Among patients with cancer, prior research suggests that patients with mental illness may have reduced survival. The objective was to assess the impact of psychiatric utilisation (PU) prior to cancer diagnosis on survival outcomes.


All residents of Ontario diagnosed with one of the top 10 malignancies (1997–2014) were included. The primary exposure was psychiatric utilisation gradient (PUG) score in 5 years prior to cancer: 0: none, 1: outpatient, 2: emergency department, 3: hospital admission. A multivariable, cause-specific hazard model was used to assess the effect of PUG score on cancer-specific mortality (CSM), and a Cox proportional hazard model for effect on all-cause mortality (ACM).


A toal of 676,125 patients were included: 359,465 (53.2%) with PUG 0, 304,559 (45.0%) PUG 1, 7901 (1.2%) PUG 2, and 4200 (0.6%) PUG 3. Increasing PUG score was independently associated with worse CSM, with an effect gradient across the intensity of pre-diagnosis PU (vs PUG 0): PUG 1 h 1.05 (95% CI 1.04–1.06), PUG 2 h 1.36 (95% CI 1.30–1.42), and PUG 3 h 1.73 (95% CI 1.63–1.84). Increasing PUG score was also associated with worse ACM.


Pre-cancer diagnosis PU is independently associated with worse CSM and ACM following diagnosis among patients with solid organ malignancies.

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Co-first authorship: Zachary Klaassen, Christopher J. D. Wallis.

Co-senior authorship: Paul Kurdyak, Girish S. Kulkarni.


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The opinions, results, and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by CIHI. However, the analyses, conclusions, opinions, and statements expressed in the material are those of the authors and not necessarily those of CIHI. Parts of this material are based on data and information provided by Cancer Care Ontario (CCO). The opinions, results, views, and conclusions reported in this paper are those of the authors and do not necessarily reflect those of CCO. No endorsement by CCO is intended or should be inferred. We acknowledge Service Ontario for providing data from ORGD. The authors would like to Simon Chen and Ruth Croxford for their assistance with data acquisition and study design, respectively. This study was funded by a Canadian Urological Association-Canadian Urologic Oncology Group-Astellas grant. Furthermore, this study was supported by the Institute for Clinical Evaluative Sciences (ICES), which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care (MOHLTC).

Author contributions

Z.K.: conceptualisation, methodology, investigation, writing original draft, writing-reviewing and editing, and visualisation. C.J.D.W.: methodology, investigation, writing-reviewing and editing. H.G.: conceptualisation, writing-review, visualisation and editing. T.C.: conceptualisation, writing-review, visualisation and editing. R.K.S.: writing-review, editing, methodology. S.B.W.: writing-review and editing, and supervision. K.A.M.: writing-review and editing, and supervision. M.K.T.: writing-review and editing, and supervision. R.K.N.: writing-review and editing, and supervision. D.U.: writing-review and editing, and supervision. P.C.A.: conceptualisation, methodology, writing-reviewing and editing, supervision, and visualisation. P.K.: conceptualisation, writing-reviewing and editing, and visualisation, and supervision. G.S.K.: conceptualisation, methodology, investigation, writing-reviewing and editing, supervision, project administration, and visualisation.

Author information


  1. Department of Surgery, Division of Urology, University of Toronto, University Health Network, Princess Margaret Cancer Centre, Toronto, ON, Canada

    • Zachary Klaassen
    • , Christopher J. D. Wallis
    • , Hanan Goldberg
    • , Thenappan Chandrasekar
    •  & Girish S. Kulkarni
  2. Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada

    • Zachary Klaassen
    • , Robert K. Nam
    • , David Urbach
    • , Peter C. Austin
    • , Paul Kurdyak
    •  & Girish S. Kulkarni
  3. Division of Urology, Medical College of Georgia–Augusta University, Augusta, GA, USA

    • Zachary Klaassen
    • , Rashid K. Sayyid
    •  & Martha K. Terris
  4. Division of Urology, The University of Texas Medical Branch at Galveston, Galveston, TX, USA

    • Stephen B. Williams
  5. Department of Urological Surgery, Vanderbilt University Medical Center, Nashville, TN, USA

    • Kelvin A. Moses
  6. Division of Urology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada

    • Robert K. Nam
  7. Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

    • Robert K. Nam
    • , David Urbach
    • , Peter C. Austin
    • , Paul Kurdyak
    •  & Girish S. Kulkarni
  8. Department of Surgery, University of Toronto, Women’s College Hospital, Toronto, ON, Canada

    • David Urbach
  9. Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada

    • Paul Kurdyak


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Competing interests

The authors declare no competing interests.

Data availability

The data for this manuscript were obtained from the Institute of Clinical Evaluative Sciences in Toronto, Ontario, Canada CENTRAL location at the Sunnybrook Health Sciences Center. The project TRIM number was 2018 0990 009 000 and permission to use the data was granted by the Cancer ICES Research Program and the University of Toronto Research Ethics Board. Z.K. had full access to the data. The data that support the findings of this study are available from the Cancer ICES Research Program, but restrictions apply to the availability of these data, which were used under license for the current study, and so are not publicly available. Data are however available from the authors upon reasonable request and with permission of the Cancer ICES Research Program.

Ethics approval and consent to participate

The University of Toronto Research Ethics Board approved this study. The need for consent from participants was waived given the population level of the analysis.


This work is published under the standard license to publish agreement. After 12 months the work will become freely available and the license terms will switch to a Creative Commons Attribution 4.0 International (CC BY 4.0).

Corresponding author

Correspondence to Girish S. Kulkarni.

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