 So, again, for today's webinar, a silent epidemic of mental health among prostate cancer survivors, a secondary analysis of the Canadian longitudinal study on aging. Let me please introduce our panelists Louise Moody and Dr. Gabriela, Ilya, or Ilya. I knew I was going to get that wrong. Louise Moody is a recent master of science graduate of community health and epidemiology from Dalhousie University. She is now a 2nd year medical student at Dalhousie. So, welcome to Louise and Dr. Gabriela Ilya is an endowed chair in prostate cancer quality of life research in the faculty of medicine at Dalhousie. Her research examines the needs and challenges of men diagnosed with prostate cancer and prostate cancer survivors. Inactions this evidence based information into tangible education and empowerment programs aimed at improving the lives of cancer survivors. So, with that, and I'm ready for my water now, I will turn it over to Louise and Gabrielle. Alright, so, hello everyone, thank you Jennifer for the introductions. So, again, my name is Louise Moody and I'm a 2nd year medical student at Dalhousie and my thesis supervisor Gabriella is here today. And so, she'll be answering any questions at the end during the Q and A. So, I just want to start off the presentation. Second, let me see if I can flip through there we go. Okay, so I just want to start off by giving you guys a bit of background about our story of how we got here. So, basically, our story of how and why we decided to do this research. So, this research began 5 years ago and we started with identifying mental health issues in a survey of maritime population of men diagnosed with prostate cancer and the survey started in March 2017. And by the end of 2018 there were about 200 men who had responded to this survey and at this time we acknowledged that this sample was quite small and also it was quite heterogeneous in the sense that we had both patients and survivors. Some of which who had been treated more than 8 years ago, but nonetheless at the time they took the survey 1 in 3 and a half men screened positive for clinical depression and anxiety. And at the same time we uncovered that survivors of prostate cancer have the lowest so less than 20% attendance to cancer support groups compared to 60 to 90% of in other forms of cancer. And these men feel lonely and isolated. They experienced challenges and satisfying their emotional needs and most rate sexual dysfunction as their major concern. So, this raised red flags for us and the immediate question that arose was how does this compare to men in the general population who have never had a cancer diagnosis. At the same time that year, the European Neurological Association conference had a presentation that showed that prostate cancer survivors up to 18 years later had severe anxiety and depression. So this prompted us to look at the Atlantic path data as well as to put in a request for the CLSA data. So the Atlantic path data had a population that included men who had never had cancer and men who had other forms of cancer as well as prostate cancer. And so in 2020, Drs. Ali Rutledge and Sweeney published the results of their population based study of 6,685 men residing in Atlantic Canada. And they found that survivors of prostate cancer had more than double the odds of screening positive for clinical depression and anxiety compared to men who had no history of cancer, which was the control group. They also found that while men with a history of other forms of cancer had comparable outcomes with this control group. So basically two questions emerged from these investigations. And the first one was, is this an issue that pertains to Atlantic Canada only given that we have the highest rates of cancer, including prostate cancer in the country. And this is what prompted our CLSA investigation. And the second question was, how do men with the prostate cancer diagnosis compared to men with other forms of cancer when it comes to their mental health. And is this situation that affects men with prostate cancer more than any other form of cancer, perhaps due to their low attendance to support groups as well as their unmet psychosocial needs, such as feeling lonely and disconnected. So, as I said, this second question was addressed in a study that was published at the end of last year by doctors, the Lee Rutledge and Sweeney showing that rates showing rates twice higher for anxiety and depression for prostate cancer survivors compared to any other form of cancer, especially among men with low socioeconomic status. So today I will be presenting on my paper that was recently published in the mood and anxiety disorder section of the frontier psychiatry journal. Which addresses this first question as to whether this is an issue across Canada for the prostate cancer population. This research was completed under the guidance of my thesis supervisor, Dr. Gabriella Ilya was here today with me. So I'm just going to jump in right now. So in the background section, so prostate cancer is the most commonly diagnosed cancer among men in Canada and the USA. Currently research indicates that 1 in 7 Canadian men will develop prostate cancer during their lifetime. Although the incidence rate of prostate cancer increases faster with age than any other cancer, about 81% of prostate cancer diagnosed cases are diagnosed in the early stages of development when patients can receive effective curative treatment. Prostate cancer treatments have improved considerably over the decades and are providing very good curative results. However, patients are still at risk of complications and side effects, especially urinary incontinence and erectile dysfunction. These side effects often negatively impact the cycle, the psychological well being of these patients. What is most important to note is that the majority of prostate cancer patients become long term survivors, so living greater than 5 years with over 70% of patients expected to live 10 years or more from the time of their diagnosis. So any unaddressed mental health disorders can negatively impact their health long term. So according to a literature review conducted in 2019 by Forveha A. All, 1 in 6 men with a prostate cancer diagnosis will experience clinically significant depression, which was shown to contribute to poorer oncological outcomes. However, this paper was a review of the literature at the time and it was based on small scale studies. So the rise in prostate cancer incidents with increased age combined with low prostate cancer mortality have important implications for the Canadian health care system. Men with co-occurring depression and prostate cancer are more likely to have worse quality of life, both short and long term, increased risk of multi morbidity, increased mortality and higher health care utilization than men in the general population. So existing studies examining the relationship between prostate cancer survivorship and mental health have not controlled for substance use. And this is important given the established relationship between mental health and substance use in the literature. Specifically, research shows that mental health disorders have long been associated with multi morbidity and unhealthy lifestyle coping mechanisms such as alcohol use and smoking. As 99% of patients diagnosed with prostate cancer are over the age of 50 and about 65% are over the age of 65, they are more likely to experience the sequel of cancer treatment in the context of co-existing medical conditions. Studies show that individuals with multi morbidity have worse physical, social and psychological quality of life. Reed et al. found that depression is two to three times more likely to be experienced by people with multi morbidity than those who have no chronic physical conditions. Alcohol use and smoking are known unhealthy coping mechanisms and risk factors associated with prostate cancer. Continued alcohol use and smoking after diagnosis can complicate treatment, increase risk for further malignancy and contribute to secondary health problems such as cardiovascular disease and diabetes for prostate cancer survivors. Therefore, we chose to examine the prevalence of prostate cancer and examine the relationship between status of lifetime history of prostate cancer diagnosis and current mental health status while controlling for the contribution of multi morbidity, alcohol use and smoking status. In a large population based sample of adult Canadian men who participated in the baseline data collection cycle of the CLSA between 2010 and 2015. Alright, so as I'm sure many of you already know, the CLSA is a national longitudinal research platform that collects comprehensive data and biological samples, which support a wide variety of age related research. So our data was based on a sample of 25,183 men between the ages of 45 to 85 years of age, and this was from the slightly more than 50,000 men and women across Canada's 10 provinces who participated in either the tracking or comprehensive cohorts of the baseline cycle. So all the variables in the analyses were assessed in both cohorts with the exception of psychological distress or the K10 variable, which was only assessed in. And I'll talk about that a bit more when I'm talking with the results. Okay, so in terms of our methods, so mental health was our main outcome variable of interest. So we used 3 indicators of current mental health that were available in the CLSA data set and these measure different dimensions of the mental health construct. So the first one was the Center for Epidemiological Studies Short Depression Scale or the CESD 10. And the CESD 10 asks individuals about their depressive symptoms and the week. Therefore, it is a measure of current depression screening. So the CESD includes 10 items comprising six scales reflecting major facets of depression. So those included depressed mood, feelings of guilt and worthlessness, feelings of helplessness and hopelessness, psychomotor retardation, loss of appetite and sleep disturbance. So our second mental health measure was the Kessler Psychological Distress Scale or the K10. So the K10 is a measure of clinical screening for current symptoms of psychological distress such as depression and anxiety within the past month. And lastly, we use the self rated mental health. So this is a measure of one's perception of their overall mental health. Individuals that participate in the CLSA were asked in general, would you say your mental health is excellent, very good, good, fair or poor. And we included this measure to see if it would align with the objective measures such as the CESD 10 and the K10. So for our exposure variables as you can guess our main predictor was lifetime history of prostate cancer diagnosis. So in the CLSA participants were asked, has a doctor ever told you that you had cancer? And if the participants answered yes, then they were prompted with a further question, what type or types of cancer were you diagnosed with? For our multi morbidity variable, we included 26 chronic conditions as they either met the definition of a chronic condition or have been included in previous multi morbidity studies such as diabetes, heart disease, thyroid conditions, osteoporosis, arthritis, etc. And then our final exposure variable was substance use and this had two facets. So the first was alcohol use and item we used from the CLSA was frequency of alcohol consumption in the past 12 months. And then for smoking or tobacco use, we use the item frequency of smoking in the last 30 days. So for covariates, we selected these based on previous literature indicating that these variables are associated with mental health. So we use six covariates, age, province, education, household income, marital status and ethnicity, and the categorizations that we used are on this slide here. So for all analyses, complex sample analysis using IBM SPSS version 25 was employed with geo strata and entity ID variables used a strata variable and cluster variable respectively in the design module. And to make the estimates generalizable to the Canadian population and to address the complexity of the CLSA survey design, we use trimmed or inflation weights in the descriptive analysis and analytic weights in the regression analysis as recommended by the CLSA protocol and which were available to us in the data set provided. So for analyses with the outcome measure psychological distress or K-10, we use the comprehensive cohort as the K-10 questionnaire was only available in that survey. So our sample size was smaller for this, so it was 14,777 and we used multiple imputation and that was performed based on 5.5% of the outcome variable missing. And so all our analyses that include psychological distress were reported for both the original end to the multiple imputation pool data, and you can find those tables in our paper. And when I'm discussing the results, I'll let you know when am I multiple imputation results were comparable with the original data. So just one sec. All right, so now we'll get into the results. All right, so for results in estimated 4% of adult men reported a lifetime history of prostate cancer diagnosis. So this corroborated the prevalence of prostate cancer in the Atlantic Path data. Of the Canadian men who reported a lifetime history of prostate cancer diagnosis, 72.8% were over the age of 65. The majority of men who reported a lifetime history of prostate cancer diagnosis were married or common law, so 83.7%. And over 70% of men who reported a history of prostate cancer had a household income of less than $100,000 per year. And of those 29% reported a household income of less than $50,000 per year. So in these descriptive analyses, increased household income and education were protective factors for lifetime history of prostate cancer. All right, so I know this table is a little small, but I highlighted the, the two most important results and I'll verbalize them now so in the logistic regression analysis, which were adjusted for covariates and the complexity of the design I revealed that men with a lifetime history of prostate cancer diagnosis has statistically significantly higher adjusted odds of screening positive for psychological distress and depression, but not for self rated mental health compared to men who had received a lifetime history of prostate cancer diagnosis. So the top blue box up there that's for psychological distress. And so men with a lifetime history of prostate cancer diagnosis had higher adjusted odds and so it was 1.52 times higher of screen and positive for psychological distress. And in this case, the multiple imputation data set was comparable with this result. And so for depression, it revealed that men with a lifetime history of prostate cancer diagnosis has statistically significantly higher adjusted odds so 1.24 times higher of screening positive for depression and that's the bottom blue box there that circled. And then as I said, it was there was no statistically significant relationship between lifetime history of prostate cancer and then the poor self rated mental health variable. So getting into the multiple logistic regression analysis. These were adjusted for the covariates as well as the complexity of the design, and we examined the contribution of lifetime history of prostate cancer diagnosis, multimorbidity, smoking and alcohol use on each of the three mental health outcomes and revealed a statistically significant contribution of all four predictors to depression, but not to psychological distress or self rated mental health. So first I'm going to be talking about the relationship with depression or the CESD questionnaire and so that's the middle column with the sky blue boxes. So the odds were so the top box there, the odds were 1.32 times higher for screening positive for depressive symptoms among men with a lifetime history of prostate cancer, compared to men without a lifetime history of prostate cancer. And then when you move down the box to look at multimorbidity, the odds were 1.62 times higher for screening positive for depression among men with multimorbidity, compared to those without multimorbidity. And then when we look at alcohol use men who were weekly drinkers or daily drinkers had odds 1.18 and 1.47 times significantly higher for screening positive for depression respectively. And then finally that last sky blue box is looking at tobacco use or smoking. And so daily smokers also had a 1.57 times higher odds of screening positive for depression at the time they were being surveyed compared to the to non smokers. And then if we go over to the left column so that's the dark blue, that's psychological distress. And so lifetime history of prostate cancer was not a statistical significant contributor of screening positive for psychological distress. But when we in the original data set, but when we did the multiple imputation analyses it showed that among men with a lifetime history of prostate cancer odds were 1.62 times significantly higher for screening positive for psychological distress compared to men without a history of prostate cancer. And so again that multiple imputation data is available in a table that's in our published paper. So, then if we look at the dark blue boxes so that first one there that's looking at multimorbidity so the odds were 1.64 higher for screening positive for psychological distress and the multimorbidity controlled analysis. So, and the results there were comparable with the multiple imputation data. And then men who identified themselves as weekly drinkers had 1.52 times higher odds and those who identified themselves as daily drinkers had 1.59 greater odds of screening positive for psychological distress than non drinkers and again that was comparable in the multiple imputation data. And then finally that last dark blue box on the left that is men who identified themselves as daily smokers and they had 1.84 times higher odds for screening positive for psychological distress compared to men who identified as non smokers. And then finally we'll look at the last column there on the on the far right. So, that is for poor self rated mental health so lifetime history of prostate cancer was not a statistically significant contributor of poor self rated mental health. But then if you look at the multimorbidity so that that top blue box on the right hand side, odds were 1.97 times higher for poor self rated mental health among men with multimorbidity than those without. And if you look down at alcohol use so the next box odds were 1.58 times higher for self rated poor mental health among daily alcohol drinkers compared to men who identified themselves as non drinkers. And lastly, men who identified as daily cigarette smokers had 1.45 times higher odds for poor self rated mental health compared to non smokers. So, our covariate results which I don't have in the table in this presentation but again are available in our published paper but I'm just going to summarize some of it so the covariate results from our final analysis also indicated that younger age not being in currently in a relationship, lower household income and residing in Atlanta, Canada may be placing men at higher odds of mental health disorders than being of older age being currently in a relationship, having over $150,000 total household income and residing in Alberta. Okay, so to get into the discussion. So, to our knowledge, this is the first study to assess the prevalence of prostate cancer survivorship in Canada. And results indicate that 4% of adult men in this Canadian population based sample reported having had a lifetime history of prostate cancer diagnosis between 2010 and 2015 when the baseline cycle of CLSA was collected. So, as I said, this estimate is comparable to the 3.9% prevalence estimate of lifetime history of prostate cancer in Atlantic Canada between 2009 and 2015. That was characterized by similar demographic characteristics through the Atlantic path data and those results are available in the paper by Dr. Ilya Rutledge and Sweeney. So, our results indicate greater psychological distress and depressive symptoms among Canadian men who reported a lifetime history of prostate cancer diagnosis compared to men who had no history of prostate cancer diagnosis in these demographic controlled analyses. And so, to our knowledge, this is the largest population based study examining these associations. So, results corroborate findings from previous smaller sample size investigations and indicate that mental health disorders are significantly prevalent among prostate cancer survivors compared to men who have never had a prostate cancer diagnosis. And support evidence that mental health care should be part of the prostate cancer survivorship plans. While a statistically significant association between lifetime history of prostate cancer diagnosis and validated mental health outcomes, so psychological distress and depression was observed and the status of lifetime history of prostate cancer was not associated with self reported mental health. So, a scoping review of the relationship between self rated mental health and validated measures of mental health show that these measures, though related, should not be considered equivalent or interchangeable because self rated mental health may be measuring people's commonly held perception of mental health and may reflect equating the question to mean whether or not the individual looked for mental health health or resources available to them in their communities. Evidence shows that men tend to report less self perceived disorders, although the rates of social isolation and suicide are higher among men compared to women. These differences may point to the possibility of less communication or verbalization of mental health problems among men and or more issues of shame or guilt around acknowledging these problems among men. Alright, so our results were not without limitations. So, first and foremost, the nature of the data is retrospective and self reported. Thus, it is subject to the challenges of accurate recall and also survivor bias. Since the CLSA data does not capture the date of prostate cancer diagnosis, survivorship time could not be controlled for in these analyses and may have bias the results. The overall response proportion in the CLSA data was around 10%, which although was adjusted for by the use of the population based weights may have introduced a non response bias. And finally, since multi morbidity and substance use increased the risk of mortality. The proportion of cases with high multi morbidity and heavy substance use may be lower in our data and could have led to an underestimate of the odds ratios observed. So, despite these limitations this project offers important contributions by providing evidence of poor mental health outcomes among Canadian men with the history of prostate cancer diagnosis by examining data from a large scale national population based survey that used it a standardized protocol. So, to reiterate the use of the CLSA data set was the main strength of our project and all the following strengths are related to the information that was available to us in this robust survey. So, the use of 3 validated mental health measures the CSD 10, K10 and self-rated mental health is a strength. Additionally, the breadth of information collected allows for several potential confounders to be controlled for in our analyses. And another important consideration is that we were able to capture 26 chronic conditions for inclusion into our multi morbidity variable. Alright, so just to conclude, I'm going to talk about implications of this research, both for researchers and clinicians. So, our present findings caution us to be particularly attentive to symptoms of mental health among men when they are observed. Our results also further emphasize the importance of including validated questionnaires and prostate cancer survivorship plans to assess mental health disorders among prostate cancer patients during their survivorship journey. And also the implementation of innovative and integrative patient education and empowerment plans through holistic interventions that aim to ease the psychosocial and physical needs of these survivors is warranted. So, some of those psychosocial and physical needs include loss of sexual function urinary leakage feeling disconnected from their intimate partners and close family members and friends lack of sleep and fatigue. So, currently, our lab is in the middle of a phase 3 RCT that helps address loneliness, disconnect and prehabilitation in this population to help alleviate some of this mental health distress. So, just in conclusion, I just want to acknowledge again the CLSA for providing this data set that we use for all our analyses. As well as the solstice lab supporters and members so Frank and Debbie so be as well as the Dalhousie medical research foundation. And again, this research was based off of the work I did for my masters and the community health and epidemiology program here at Dalhousie. And so I had two supervisors, Dr. Gabriella Ilya, as well as Dr. Susan Kirkland, who is a co principal investigator for the CLSA. And then Dr. Pan Andreu and Dr. Rob Rutledge, who are on my thesis committee as well. And then I have to acknowledge my parents marine and death for all their support. Over the last few years. So, yeah, those are just some references from the slides today. And again, those can all be found in our paper. And I just want to thank you guys all for listening and Gabriella and myself are here to field any questions that you may have. Thank you. Well, thank you so much for the presentation. And, you know, I think it was definitely. A very important topic, especially for men clearly. I'd like to open it up to questions sort of formally, even though questions could have been coming in throughout. So just a reminder, your muting will remain on and you can enter your questions into the chat box, which is in the bottom right of your corner. But first, I just wanted to touch base on one of your last points about the RCT. You're you're currently conducting. Can you tell us a little bit more about that? Yes, yes, yes. So it became very apparent right about 5 years ago that we're dealing with a silent epidemic of unmet needs and men needs at all stages of the prostate cancer diagnosis. So really pointing out to the fact that we can't ignore psychosocial requirements, things like lifestyle, things like really finding out what happens after you get a prostate cancer diagnosis. What sort of active treatments are there? What are the implications associated with them? And now that you got a cancer diagnosis, are there some ways in which you can control the direction of the diagnosis? Could you change, could you improve your lifestyle? Could you change your diet and eat better? And if so, what should you eat? What should you avoid? Could you control the amount of exercise? Should you maybe start exercising or if you're exercising only once a month, could you bring a little bit of routine into that to help you along? Are there any things that are pre-habilitating, meaning the sooner you do them, the better it's going to be. So for instance, we know that having a high BMI and going into surgery is not a good thing because that surgeon is going to have to navigate through that fat. So, so getting rid of it before your surgery is a good thing. And of course, you know, healthy manner. So we basically went to the literature with the help of patients. So we had patients involved in this research from day one. And now we have almost an army of research citizens that are cheering us along the way and being involved in every aspect of our research. We don't make any decisions without patients' involvement. And because they give us a reality check, including this intervention that we developed, they said, well, let's, let's talk about us and what happens here. Because we don't want to end up with yet another intervention on which billions of dollars are being spent and it sits there on an internet site and nobody's using it. So very important to bring the voice of the patient back into the medical system, see whatever size is there to support patients and empower them from day one. Really, oncological outcomes can be improved by working with a patient, by informing them rather than leaving them in a black hole. You don't know what's going to happen. You don't know what side effects, you don't know how to navigate your way through appointments. There's a lot, there's a lot of unknown there. And that plus the big cancer diagnosis creates a lot of anxiety. And especially in a time like this one, on top of it, you have a world pandemic. So it is so important to start looking at what we have and do better. Yes. Yeah. I can talk about this. We're so passionate about it. You're definitely clearly passionate about it. So just in terms of the RCT, what were the interventions that were part of the RCT? I'm just curious about that. Yeah, we do have some questions that are coming up as well. So, so the intervention has an exercise component, which includes also pelvic floor exercises, which are very important for men who have been diagnosed with a prostate cancer diagnosis because they have potentially they could have a red file dysfunction or urinary dysfunction. So it's important to engage in pelvic floor exercises that are rehabilitating and we know that they work well when they're started before the actual active form of active treatment. So there is an exercise component. There's a diet component. There is a social connection component. There is an intimate intimacy education and sexuality education. And, and there is a meditation and stress reduction, which involves a biofeedback mechanism. So we did a proof of concept at the beginning of 2019. That worked very well. We published the results of the study. We showed that not only is it feasible and it's working and men will engage in that routine, but that actually there are results that were noticing even after 28 days. Now, we're in the middle of an RCT that goes on for six months as soon as you get diagnosed. So the RCT either assigns you to the intervention or the standard of care. Six months, the program gets evaluated. We have weekly compliance surveys. We also have daily videos that are sent to people. So it's very engaging. We get together with everybody in the team once a month, all the patients in the trial. It's very supportive from, from a social point of view and social interaction and social connection. And then we evaluate again patients at a year later. So patients in the late group get to get the program six months later. So nobody's left out. So it's a wonderful design and we have already run a few preliminary analysis and the results are looking amazing so far. But we only have about 50 men that have completed the trial. So we're in the middle of it. Thank you. So 1 question we had is whether you controlled for physical activity. I presume this isn't from your original the main study that you're talking about today and not the RCT. Oh, you mean in the analysis? No, we did it. Okay. No, no, we control for this particular lifestyle. What else do we have here in terms of there's also a very positive comment from Valentina just emphasizing the fact that you're addressing the psychosocial determinants of health and. That this is a very important to patients with prostate cancer. So that's just a kudos to you. Next question, which I usually also ask because my background is a knowledge translation is how to envision the study may change policy. And I guess I was thinking, you know, or have you, do you have any partners, you know, like cancer or whatnot. Yeah, yes, we've done quite a bit of work in terms of implantation. In fact, we're in the middle of planning for phase 4. RCT. It's an implementation study that we're going to run throughout Canada, New Zealand and Australia. We have received some money for funding and we're waiting results of yet another funding opportunity for which we applied. But we are talking with a lot of state. There are a lot of stakeholders in this. So, yeah, and including, including here in Nova Scotia. So we're already rolling the ball to make the standard of care within our own province. And so, yeah, many from prostate cancer Canada to November to which are the typical organizations that support this kind of research. Incredible research citizen support patient support. Not just here but throughout Canada and in New Zealand and Australia we have established groups of research citizens in New Zealand and Australia that are so excited to help along. We have a group of mentors, people that have gone through the program that don't want to say goodbye. They want to remain involved and they want to make sure that they help along. So lots of ideas on the table. But most importantly, this phase 4 randomized clinical trial, which is going to start this year. So exciting. Great. There's a mess. There's a chat from Prakash here. Oh, I just lost it there. I think Prakash, I think you were more asking something more general. So, I might encourage you to send me a message or send the team a message about. Access to CLSA data more generally. Okay, so, in terms of the current presentation, do you know if any of the men with prostate cancer in the study attended support group meetings? And also, second part to the questions did attending the meetings result in reduction in any depression or anxiety. So, yeah, so from this study that I presented on today, we didn't have access to that variable in the CLSA data set. We didn't know if they had attended cancer support groups as well as I mentioned that we also didn't have a date of diagnosis. So we didn't know their survivorship time. So all of those things would have really aided in our analysis. But I, and then to answer the second part, we know from other research that we've done that attending these meetings can really drastically help reduce anxiety and depression as well as distress for these men. We didn't have access to that in this study. And just going back to the RCT, which you talked about, what was the control arm for the study? The control arm is currently standard of care. So men go through the normal standard of care. So they would have their appointment with their neurologist or radiation oncologist and have their form of active treatment and just follow along. I'm not seeing. I hope I got everybody's questions. There's also another sending kudos and congratulations on an excellent presentation. From Louise and her master's work. I'm so proud of her. It's a great work. It's such an amazing student. I'm working part at work of the Solace lab and Gabrielle's larger prostate cancer research portfolio. So I think that's just a testament of the great work that that you're doing. Louise is phenomenal. We have, I mean, we're so proud of her. And this is, imagine someone that is being trained to be a medical donor. She said access to this type of research talking to patients directly from the start of her master's program, even before, even before. And it's yeah, one of the things I think that stood out to me the most do doing like the preliminary RCT stuff was like this age group and this, this group of men that come to these like interventions. They are so dedicated and they want, they want it to work and they, they come to everything and put 120% effort in and like that is phenomenal to see. And I think that really shows like, you know, that there is a need for this, like they, they want this kind of intervention. They want this holistic approach and they have the time and the dedication to, to put the work in. And the results have been quite amazing so far. And I know that they will be even more in the future. And I think it's just a true testament to like the patients like want and need to do. Yeah, it's really important to get them involved. Exactly. Bring the voice of the patient back into the medical system. There's a lot of wisdom there and practicality and with something as, you know, inexpensive of this is the program that we're working on. And it's easy to be sustainable clinicians love it nurses love it why because they don't have to do as much maintenance on those patients, you know, so, and it's easy to be implemented. At the end of the day, this is a good program for all of us. I mean, listen, anyone of us would get a cancer diagnosis, tell me something, would you like to actually be empowered by information that is good for you. And again, nobody's forcing you to do anything, but you might want to try to just want to try it. And what we're seeing from our patients is that they are eager. They want to try. You know, they want to change something and they want to do it as soon as they get their diagnosis. They don't want to have to wait and wonder and create their own narrative about what's happening and going to that depression hole where you don't quite know and, you know, you start thinking of the worst and and then you start isolating yourself because you're saying, you know, I'm going to go through this alone. I went through, you know, bad things before I'm just going to go through this on my own, because look that that erodes your soul and doesn't help anybody doesn't help the medical system was going to now end up having to spend money and find resources to treat them doesn't help the patient doesn't have the family doesn't anybody at the end. Definitely an upstream approach, which we need more of in the healthcare system. I think we had a, I don't let you determine if you want to answer this, but I guess there's a question of why you became interested in this topic. And so, I don't know if this is directed towards. We either Gabriel, but you're both interested in it, which, you know, if you want to feel free to comment or not, or I can tell, yeah, I can comment on it a bit and then I Gabrielle can go into more detail about prostate cancer and particularly, but what was interesting for me is I decided to pursue my master's degree and I reached out to the department and I by like honestly a stroke of luck somebody put me in contact with Gabrielle because we have similar background so I had just completed my undergraduate degree in neuroscience and religious studies and had always been interested in kind of the psychosocial, you know, part of patient care and so and Gabrielle was just beginning her she had just moved to Halifax. And so we got connected that way because of our shared backgrounds. And then Gabrielle had the solstice chair position in prostate cancer research. And so kind of the combination of the prostate cancer research and then our both are collective. Like appreciation for just mental health care. We kind of went down this path. And I'll just tell you very briefly my story. So I came from University of Toronto where I did research on quality of life and cash and brain tumor. Completely. I mean, going from brain to. Okay, so so I started my research. So I got a position a chair in in prostate cancer quality of life research here at the House University. And what attracted me because at that time I had three offers I could have gone in three different directions, well, two of them, much more similar to what I was doing before and then there was this House University position. But what really got me was that the actual there was there was a Frank so be donated money for an endowed fund to support research that sheds a light on the issues that men with this condition have to go through. And I talked to him and I remember being, I mean, when I started the position I never thought this is going to be so focused on mental health, which I had such extensive background on, because prior to that I had over 50 publications in mental health and substance use and how adverse health correlates influence the quality of life of people that have had a big question or brain tumor and so on. I thought that this is going to be very good as prostate cancer I've heard about sexuality being, you know, affected by the disease I didn't know almost anything about prostate cancer. I went the first thing I did I remember I picked up the phone I called David Bell who's a urologist here in in Holly Fox and I said, I want to learn I want to go everywhere I want to go to every support group I want to see patients I want to hear what's happening. And I remember interviewing clinicians and I said okay tell me tell me what's the biggest issue here. And they said, you know, we love them so much we do our best but you know I'm focusing on the surgery or I'm focusing on radiation or I'm focusing on chemotherapy and why don't you ask the patient. Honestly, honestly, and I started going to support groups and I was very open I said I want to know everything. Tell me what's going on. So I can start pulling together go go out there and find out the golden standard questionnaires, put them together and survey. I didn't tell them what I'm going to survey them on of course with my background I just went up you know psychosocial from left 180 degrees the whole board. But I wanted to know from them directly and they started talking. And then this is what I did, my, even to now, I'm still attending support groups I dedicate in my free time my holidays I spend going to prostate cancer support groups or cancer support to give them everything I've got, all the knowledge, all the papers that I read everything that I have goes right back to them, and it's empowering. It's empowering to me and makes my life purposeful, because here we are, we're a community we're so much more like than different. Those are issues that can affect all of us. And so low and behold through the survey, we find out that there is an epidemic of mental health issues. It's quite interesting and then you start to scratch your head but why is that. And so we're still doing so many investigations we're looking at sexuality urinary function we're looking at relationships, we're looking at this idea of meeting emotional needs, social support what does that even mean. And what role do they play so this RCT that we put together and the intervention which is called prostate cancer patient empowerment program, which is a trademark now. Yes, it's something that took years to develop. It took science, it was top down meaning scientific evidence into the intervention but also the wisdom of the patients going back to bottom up. And I think there has to be a marriage of the two of them. Mike Strong, who's the president of CHR I think we have some amazing people in leadership today that really get it that you can't do research without involving the patient if you're going to say something or do something about the patient that affects the patient. Yeah, very important. Yeah, I think we all think we've most people would would agree on that. I don't see any more questions coming in and I, you know, thank you again. Very passionate presentation. I think one of the more passionate presentations or webinars that we've had. So, thank you again for your participation in these webinar series. I'd like to remind everyone that the CLA data access request applications are ongoing. The next deadline is April 14th of next month. Please visit the CLA website under data access to review available data, including the COVID-19 questionnaire study data as well as additional details about the application process. I'd also like to remind everyone to complete their survey, which is located under the polling option. Option. If you didn't see it beside the chat button, please click the drop down arrow and it will come up. So, our next webinar sadly today's webinar does need to come to an end is entitled the impact of COVID-19 of the COVID-19 pandemic on the mental health of older adults. Longitudinal analysis from the Canadian longitudinal study on aging, and we will have Dr. Perminder Reina, who's the lead principal investigator of the CLA lead that webinar. The webinar will present findings on mental health outcomes from the COVID from the CLA COVID-19 questionnaire study. So, actually, it'll be a nice follow up from the webinar focused on mental health this month to talking about COVID next month. And remember, the CLSA does promote this webinar series using the hashtag CLSA webinar and we invite you to follow us on Twitter at CLSA underscore ELCV. And finally, just thank you once again for everybody attending and to our presenters and we will see you next month.