Mental health, mental health, we talk about active surveillance,
But I don't know about Canada; I've talked to you about this, but you got to give my
your opinion on mental health, and the reason I say that is I would look at some of your data
and one of the number one reasons for dropout—or the top reason—it would say anxiety
and I'm going, "Yeah, exactly because you're not being treated." People are freaking out,
you told me you had cancer. How do you address the mental health aspects of active surveillance?
Yeah so so, there's a lot of myths about this. Okay so for instance, in our cohort 11%
dropped out because of anxiety. Now you have you have to understand when we started doing this,
you know, there was not this understanding that I think there is now of latent cancers, or
over-diagnosis, or indolent cancer, so, you know, 15 years ago as a clinician you say to a patient,
"You have cancer, but you don't need any treatment," and they look at you like are you
insane, you know, could you please send me to some doctor who knows what he's talking about.
Right.
So, there was much higher level of anxiety. Now I think
this is now kind of part of the public discourse. People are aware of some of these issues of over
diagnosis, and over treatment, and indolent indolent cancers so the sort of overall
societal level of anxiety about this has gone down and we also have data from many many studies
that, you know, there's anxiety associated with prostate cancer for sure—there's increased suicide
rate in people that been diagnosed, all kinds of things—but how they are treated has no impact,
like no measurable—doesn't seem to make any measurable difference. The one exception,
there's a group of patients, not that common, socially isolated, no social supports,
prone to anxiety disorders — they don't do well on surveillance, and, you know, maybe they—although
even so it responds to counseling—but my personal experience has been if you give
patients the right information, you use the right phrases, you talk about things like pseudo-cancer,
a part of the aging process, the anxiety just melts away. You know, and the other side of it is
that these patients who avoided treatment, they get to know more about the disease,
they meet guys who've had treatment, they after a while they develop ebullience — like
they're so gratified that they didn't end up having radical therapy.
Yeah.
...and so, I just don't see — and also the the proportion of patients who insist on treatment now
has definitely gone down; it's nowhere near 10% anymore, it's probably in the 2-3% percent range.
So, it's just not an issue as far as I can see it for the vast majority of people.
I wonder if you went back on the data or look now,
so I think it's better with you out there and other people, people have less anxiety,
but what I still see is spouse anxiety and family anxiety because they don't get it,
you know, and I understand, so maybe we have to start educating family members and spouses because
I see a lot of times where someone will say okay this makes sense, but the other person
says well in other cancers this doesn't and then there's this battle back and forth.
Yeah ... and someone gets convinced to treat,
so I don't know if you see that or maybe you see more cohesiveness
Listen, I know—I mean we have data on this—the range of practice is still huge. Like there is
the MUSIC, your colleagues in the University of Michigan, the MUSIC collaboration, you know,
the range in one region you have clinicians for whom zero percent of their low-grade prostate
cancer patients are managed with surveillance, and down the hall, it's 95%. So, I mean clearly,
there's still a lot of room for improvement in terms of complying with this approach.
That's a really good point, and that was part—you know we had Jim Monty was my past chairman,
our past chairman, he wanted to push that because he started seeing this discrepancy,
so that's an interesting shout out.