Q. When it comes to oncology, what is one specific example of how the system is performing well, or what we’re calling a “Hotspot”?
A. The Veterans Administration’s partnership with the Prostate Cancer Foundation (PCF), a philanthropic group that funds research to prevent and cure prostate cancer is a good example. The partnership is speeding the development of treatment and cures for Veterans with aggressive—or metastatic—prostate cancer through precision oncology. This represents a “Hotspot,” where the healthcare system is making strides and performing well for patients.
Q. What makes it a “Hotspot”?
A. As a public-private partnership and a model of how to develop, diagnose, and deploy treatments that reflect the best science to patients, this is a “Hotspot” that has made a difference for thousands of patients. This program is uniquely fashioned to go beyond the research itself and invest in the infrastructure necessary to bring these great leaps forward directly into the lives of our Veterans. The commitment of a private sector partner combined with visionary leadership within the public sector partner provided the impetus and momentum to build a coalition motivated to create a system-wide effort.
Q. What is the challenge?
A. Our challenge was to work together with PCF to make best-in-class medicine available to our Veterans at every stage of prostate cancer. This meant consistently providing outstanding care throughout a highly decentralized healthcare system. PCF made targeted investments to accelerate the work of the most promising physician-scientists and showcased their work at external conferences. The VA, in turn, shared unique treatment insights derived from their work with a more diverse patient population and from the one of a kind VA dataset, which captures Veteran clinical information from the time Veterans leave active duty to the end of their life. Through the PCF partnership, ground-breaking work was done to create the foundation of Centers of Excellence (COEs.) The VA then saw the opportunity to build on the COE model and integrate the VA’s unique assets. These include the fact that the VA serves the largest and most diverse US patient population and has a robust longitudinal dataset. The VA also benefits from a leadership team driven by healthcare outcomes rather than financial reimbursement, and openness to continuing to learn from the expertise of its external partners. The VA has embraced this opportunity to develop a comprehensive plan to become a leader in delivering outstanding care to prostate cancer patients. Currently, nearly 500,000 living Veterans have been diagnosed with prostate cancer. Of those, an estimated 3% have metastatic prostate cancer. So we know a significant proportion of our veterans will benefit from this work.
The program is very new, but we already see the results of integrating the data resources of the VA to advance research. For example, we have jointly appointed staff at labs who have done genetic sequencing. Their critical findings on prostate cancer have appeared in high-profile journals. Work on the CDK-12 gene, known to be altered in cases of prostate cancer, among other types of cancer, came out of the academic sequencing lab at our partner lab at the University of Michigan.
Q. As a Hotspot example, what was the solution?
A. This was an effort that involved multiple teams within the VA. To succeed, we had to ask teams to collaborate in ways that they had never done before. We brought together people representing multiple functions, including our Office of Research and Development, the National Oncology Program Director, the Leaders of the Centers of Excellence, the Genetic Counseling service, Radiology, Surgery and Urology leadership, our Informatics and Computing team, and others.
Our plan was to start with ten centers of Excellence and to expand from there. The team identified the sites within the VA which were best suited for the program- considering factors like which ones had a large number of prostate cancer patients and whether the sites had certain kinds of research capabilities. We convened a working group across multiple functions and worked in lockstep to collaborate with PCF to develop the Centers of Excellence (COE) models and replicate them, several at a time.
We announced the tenth Center of Excellence in November 2019, and the program’s success has proven a catalyst for change in the entire VA. Dr. Stone, the Executive in Charge of the Veteran’s Health Administration, saw that the VA had a unique opportunity to leverage this partnership to build a “System of Excellence.” This System has the potential to generate powerful treatment insights, revolutionizing the way prostate cancer is treated and saving the lives of Veterans cancer patients and all Americans. In fact, his vision was to create an unrivaled standard of care in prostate cancer within the VA that would make those receiving care outside the system want to receive their care in the VA. With a new System of Excellence strategy in hand, Dr. Stone made expanding this initiative his highest priority funding request to Congress for the coming year, enabling the VA to expand this program further, faster. [
In addition, the strategic engagement of the VA delivered value beyond PCF’s initial expectations, As a result, PCF has expanded its original commitment to fund 10 COEs and is now working diligently to fund up to 18 VA COEs .
The program has grown the capacity of the organization while recognizing our outstanding scientists. It started with two investigators. By 2019, over $40 million invested, PCF estimates that more than 100 investigators form part of our PCF-VA research community. This includes $25 million support our 10 Centers of Excellence, $11.5 million to 12 Challenge Awards team science “Valor Awards”, and $3.8 million to 18 PCF-VA Young Investigators/ Those awards represent one of the most notable aspects of this effort: the recognition it earns our wonderful VA scientists. Every year, PCF hosts a large scientific retreat and gives these awards to the most transformative research and promising scientists in the field of prostate cancer from organizations across the country. It’s a massive stage for our scientists to showcase their successes among their peers, fuel further research and be recognized for their meaningful contributions.
Q. Can you describe how an individual patient’s journey may be impacted by this program?
A. For example, Navy Veteran Allen Petchnick, who receives his care at the VA Puget Sound Health Care System in Seattle, received a PSA blood test that was dangerously high and his cancer had spread to other parts of his body. If you speak with Dr. Bruce Montgomery, his oncologist, he will tell you that Allen received standard hormonal based therapies that stopped working and he had no treatment options left. Instead, this partnership provided Dr. Montgomery with the tools and team to perform DNA sequencing on tissue from Petchnick’s lymph nodes. They spotted mismatch repair (MMR) deficient cells, which usually have genetic mutations that could lead to cancer. Armed with this information, they were able to provide Petchnick with immunotherapy, a form of precision oncology in which T cells in the body’s immune system are used to fight cancer. Now age 79, he’s been on immunotherapy drugs for nearly two years. He has gone from dangerously high PSA levels and pain which kept him from walking or enjoying life to undetectable and his tumor continues to shrink. That’s the life-saving and life-changing difference that the right tailored therapies can provide.
Q. What domains are most relevant for this hotspot and why?
A. The most relevant domains are capacity, collaboration and transparency, and equitable access and use.
Capacity:
This program represented a major shift in the capacity of the VA system to address prostate cancer. By investing in the infrastructure, and ensuring adequate workforce – for example, hiring needed data managers for Centers of Excellence, this program truly allowed for sustainability. The participation of external partners demonstrated commitment and support for the continued growth of these efforts.
Collaboration and Transparency:
As a comprehensive health care system, the VA requires powerful internal collaboration to be most successful. This program not only created ten Centers of Excellence, but it also created a team of Center of Excellence leaders who meet regularly, educate new Center leaders, and are able to identify challenges, modify the system and collaborate on developing innovative new programs like this “System of Excellence” evolves.
Equitable Access and Use:
This is an exciting area for generating results from our research efforts. African-American men are 76% more likely to develop prostate cancer, compared with any other race or ethnicity, and 2.4 times more likely to die from the disease. One advantage of the VA records is that they include a patient population that has health coverage and access to VA care. This means that researchers can study disparities in patient groups that still exist even when patients have health coverage. VA investigators are working through genetic research to define causes for the greater numbers of lethal cancer in African American men.
References:
https://www.pcf.org/va-partnership/
https://www.va.gov/opa/pressrel/pressrelease.cfm?id=2837