psycho-oncology standpoint?

Cristiane Bergerot: Yeah, it's really crazy. Because even the insurance, it's really tough here, for example, for a patient to get abiraterone. Sometimes they have to, I don't know, find ways to get this type of medication. And we know that this can really change the story of their disease. So it's really hard still here. So I think we don't know enough about the financial issues in Brazil. We really don't know. We have a small proportion of patients who are doing pretty well, but I think the majority are really facing a lot of difficulties, and also a lot of hardship during this process, that is really impacting on their quality of life, and also on the way they're coping with their disease, and also with their prognosis.

Zach Klaassen: Yeah, it's quite sobering when you see some of these studies that the patients that have financial toxicity are even at risk of worse outcomes, and not even thinking about the depression and everything else, but even just cancer outcomes can be worse for these patients. So it's something that we face here, and it sounds like you face it there as well.

Cristiane Bergerot: Yeah, definitely.

Zach Klaassen: So my last question is, basically just allowing you the floor, to speak to anything that we may not have touched on, but also to maybe give our listeners and viewers just a couple of take home messages. The majority, I would imagine, are not psycho-oncologists, but what can we be looking for as medical oncologists, radiation oncologists, urologic oncologists, so maybe a platform to say anything else we may not have touched on, plus a couple of key take home messages for our colleagues.

Cristiane Bergerot: I would highlight the importance of survivorship care planning. Also, we should be monitoring for and managing side effects of cancer treatment. Promoting healthy lifestyles, behaviors. We know that physical activity is really great for patients with prostate cancer, so we definitely should try to have our patients to get more involved in this, and also trying to have a better habit of deciding which type of food they will take. And also I will highlight, promote addressing some emotional and physical needs. So we should be aware of that.

And I think one of the points that is really key is the shared decision making. We are really having more information about that, and more information about which type of treatment is best for our patients. So we really have to involve our patient in this process, and try to find ways to discuss and to document the benefits and risk of cancer treatments and side effects, and identify barriers that may impact on their decision, and refer all patients that are having some issues with this to appropriate service.

Zach Klaassen: Yeah, no, that's great. I think the one message I say too is, as you're a urologic oncologist, and then, in the clinic, we're busy, but we have to understand. We don't have to treat all of these issues, but we have to be able to identify them. Because as the oncologist, we may be the frontline, but understanding the patient that may be depressed, and having screening tools like the NCCN thermometer. And educating our staff and the clinic to look for these signs, and then making the referrals to appropriate people like yourself. I think that's the key is, we have to take those five to 10 seconds and read the room, and understand what the body language is, or what they may be saying to us.

Cristiane Bergerot: Yes, for sure. Definitely.

Zach Klaassen: Dr. Bergerot, thank you so much. I know our listeners will get a lot out of our conversation. I appreciate your time, and I look forward to chatting again soon.

Cristiane Bergerot: Thank you, have a great day. Bye-bye.