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.

Grant Number: 5I01HX003687-03
NIH Institute/Center: VA
Principal Investigator: Megan Caram