- Introduction: A Top-Level Look at the Future of Federal Medicine
- Military Health System in Time of Transition as Conflicts End
- Army Medicine: Redefining Its Role in the Generation of a Ready and Resilient Force
- Air Force Medicine: Averting an Identity Crisis
- Moving Forward with Reforming the Indian Health Service
- The Clinical Pharmacy Specialist's Growing Provider Role in VA
- Public Health Service Pharmacy: Accelerating Transformation
- Military Pain Management’s Future: Less Invasive, More Data-Driven Techniques
- Navy Medicine: Strong, Agile and Ready
- Telemental Health in VA: A New Source of Support for Veterans
VA Proposes Team-Based Model for Prostate Cancer Care
By Michael Kelley, MD
National Program Director for Oncology, Specialty Care Services, Patient Care Services, VHA, Chief, Hematology-Oncology, Durham VA Medical Center, Durham, NC, Associate Professor of Medicine, Duke University Medical Center, Durham, NC
Prostate cancer is the most common cancer among men in the U.S. (Siegel 2012) with more than 12,000 new diagnoses per year among veterans in Veterans Health Administration (Zullig 2012). The incidence of prostate cancer increases continuously with age and occurs with higher frequency and at an earlier age in African-American men. Among the several additional risk factors for prostate cancer, exposure to herbicides is of particular interest to VHA; prostate cancer is a presumed service-connected condition for veterans who served in Southeast Asia during the Vietnam War. Since the introduction of Prostate-Specific Antigen (PSA) as a screening test in the 1980s, over 80 percent of prostate cancers diagnosed in VHA are localized to the prostate gland with only about five percent of patients having metastatic cancer at the time of diagnosis (GPRA Report on Prostate Cancer, 2009).
Ensuring Highest Quality of Care Based on the Best Evidence
The general approach to ensuring high quality of care for veterans with prostate cancer follows an outline beginning with synthesis of medical knowledge into practice guideline(s), identification of quality indicators based on practice guidelines, then measurement of compliance with practice guidelines using these quality indicators. Data from compliance then drives quality improvement efforts using systems engineering approaches such as PDSA (plan-do-study-act) cycles. The availability of data on compliance with well-defined quality indicators remains the rate-limiting factor for continued quality care improvement.
In 2011, the primary result of a comprehensive external review of the VA Oncology Program was published. The quality of oncology care in VHA, including that for prostate cancer, was similar to or better than care provided in the private sector (Keating 2011). However, analysis of care provided within VHA demonstrated substantial variation in preference-related care, particularly with regard to treatment of primary prostate cancer with radical prostatectomy, radiotherapy or watchful waiting. This observation suggested that factors other than patient and disease characteristics influence the care a patient receives.
To evaluate the impact of past and ongoing efforts to improve the quality of prostate cancer care, ongoing measurement of the quality of care is needed. VHA recently performed a study to assess the feasibility and reliability of using Veterans Affairs Central Cancer Registry (VACCR) data linked with VHA administrative data to construct measures that could be obtained from electronic data sources (“e-measures”) to monitor the quality of prostate cancer care delivered in VHA (Shelton, et al, 2012). This study compared the performance of proposed e-measures with corresponding measures determined by chart abstraction of all 2008 External Peer Review Program (EPRP) Special Prostate Cancer chart abstraction study. It was feasible to construct valid e-measures for three quality measures of diagnosis and treatment and seven descriptive measures of care.
The utilization of e-measures holds the promise of guiding prospective individualization of high-quality care through decision support and immediate feedback to oncology care providers. However, the currently designed e-measures are dependent on VACCR data for case identification, staging and risk stratification. Thus, to be applied uniformly and prospectively, the current six month (or longer) delay in VACCR data acquisition would need to be reduced to a few weeks or less, similar to the lead time of the EPRP measurement process used to evaluate and drive improvements in quality of care in other clinical areas within VHA.
Team-based Oncology Care
Most patients in VHA receive their primary care from a Patient-Aligned Care Team, modeled on the concept of patient centered medical home model of care. For patients with cancer, a team-based model is being proposed (Patient-Aligned Specialty Team for Oncology, or PAST-O). Delivery of oncology care in a team-based model includes tumor boards, multispecialty clinics and care coordinators/navigators. Oncology care generally includes required visits to a hospital; the team-based approach ensures those visits are as efficient as possible.
An important goal for PAST-O is to ensure patients receive complete, accurate and unbiased information on which to make decisions about their healthcare so that the variations in provided care, such as that seen for primary treatment of prostate cancer are reduced or eliminated. For example, patients diagnosed with prostate cancer might be offered the opportunity to review a video presentation prepared by prostate cancer specialists describing the harms and possible benefits of treatment options. Patients also are able to review online educational materials through MyHealtheVet that are adapted to varying educational levels and learning styles. A traditional discussion with a physician would continue to be available either in person at a hospital or through a video connection at the clinic closest to the patient’s home.
Integrating New Knowledge into Clinical Care
Screening for prostate cancer. Recent results of large randomized studies of screening for prostate cancer with PSA have raised doubts about relative harms and possible benefits. The large U.S.-based Prostate, Lung, Colorectal and Ovarian (PLCO) trial showed a net harm to PSA screening (Andriole 2012). A review of the available evidence led the U.S. Preventive Services Task Force (USPSTF) to recommend against prostate cancer screening. VHA, which gives significant weight to USPSTF recommendations, is considering revision of its prior recommendation to offer PSA screening to asymptomatic men.
Radical prostatectomy of screen-detected prostate cancer. VHA recently completed and published the results of the crucial Prostate Cancer Intervention vs. Observational Trial (PIVOT) study comparing radical prostatectomy against observation for men who primarily had been diagnosed with prostate cancer after PSA screening. Radical prostatectomy did not improve the overall survival (Wilt 2012).
The failure of both PSA screening and radical prostatectomy to reduce mortality from prostate cancer lies primarily in the inability of PSA or other current technologies to distinguish the minority of aggressive prostate cancers from the much more numerous indolent prostate cancers that do not lead to cancer morbidity or mortality. Several novel approaches to make such a distinction are being tested in the clinic, including genetic, genomic and proteinomic approaches. Should these provide greater accuracy in predicting prostate cancer mortality, the issues of screening and surgery for early stage cancers will need to be revisited.
New therapeutics. In the past four years, five new anticancer therapeutic drugs have been approved for patients with prostate cancer, and many more are in various stages of development (Sartor and Fitzpatrick 2012). These drugs include gonadotropin-releasing hormone (GnRH) antagonist, androgen receptor antagonist, androgen synthesis inhibitor, cytotoxic tubulin poison and immunotherapies. In addition, treatment with targeted radiation agents (e.g., radium-223) and bone-protecting medications (e.g., denosumab) are new approaches for management of the bone metastases that are so common in prostate cancer (Kim 2011). Similarly, alternative local treatments of primary disease, such as cryoablation, laser thermoablation, high-intensity ultrasound and proton beam radiotherapy, are being investigated (Wolff and Mason 2012). The availability of new therapeutic approaches implies ongoing efforts are needed to ensure practice guidance documents remain up to date and quality indicators are assessed to ensure that future care in VA continues to be of the highest quality anywhere.
Shelton J. Malin J, Saigal C. Linking Cancer Registry Data with Administrative Data for Prostate Cancer Care Quality Monitoring in the Veterans Health Administration. VHA, 2012.
GPRA Program Evaluation of Oncology Programs in Veterans Health Administration, Department of Veterans Affairs Office of Policy and Planning, Report on Prostate Cancer, November 2009.
Andriole GL, Crawford ED, et al. Prostate cancer screening in the randomized Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial: mortality results after 13 years of follow-up. J Natl Cancer Inst 2012;104:125-132.
Keating NL, Landrum MB, et al. Quality of care for older patients with cancer in the Veterans Health Administration versus the private sector: a cohort study. Ann Intern Med 2011;154:727-736.
Kim JJ, Keizman D, et al. The unfolding treatment landscape for men with castration-resistant prostate cancer. Clinical investigation 2011;1:1533-1544.
Sartor AO and Fitzpatrick JM. Urologists and oncologists: adapting to a new treatment paradigm in castration-resistant prostate cancer (CRPC). BJU international 2012;110:328-335.
Siegel R, Naishadham D, et al. Cancer statistics, 2012. CA Cancer J Clin 2012;62:10-29.
Wilt TJ, Brawer MK, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012;367:203-213.
Wolff JM and Mason M. Drivers for change in the management of prostate cancer — guidelines and new treatment techniques. BJU international 2012;109 Suppl 6:33-41.
Zullig LL, Jackson GL et al. Cancer incidence among patients of the U.S. Veterans Affairs health care system. Mil Med 2012; in press.