Expanding access

To put precision medicine within reach of all veterans with prostate cancer, the VA has implemented a multitiered structure. A network of prostate cancer centers of excellence serves as the foundation. Currently, the VA has 10 of these centers located in Ann Arbor, MI; Bronx, NY; Chicago; Durham, NC; Los Angeles; Manhattan, NY; Philadelphia; Puget Sound, WA; Tampa Bay/Bay Pines, FL and Washington, DC.

More centers are on the way. “Hopefully, there will be 12 centers by the end of the year,” said Bruce Montgomery, co-leader of the PCF-VA initiative, medical oncologist at the VA Puget Sound, and clinical director of genitourinary medical oncology at the Seattle Cancer Care Alliance.

“The goal is to have hub sites in each VISN and to bring care to veterans through a hub and spoke model,” Myrie added.

Telemedicine will further expand access to specialists. “Tele-oncology is very essential to providing quality care to veterans,” said Michael Kelley, national program director for oncology at the VA and professor of Medicine at Duke University. “One-third of the veterans served by the VA live in rural areas, but oncologists and other specialists are concentrated in urban areas. We didn’t want to have happen at the VA what we’ve seen outside the VA where excellent oncology care is available in urban areas and rural residents have to travel a long way or make do.”

Instead, the VA has started ramping up a three-year program to bring advanced care for prostate cancer to every part of the country. “We can deliver care with the help of telehealth to centers that have lost most of their oncologists or have just one,” Kelley told U.S. Medicine. “We’re reaching out to smaller medical centers and identifying what they need in terms of expertise, not just an oncologist, but even subspecialists in prostate care who know the field well and deliver efficient, quality care.”

Personalizing Care

While the VA expects to quickly bring access to precision medicine to veterans across the country, six centers (Ann Arbor, Bronx, Chicago, Los Angeles, Manhattan and Puget Sound) are performing next generation genetic sequencing of prostate cancer tumors, Montgomery told U.S. Medicine.

Sequencing “allows us to detect tumors that have particular types of defects and identify patients for clinical trials” matched to those genetic defects, Kelley said. The trials enable veterans to receive treatments that may not have U.S. Food and Drug Administration approval for use in prostate cancer but have been shown to have activity in tumors with specific mutations.

In men with early stage prostate cancer, “we can use the same information to evaluate their risk,” Kelley noted. “It helps us understand who needs therapy and who, if left alone, won’t have problems with prostate cancer. That allows us to focus on those who are much more likely to have morbidity and mortality.”

Building a database of genetic defects associated with prostate cancer can also help men who have not been diagnosed with prostate cancer. The VA has already seen this benefit from the Million Veteran Program, the largest genomic database in the world with samples from more than 775,000 veterans.

In prostate cancer tumors analyzed through the MVP, researchers found that about half of the genetic defects were inherited. “For men who don’t have prostate cancer, this information helps us predict their risk based on whether they have specific germline mutations,” Kelley explained.

To garner even more information from the MVP database, the VA has partnered with the U.S. Department of Energy to leverage the DOE’s supercomputing capabilities through the MVP Computational Health Analytics for Medical Precision to Improve Outcomes Now program.

That program aims to identify genetic clues that indicate whether a prostate cancer tumor is aggressive or indolent, so that clinicians can use that information to guide treatment in combination with more traditional risk factors, Kelley added.

“At this point, the VA is a little ahead of the curve in terms of precision oncology, the focus on molecular alterations and effectively targeting them,” Montgomery said. “We now have a functional system where all men with metastatic prostate cancer are getting sequenced and have access to clinical studies. That’s unique in large healthcare systems.”

1. Zullig LL, Sims KJ, McNeil R, et al. Cancer Incidence Among Patients of the U.S. Veterans Affairs Health Care System: 2010 Update. Mil Med. 2017;182(7):e1883–e1891. doi:10.7205/MILMED-D-16-00371.