Optimizing Advanced Prostate Cancer Care Among US Veterans

背景：到2023年，超过500万越南退伍军人将达到70多岁，这是转移性前列腺癌发生的年龄。 癌症是常见的诊断-黑人男子和男子暴露于代理橙子在近两倍的速度。 幸运的是，新的治疗方法提高了转移性前列腺癌患者的生存率。然而，在这方面， 向这一不断增长的男性群体提供新的疗法是复杂的，并引起了对公平，安全， 经验丰富的老兵。 意义：该提案将扩大对指南一致性护理面临的障碍的了解， 退伍军人与转移性前列腺癌，治疗的安全性，并详细介绍退伍军人的经验， 转移性前列腺癌该提案直接与退伍军人事务部财政年度保持一致 2022- 2028战略计划（目标1和2），以消除差距和障碍的健康，以提高退伍军人 结果，经验和生活质量，并通过倾听退伍军人来预测未来的趋势和需求。的 VA是唯一一个能够进行这种及时和全面的研究，由于独特的VA- 开发的自然语言处理工具，可以快速确定男性转移性乳腺癌患者的病例 前列腺癌 创新和影响：该提案有可能通过未来的临床实践改变当前的临床实践。 多层次的干预，减少治疗强化的障碍，并对高危人群进行个性化治疗。 老兵创新的自然语言处理工具允许快速的案例确定伊利 识别新的转移性患者，这只能在VA中完成。 具体目的：目的1：调查影响男性偶发转移性前列腺患者公平治疗的因素 癌目的2：对因偶发转移性前列腺癌接受治疗的男性进行实时安全性评估。 目的3：了解诊断为偶发转移性前列腺癌后的医生和患者经验。 方法学：所有患者均为18岁或以上，诊断为偶发转移性前列腺癌。我们 将前瞻性地识别退伍军人使用自然语言处理工具，可以识别男子与新的 转移性前列腺癌，一旦他们被诊断出在弗吉尼亚州。对于目标1，我们将使用多层次 多变量模型，以评估邻里剥夺，病人人口统计学和设施的关联 接受指南一致的强化治疗的因素。强化治疗定义为 雄激素剥夺疗法加多西他赛或次级雄激素信号传导抑制剂（即， 阿比特龙、恩杂鲁胺、阿帕鲁胺）。目标2： 比较急诊室就诊、住院和门诊就诊的频率， 癌症转移性疾病事件诊断后一年与临床试验中的类似事件和历史性 VA患者队列。对于目标3，我们将调查转移性肿瘤发生四个月内的不同患者样本， 诊断，以了解他们接受癌症治疗的经验。我们还将调查 对这些患者进行治疗以了解其分娩障碍经历的医生样本 强化治疗。 下一步/实施：我们将利用这项研究的结果来制定一个多层次的干预措施， 将减轻公平医疗服务的障碍，并帮助临床医生告知患者有关现实世界的风险， 强化治疗。我们将与国家合作伙伴合作，在下一年实施此类干预措施 提议

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.