Spotlight on Cancer Research

October 2021

The National Cancer Institute generally defines cancer as a group of diseases “in which some of the body’s cells grow uncontrollably and spread to other parts of the body.” ^[1] When this process occurs, the uncontrolled cell growth may eventually crowd out and overtake normal, healthy tissues. Cancer generally takes two forms—solid tumor or blood borne.

Among Veterans, more than 50,000 cancer cases are reported to VA's Central Cancer Registry each year and research has shown that certain experiences during military service may put Veterans at increased risk for cancer. Those experiences may include exposure to radiation from nuclear materials (from weapons or nuclear navy vessels) or chemical agents (i.e., nerve gas or Agent Orange); handling asbestos; or inhaling toxic fumes from burning oil or fire pits. Overall, Veterans have slightly higher ^[2] rates (11.4%) of cancer diagnoses compared to non-Veterans (10%), with the most frequently diagnosed cancers ^[3] in Veterans including: Prostate cancer, Lung cancer, Colorectal cancer, Bladder cancer, and Melanoma.

Investigators with VA’s Health Services Research and Development (HSR&D) service conduct a variety of research studies to help understand why Veterans may be at increased risk for certain cancers, improve access appropriate treatment, and support effective prevention strategies. The following studies represent just a few of the ongoing and recently completed HSR&D-funded research into cancer and cancer prevention.

• Racial Differences in Conservative Management of Low- to Intermediate-Risk Prostate Cancer among Veterans
• Colorectal Cancer Screening Roadmap
• Timely Palliative Care is Associated with Survival for VA Patients with Advanced Lung Cancer
• Achieving Appropriate, Safe, and Patient-Centered Lung Cancer Screening

Racial Differences in Conservative Management of Low- to Intermediate-Risk Prostate Cancer among Veterans

Implications

Conservative management (active surveillance or watchful waiting) of low- or intermediate-risk prostate cancer is a guideline-based alternative to definitive therapy (i.e., prostatectomy, radiation, androgen deprivation therapy). In this study, data indicated that conservative management for low- and intermediate-risk prostate cancer may be less durable for Black Veterans compared to white Veterans. Investigators suggest that future research look at the effectiveness of conservative management in Black men to determine if race-specific recommendations regarding conservative management are warranted.

Overview

Rates of conservative management for prostate cancer have increased substantially over the past decade. However, the possibility of race-based biological differences in low-risk prostate cancer has led to a debate about whether Black Veterans should be candidates for conservative management. This study sought to determine whether there are any racial differences in the receipt and duration of conservative management among Veterans treated in the VA healthcare system.

Using VA data from January 2004 through December 2018, investigators identified 51,543 Veterans (14,830 or 29% were Black) with low- or intermediate-risk prostate cancer who received either definitive therapy or conservative management. Covariates included age at diagnosis, pre-treatment PSA, VA enrollment priority group, marital status, comorbidities, and urban vs. rural location.

Findings showed that Black Veterans were slightly less likely to receive conservative management than white Veterans with localized prostate cancer. Further, among patients receiving conservative management, Black Veterans had a higher risk of receiving definitive therapy within five years of diagnosis than white Veterans. The median time to definitive treatment was 719 days for Black Veterans and 787 days for white Veterans. Findings also showed that compared to white Veterans, Black Veterans were more likely to have intermediate-risk disease (58% vs. 52%); at least three or more comorbidities (51% vs. 42%); and high disability- or income-related needs (31% vs. 25%).

Citation

Parikh R, Robinson K, Chhatre S, et al. Comparison by Race of Conservative Management for Low-Risk and Intermediate-Risk Prostate Cancers in Veterans: 2004-2018. JAMA Network Open. September 28, 2020;3(9):e2018318.

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Colorectal Cancer Screening Roadmap

Colorectal cancer (CRC) is the third most commonly diagnosed cancer and the third leading cause of cancer-related death among men and women in the United States. In 2018, attendees at a consensus conference held by the American Gastroenterological Association’s Center for Gastrointestinal Innovation and Technology, sought to envision a future in which CRC screening and surveillance are optimized—and to identify barriers to achieving that future.

In a white paper that originated from the conference, HSR&D investigator Thomas Imperiale, MD, of the HSR&D Center for Health Information and Communication, and his colleagues outlined practice changes that would improve outcomes related to CRC screening—namely, avoiding an oversimplified "one size fits all" approach and the development of structured, organized screening programs, rather than provider-driven recommendation. The paper delineates priorities and steps needed to improve CRC outcomes, with the goal of minimizing CRC morbidity and mortality.

Investigators discussed that CRC screening has not and is unlikely to result in increased screening uptake or desired outcomes owing to barriers stemming from behavioral, cultural, and socioeconomic causes, especially when combined with inefficiencies in deployment of screening technologies. Overcoming these barriers will require: 1) efficient use of multiple screening modalities to achieve increased uptake; 2) continued development of non-invasive screening tests, with reassessments of how best to integrate new technologies; and 3) improved personal risk assessment to better risk-stratify patients for appropriate screening testing paradigms.

Citation

Melson J, Imperiale T, Itzkowitz S, et al. AGA White Paper: Roadmap for the future of colorectal cancer screening in the United States. Clinical Gastroenterology and Hepatology 2020; July 2020;4;S1542-3565(20)30917-4.

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Timely Palliative Care is Associated with Survival for VA Patients with Advanced Lung Cancer

Implications

Palliative care is often underutilized or is delivered too late in the progression of a patient’s disease or condition. This study sought to determine whether the early use of palliative care—received soon after diagnosis—was associated with improved survival, if referral did not occur as part of the dying process. Results showed that for the first time, in real-world clinical settings, specialist-delivered palliative care is associated with an increase in survival among patients with advanced-stage lung cancer. Further, results suggest that for patients with advanced lung cancer, palliative care might be considered a complementary approach to be integrated with standard disease-modifying therapies earlier in the treatment plan.

Overview

Investigators identified 23,154 VA patients diagnosed with advanced-stage lung cancer from 2007-2013, with follow-up until January 2017. Overall, 13,109 Veterans (57%) received palliative care, and there was a 41% relative increase in the use of palliative care from 2007 to 2013.

Findings show that palliative care was associated with survival among patients with advanced lung cancer; however, the timing of palliative care receipt was an important component of this benefit. Palliative care received 31 to 365 days after cancer diagnosis was associated with increased survival, while palliative care received within 30 days of diagnosis was associated with decreased survival. Palliative care also was associated with a reduced risk of death in an acute healthcare setting—an important measure of high-quality, end-of-life care.

Principal Investigator: Lynn F. Reinke PhD, ARNP, is an investigator with the HSR&D Center of Innovation for Veteran-Centered and Value Driven Care in Seattle, WA.

Citation

Sullivan D, Chan B, Lapidus J, et al. Association of Early Palliative Care Use with Survival and Place of Death among Patients with Advanced Lung Cancer Receiving Care in the Veterans Health Administration. JAMA Oncology. 2019;5(12):1702–1709. doi:10.1001/jamaoncol.2019.3105

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Achieving Appropriate, Safe, and Patient-Centered Lung Cancer Screening

Implications

One of VA’s top priorities is to efficiently focus healthcare resources for health issues that disproportionately impact Veterans. Lung cancer is the leading cause of cancer death among Veterans, and VA is implementing lung cancer screening (LCS) via CT scan in order to reduce mortality. But clinicians struggle to identify when LCS is most appropriate, such that some Veterans with little likelihood of benefit undergo screening, while Veterans who might benefit most are not screened, denying them a potentially life-saving intervention. Investigators expect that data from this study will help to maximize the life-saving potential of LCS without creating additional harm; will inform future development, testing, and implementation of a personalized decision tool to optimize patient selection for LCS; and will help facilitate shared decision-making between Veterans and VA clinicians at the point of care.

Overview

In this mixed-methods study, investigators are using real-world VA data to develop a clinical prediction model that identifies Veterans for whom LCS would not be beneficial. Investigators also hope to further the understanding of how VA clinicians and Veterans make LCS decisions at the point of care.

The study has three aims:

1. identify factors that predict little benefit of LCS due to limited life expectancy or increased LCS harms;
2. identify clinical patient factors associated with real-world clinician and Veteran LCS decisions; and,
3. characterize approaches to and needs for decision-making when predicted LCS benefit is marginal.

For Aim 1, investigators will conduct a survival analysis among LCS-eligible, but unscreened Veterans; build a “competing risks” model; and identify clinically meaningful risk groups. For Aim 2, investigators will compare how well factors associated with actual LCS decisions align with factors that predict little LCS benefit by using data from 10 VA sites that tracked rates at which LCS-eligible Veterans were deemed “too sick” for LCS; were offered LCS; and accepted LCS. Finally, for Aim 3, investigators will interview up to 30 clinicians and 30 Veterans for whom predicted LCS benefit is marginal based on models created in Aim 1.

Principal Investigator: Renda Wiener MD, MPH, is Associate Director of the HSR&D
Center for Healthcare Organization and Implementation Research in Bedford, MA.

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