b'VA Looks Deeper at Treatment SelectionIn Metastatic Prostate Cancer Outside partnerships have helped the VA improve access to and the use of both tumor testing for somatic mutations and germline testing for hereditary mutations in prostate cancer. Improved responses to targeted medications, plus better adherence to guidelines for treatment intensification, appeared to be having a positive effect for metastatic disease. By Annette BoyleDURHAM,NCVeteransfacetwicetheriskofno difference in overall survival. The same was true prostate cancer compared to those who have neverfordualMedicare/Medicaidbeneficiaries.Among servedwithapproximately15,000veteransdiag- Medicare-onlybeneficiaries,however,treatment nosed with the disease annually. Breakthroughs inintensificationandoverallsurvivalwerenotably treatment have allowed those patients to live longerlower for Black vs. white patients.than ever and swelled the number of veterans withAll patients in the study were followed from date of prostate cancer receiving care through the VHA toandrogendeprivationtherapy(ADT)treatmentini-nearly 500,000.tiation until death, end of enrollment or end of data While treatment for localized prostate cancer (PC)availability, whichever came first. can be curative, about half will progress to metastaticThe Medicare group included 2,226 Black patients disease following treatment for localized disease and(12.2%) and 16,071 white patients (87.8%). Of those, a further 8% of patients will have distant metastases40.3% of Black and 9% of white patients were dual at diagnosis. enrolled in Medicare and Medicaid. In the VHA group, Several studies involving VA researchers recently30.1% of the patients (1020) were Black and 69.9% examinedtreatmentselectioninmetastaticPC,(2364) were white. Black patients were younger on the first looked at adherence to and the impact ofaverage than white patients in both groups, with mean guidelines for treatment intensification in veteransage of 73.9 vs. 76.9 years and 70.1 vs. 74.4 years, in with metastatic castration-sensitive PC (mCSPC),the Medicare and VHA groups, respectively. while the others analyzed molecular testing andDuring the study period, consensus guidelines rec-treatment in veterans with metastatic castration- ommendedtreatmentintensificationforallpatients resistant PC (mCRPC). with mCSPC based on evidence that adding docetaxel, ResearchersattheDurhamVAMCandDukenovelhormonaltherapy(NHT)withabiraterone, UniversitySchoolofMedicine,bothinDurham,apalutamide or enzalutamide or both docetaxel and NC, drew on data from the Centers for Medicare andNHTto ADTsignificantlyimprovedsurvival. Yet, Medicaid Services (CMS) Medicare Fee-for-Servicefirst-line treatment intensification (TI) improved only beneficiariesfromJan.1,2015,toDec.31,2018,slowly across the board, though veterans were almost and the VHA Corporate Data Warehouse from Jan. 1,twice as likely to receive guideline-directed care with 2015, to June 22, 2019, to compare treatment selec- TI on average compared to Medicare beneficiaries, tion in mCSPC by race. 1 19.9% vs. 10.3%, respectively.Theyfoundthat,whileBlackveteranswerelessAmongMedicarepatients,theproportionwho likelytoreceiveguideline-recommendedtreat- had treatment intensification (TI) rose from 5.9% ment intensification than white veterans, there wasto 11.9% in Black patients and from 6.8% to 17.3% 56'