Optimizing Advanced Prostate Cancer Care Among US Veterans

Background: Over 5 million Vietnam Veterans will be in their 70s in 2023, the age when metastatic prostate cancer is commonly diagnosed – Black men and men exposed to Agent Orange at nearly twice the rate. Fortunately, new therapies have improved survival for men with metastatic prostate cancer. However, delivering new therapies to this growing group of men is complicated and raises concerns about equity, safety, and Veteran experience. Significance: This proposal will extend knowledge about barriers to guideline-concordant care faced by Veterans with metastatic prostate cancer, the safety of treatment, and detail the Veteran’s experience with metastatic prostate cancer. This proposal directly aligns with the Department of Veterans Affairs Fiscal Years 2022-28 Strategic Plan (Goals 1 & 2), to eliminate disparities and barriers to health, to enhance Veterans’ outcomes, experiences and quality of life, and to project future trends and needs by listening to Veterans. The VA is the only institution that can perform such a timely and comprehensive study due to the unique VA- developed natural language processing tool that allows rapid case ascertainment of men with metastatic prostate cancer. Innovation & Impact: This proposal has the potential to change current clinical practice through a future multilevel intervention that mitigates barriers to treatment intensification and personalizes treatment to high -risk Veterans. The innovative natural language processing tool allows rapid case ascertainment to prospectiv ely identify new metastatic patients, which can only be done in the VA. Specific Aims: Aim 1: To investigate factors affecting equitable care for men with incident metastatic prostate cancer. Aim 2: To conduct real-time safety assessment of men treated for incident metastatic prostate cancer. Aim 3: To understand physician and patient experience after diagnosis of incident metastatic prostate cancer. Methodology: All patients will be age 18 or older with a diagnosis of incident metastatic prostate cancer. We will prospectively identify Veterans using a natural language processing tool that can identify men with new metastatic prostate cancer as soon as they are diagnosed in the VA. For Aim 1, we will use multilevel multivariable models to assess the association of neighborhood deprivation, patient demographics, and facility factors with receipt of guideline-concordant treatment intensification. Treatment intensification is defined as androgen deprivation therapy plus either docetaxel or a secondary androgen signaling inhibitor (i.e. abiraterone, enzalutamide, apalutamide) within four months of metastatic diagnosis. For Aim 2, we will compare frequency of emergency room visits, hospitalizations, and outpatient visits for conditions unrelated to cancer the year after incident diagnosis of metastatic disease to similar events in clinical trials and a historic cohort of VA patients. For Aim 3, we will survey a diverse sample of patients within four months of metastatic diagnosis to understand their experience with receiving treatment for their cancer. We will also survey a sample of physicians who treated these patients to understand their experience with barriers to delivering treatment intensification. Next Steps/Implementation: We will use the findings of this research to develop a multilevel intervention that will mitigate barriers to equitable care delivery, and help clinicians inform patients about real-world risks of treatment intensification. We will work with national partners to implement such an intervention in our next proposal.