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Zach Klaassen: Hello, my name is Dr. Zach Klaassen. I'm a urologic oncologist at the Georgia Cancer Center. We are here live at ASCO 2023 in Chicago. I'm pleased to be joined with Dr. Khalid Alkhatib, who is a clinical research fellow in urology at the University of Pennsylvania. Welcome.

Khalid Alkhatib: Happy to be here.

Zach Klaassen: That's great to have you here. So we're going to discuss some of that's near and dear to my heart and some of your research that you're presenting at the meeting this week discussing depression and anxiety among testicular cancer patients. So what makes this group of young men, particularly of interest for looking at depression, anxiety, and what makes them susceptible to it? So

Khalid Alkhatib: We think that testicular cancer patients are unique in comparison to other cancers, mainly because of the age population that those patients belong to.

Zach Klaassen: Sure.

Khalid Alkhatib: As we know that testis cancer is the most prevalent cancer among young patients. And testis cancer is the most prevalent cancer in young men aged between 18 and 40. And someone might recognize that being at this age, you are probably more vulnerable to developing anxiety and depression, especially if you know that you have cancer.

Zach Klaassen: Sure.

Khalid Alkhatib: I mean, at this period of your life, most men are more focused on other life aspects such as education, employment, starting their own life, becoming independent, finances, education, and to having to deal with testis cancer or cancer diagnosis at this early stage of your life really does compound your risk of developing anxiety and depression.

Zach Klaassen: That's a great summary and I totally agree. I think you look at these patients in your clinic, 22 year old in college, they think they got their whole life is ahead of them, which it is, of course. But then they get hit with the C word. I think that can really tailspin and you see people that from the extreme of breaking down in clinic to completely shutting down, it's almost like you're going through the denial, all these stages of grief when they're seeing these patients. So your work is very important. So tell us about the objective of the work you're presenting this week.

Khalid Alkhatib: So as I said, we already know that testis cancer patients are at a higher risk of developing anxiety, and depression. I mean, some of the literature already described that one in five men are at risk or testis cancer patients and survivors at risk of developing anxiety. And also one in about 10 developed depression. Knowing that, we wanted to look at hospital anxiety and depression risk scores, which are clinically validated scores that can help predicting if patients have depression or anxiety. And we wanted to look at if these scores would change over time in patients who completed their active treatment. And also for us, we wanted to know if those scores would improve over time. So in other words saying that patients would get better mentally after they complete the active treatment or as they are far from being treated.

Zach Klaassen: Sure.

Khalid Alkhatib: So we did conduct this study hypothesizing that those scores will improve over time, but however, the results were a little bit different than what we hypothesized earlier.

Zach Klaassen: So tell us about the study design. This was a single institution study, correct?

Khalid Alkhatib: Yes. That was a single institutional study, prospective study that was conducted at our cancer center at the University of Pennsylvania. Patients were surveyed using these questionnaires almost about two years after they finished their active treatment. Whether the treatment was chemotherapy, chemotherapy and RPLND or even primary orchiectomy. Those patients and their follow-up for their ... in their treatment management, they administered those surveys. And those surveys are conducted annually once every year for a period of five years. So we continued following up patients for five years since their first initial survey.

Zach Klaassen: That's great. So all these patients coming into testicular cancer clinics are all getting these surveys routinely, which is ... I mean, you guys have a very good sample size as well.

Khalid Alkhatib: Yes. The study was well powered to see if there's any significant change in trends. Yeah. Amongst these scores. Well, initially, we wanted to recruit more patients, but we think we're happy with the sample size that we got.

Zach Klaassen: Yeah, absolutely. So tell us about the results you guys looked at overall HADS, HADS anxiety, and HADS depression, correct?

Khalid Alkhatib: Yes. So we look at three parameters. So HADS scores are very specific and sensitive, predicting having anxiety, depression, or even both. So there are three forms of the survey. We looked at the depression score and the anxiety score and the score for both. What we found that those scores are not likely to change over time as far as you get from completing your treatment. That was the same for anxiety, depression, and even both. So that was contrary to what we hypothesized initially because we thought that those scores will improve and get better over time. But in our adjusted analysis, that was not the case.

Zach Klaassen: I see.

Khalid Alkhatib: And in fact, we learned other stuff from our adjusted analysis.

Zach Klaassen: Tell us about that as well. What else did you guys learn from that?

Khalid Alkhatib: So we conducted a longitudinal-linear multivariate analysis, adjusting for other age and other social demographic factors in addition to the type of treatment that patients get their stage and even their histopathology.

Zach Klaassen: I see.

Khalid Alkhatib: So what we found is that neither your stage nor the type of treatment you get really predicts what kind of score you get.

Zach Klaassen: I see.

Khalid Alkhatib: However, we found that other social demographic factors such as employment, income, education has more implication into what the kind of scores that you get over a period of time.

Zach Klaassen: So even somebody on surveillance may have worse scores than somebody who's been through post-chemo, RPLND all depending on more of their socio-demographics.

Khalid Alkhatib: Exactly. And what we learned that your scores after two years of completing your treatment are not likely to change over time.

Zach Klaassen: I see.

Khalid Alkhatib: So if you had low scores that are associated with clinical anxiety or depression two years post of your treatment, those scores are most likely not going to change.

Zach Klaassen: So the $64,000 question is from a clinical application, how do we think about this data and how do we support these men knowing that even over time they're going to probably be right where they were to start with?

Khalid Alkhatib: So clinically, we think our results are very, very important.

Zach Klaassen: I do too.

Khalid Alkhatib: Because what we are learning now that if you are experiencing any kind of anxiety or depression, even after your treatment, you're not likely to improve over time. So clinically, we think that's very important for people, for clinicians who see those patients. I mean, we acknowledge that most testicular cancer patients are not seen by psychiatrists. They're mainly seen by medical oncologists and neurologists, nurse practitioners. But this is very important for us to be vigilant and educate ourselves about those patients having a higher risk of mental health issues. And those mental health issues are not likely to change over time.

So counseling those patients, screening for depression, anxiety, and even suicidal thought-

Zach Klaassen: That's right.

Khalid Alkhatib: And referring them to the right people, so that's very important. At least that is what we were learning from this type of study.

Zach Klaassen: I totally agree. I think I'm fortunate in my cancer center, I've worked very closely with psycho-oncology and if I look anecdotally at the number of people are from each disease state that go see psycho-oncology, it's highest in testis cancer. And I think your data totally plays that out, so.

Khalid Alkhatib: Thank you.

Zach Klaassen: Any take home messages for our audience today? We've had a great discussion about this.

Khalid Alkhatib: Yes. Patients who are more likely to experience anxiety and depression after the treatment, they're most likely not going to improve our time. We know this from the hospital anxiety risk scores. We saw that scores do not change over time. That was true even for those who do have scores that are associated with clinical depression and anxiety. This is one thing, and also we learned from our study that other social demographic factors or variables that we adjusted for in our analysis, namely socioeconomics, finances, income, employment, are more implicated in predicting whether patients have low scores and high scores. And that was not true for the type of treatment that you get and for the stage or even the histopathology.

So this is very important clinical information, at least from a clinical perspective because you know that these other sociodemographic factors are modifiable and you can work on this to improve the quality of life of our patients.

And also, one of the secondary outcomes that we looked at in our patients, we did cluster our cohort by the type of treatment because we wanted to look whether the type of treatment would impact the way this scores change over time, particularly with patient treated with cisplatin or platinum-based chemotherapy. And our results did indicate that neither the type of treatment does really impact the way these scores fluctuate over time.

So this is also a very valuable piece of information, at least clinically because it has been hypothesized earlier by many of our colleagues that cisplatin-based chemotherapy could have an long-term impact, particularly in mental health.

Zach Klaassen: For sure. I think you mentioned earlier vigilant, and I think whether we're your urologic oncology, whether we're rad onc or med-onc, we have to be vigilant and we don't have to treat these patients, but make the appropriate referrals when we see these red flags, so.

Khalid Alkhatib: Of course, very important. I think this is the highlight of our study. We think that clinicians, I mean, urologists, medical oncologists should be aware and vigilant about red flags. Even simple stuff like having difficulties in life, not sleeping well.

Zach Klaassen: Sure.

Khalid Alkhatib: Having bad relationships, having issues at work, these could be red flags.

Zach Klaassen: That's right.

Khalid Alkhatib: And it's worth to screen and ask questions. I mean, if referring patients early to a specialist, it's worth, it could have an impact on the quality of life of patients and even considering those patients being at high risk of other stuff like suicide-

Zach Klaassen: That's right.

Khalid Alkhatib: Changing the way we practice or being vigilant could be a life-changer, I mean, lifesaver for those patients.

Zach Klaassen: Absolutely. Dr. Alkhatib, great conversation.

Khalid Alkhatib: Thank you.

Zach Klaassen: Very important. And thank you very much for your time.

Khalid Alkhatib: Thank you. Thank you. It's my honor.

Zach Klaassen: Thanks.