Optimizing Advanced Prostate Cancer Care Among US Veterans

背景：到2023年，超过500万越南退伍军人将步入70多岁，也就是前列腺癌转移的年龄 癌症通常被诊断为癌症--黑人男性和接触橙剂的男性的发病率几乎是前者的两倍。 幸运的是，新的治疗方法提高了转移性前列腺癌患者的存活率。然而， 向这一日益增长的男性群体提供新的治疗方法是复杂的，并引发了对公平、安全、 和老练的经验。 意义：这项提案将扩大对以下人群面临的与指南一致的护理障碍的了解 转移性前列腺癌的退伍军人，治疗的安全性，并详细介绍退伍军人的经验 转移性前列腺癌。这项建议与退伍军人事务部的财政年度直接一致 2022-28年战略计划(目标1和2)，消除健康方面的差距和障碍，提高退伍军人的 结果、体验和生活质量，并通过听取退伍军人的意见来预测未来的趋势和需求。这个 由于退伍军人管理局的独特之处，退伍军人管理局是唯一能够进行如此及时和全面研究的机构。 开发的自然语言处理工具，可以快速确定转移性男性的病例 前列腺癌。 创新和影响：这项建议有可能在未来改变目前的临床实践 多层次干预，降低了强化治疗的障碍，并使高危患者的治疗个性化 退伍军人。创新的自然语言处理工具使案件快速查明具有前景 识别新的转移患者，这只能在退伍军人事务部完成。 具体目标：目标1：调查影响转移性前列腺癌患者公平护理的因素 癌症。目的2：对突发转移性前列腺癌患者进行实时安全性评估。 目的3：了解转移性前列腺癌确诊后的医患经验。 研究方法：所有确诊为前列腺癌转移性病例的患者年龄均为18岁或以上。我们 将使用一种自然语言处理工具来前瞻性地识别退伍军人，该工具可以识别新的男性 一旦他们在退伍军人管理局被诊断为转移性前列腺癌。对于目标1，我们将使用多级别 评估邻里剥夺、患者人口统计和设施之间关系的多变量模型 接受指南一致性治疗强化的因素。强化治疗的定义为 雄激素剥夺疗法加多西紫杉醇或二次雄激素信号转导抑制剂(即 阿比特龙、苯扎鲁胺、阿帕鲁胺)在转移诊断的四个月内。对于目标2，我们将 比较急诊室就诊、住院和门诊就诊的频率与 癌症发生后一年被诊断为转移性疾病的事件类似于临床试验中的事件和历史性的 退伍军人病患队列。对于目标3，我们将在转移后四个月内调查不同样本的患者。 诊断以了解他们接受癌症治疗的经验。我们还将调查一项 治疗这些患者的医生样本以了解他们在分娩障碍方面的经验 强化治疗。 下一步/实施：我们将利用这项研究的结果来开发多层次的干预措施 将减少公平提供医疗服务的障碍，并帮助临床医生告知患者现实世界中 强化治疗。我们将与国家伙伴合作，在我们的下一次行动中实施这样的干预。 求婚。

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.