Implications of Mental Health Illness on Outcomes of Prostate Cancer Patients in the Veterans Affairs Medical System

Scientific Objective and Rationale for the Proposed Project: There is limited research to date examining whether Mental Health Illness (MHI) affects risk of prostate cancer (PC). Moreover, when men who have MHI receive a diagnosis of localized PC, there are no studies to date assessing whether they receive appropriate treatment, adhere to post-treatment surveillance protocols, or have PC outcomes comparable to men without MHI. This research proposal addresses PC (Topic Area), MHI exposure (Focus Area), and PC outcomes (Focus Area) to address these unmet needs. PC is common in the United States (1 in 7 men will be diagnosed), as is MHI (~20% of the population). We believe that MHI will be associated with lower PC risk, but advanced stage and grade at diagnosis, in addition to poor treatment allocation for localized disease, adherence to follow-up, and PC-outcomes. However, we also anticipate that MHI-specific therapy (psychiatrist, psychologist, psycho-oncologist, pharmacotherapy) will improve the outcomes of MHI patients to the level of PC patients without MHI. We will use medical data from the largest health system in the country, (the Department of Veterans Affairs (VA) Health System, to develop the largest nationwide MHI/PC database to definitively answer these questions.

Principal Investigator's (PI's) Career Goals in Cancer Research: As a urology resident, Dr. Klaassen (PI) became interested in research centered around mental health and suicidal death among patients with urological cancers. Dr. Klaassen participated in multiple studies using large patient databases and found that patients with genitourinary malignancies have an increased risk of suicide—specifically PC patients—even up to 15 years after their cancer diagnosis. Dr. Klaassen's next stage in his career development, a Urologic Oncology fellowship, allowed him to apply his prior research experience to a graduate degree, where he found that patients with cancer have an increased risk of suicide compared to the general population, even when controlling for previous psychiatric care. Dr. Klaassen has knowledge in research, including study design, primary data collection, biostatistics, and manuscript preparation. Receipt of this award will ensure that he acquires the advanced research skills, such as project development, nationwide administrative data critical analysis, and management of a research team, in order to develop into an independent investigator and leader in identifying at-risk PC populations to target MHI interventions to improve PC outcomes and survival. The guidance/mentorship by Dr. Freedland and the entire professional development advisory committee will further reinforce Dr. Klaassen's research development and bring his current and future research to the next level. At the conclusion of 4 years, Dr. Klaassen will have a PC research team with the largest database ever created to study MHI and PC to successfully apply for further grant funding opportunities.

Applicability of the Research: We will determine PC risk according to MHI exposure. Using a large, nationwide VA group of patients, these results will be useful to anyone with MHI and have major policy implications, regardless of our findings. We will also provide a comprehensive assessment of PC treatment and outcomes according to MHI exposure. Additional contributions will include insight into whether MHI-specific therapy in the VA system is improving the outcomes of MHI PC patients to the level of patients without MHI. During the 4 years of the award, we expect to publish PC risk results within Years 1 and 2, with PC-specific treatment/outcomes and the impact of MHI-specific therapy results completed in Years 3 and 4.

Benefit to Active Duty Service Members, Their Families, Veterans, and Other Military Beneficiaries: These results will establish the risk of PC according to MHI exposure and help guide interventions (i.e., screening) directed at improving care among Service members, Veterans, and/or family members with MHI. The VA has established rigorous health exam clinics aimed at screening for MHI and risk of PC. Furthermore, if our study finds that MHI exposure decreases risk of PC (but increases advanced PC), as well as worse treatment of localized disease, adherence to follow-up, and/or PC-specific outcomes, this will provide an opportunity for early intervention (i.e., better PC screening for men with MHI or targeted treated to reduce the effects of MHI or both). Assessing the current impact of MHI-specific therapy will provide information as to areas for improved intervention when MHI patients are diagnosed with PC. Alternatively, if we find no association between MHI and PC (or PC treatment, follow-up, and outcomes), this has important policy implications, as MHI-focused resources can be directed toward risk reduction for other MHI sequelae and not specifically patients with PC. Regardless of our results, we will establish a very large VA PC/MHI database that will provide epidemiologic data to conduct future PC studies. This will be useful to military personnel and family members with or without MHI, which will be a huge boon both for PC research in general and, specifically, for Dr. Klaassen's career as a future leader in PC research.