Enhancing Precision Oncology for Veterans through VA's Strategic Partnerships - Isla P. Garraway

June 2, 2023

Isla Garraway discusses the innovative strides being made in the Veterans Affairs (VA) system towards improving cancer care for veterans, particularly African-American vets. She details the success of initiatives like the partnership with the Prostate Cancer Foundation and the Precision Oncology Program, which facilitate critical genetic testing for veterans with metastatic prostate cancer. A significant emphasis is placed on expanding access to precision oncology treatments and clinical trials within the VA itself, thus eliminating barriers like transportation and work leaves. Another key focus is the multi-level analysis of social determinants of health, including income level and neighborhood characteristics, which often impact non-veteran outcomes. Preliminary studies suggest that VA care might successfully mitigate these factors, presenting a promising model for equal-access healthcare. Dr. Garraway also emphasizes the potential of telehealth and remote patient management as a pivotal strategy in extending care to all veterans.


Isla P. Garraway, MD, PhD, Associate Professor and Director of Research, Department of Urology, UCLA School of Medicine, UCLA Health, Los Angeles, CA

Samuel L Washington III, MD, MAS, Assistant Professor of Urology, Goldberg-Benioff Endowed Professorship in Cancer Biology, University of California San Francisco, San Francisco, Ca

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Samuel Washington: Hello, it's Dr. Sam Washington with UroToday. I'm here with Dr. Isla Garraway to talk about efforts within the VA system to improve care and outcomes for African-American vets.

Thank you for coming today. I know you're incredibly busy, but taking out a little bit of time to talk to us is amazing.

Isla Garraway: Oh, it's always a pleasure to talk with you. So, thank you.

Samuel Washington: Now, I did want to talk just broadly about what new initiatives and things are happening within the VA to better improve care for our vets?

Isla Garraway: Well, that's a big one. I think in general, all veterans really benefit from the large initiatives that have occurred in recent years, especially through the partnership with the Prostate Cancer Foundation and the Precision Oncology program, because what that has done is it really has made sure that all veterans with metastatic prostate cancer and in high risk cases also are getting the genetic testing that they need to be considered candidates for precision oncology treatments, as well as the support needed to get cascade testing if it turns out they have a hereditary alteration, so that they can get family counseling and everything like that.

I think that's huge because it's really now clearly baked into our clinical pathways. The National Precision Oncology Office puts out these pathways that all of us clinicians try to follow and they say explicitly who is eligible for this testing. They make it really clear and they've made the testing available. It's still a little bit difficult of a challenge sometimes to order it, because it's kind of every single system has a different way of ordering it. But that's improving also. They're definitely finding more innovative ways to integrate the orders into the medical records and to make sure that providers have access to the portals.

They're also employing more clinical navigation, which is amazing, so that busy physicians like you and I don't have to spend 15 minutes trying to figure out how to do the order. We can pass that off, hand that off to one of our partners who can make sure to follow up with the patient and get that test ordered. What that's done, especially to the individuals who are most marginalized or have the most difficulty accessing this care, it's made it easier for them to access the care and it's made follow-up a lot better. And so, that's been amazing.

We see it in the numbers. We see that veterans with metastatic prostate cancer are getting the testing that they need. We're able to apply more precision oncology approved drugs in these situations, and we're able to offer them clinical trials, which is another huge improvement I think in the past few years, is really bringing precision oncology clinical trials to the veteran, so in the VA. They don't have to go to the academic medical center, which can be a huge challenge for veterans to find the transportation and get the access and the time off work or whatever it is to get over to participate in trials. Now, they can do it in their own VA, and so that's been amazing.

Samuel Washington: There's been a lot of discussion even at the AUA in PCF about improving access to clinical trials, improving care for patients of all groups. But we know African-American men harbor that greatest burden and the worst outcomes.

Isla Garraway: Yes.

Samuel Washington: You mentioned Prostate Cancer Foundation and VA partnership. Would you be able to talk a little bit more about that?

Isla Garraway: Yeah. Basically, that is a partnership again with the Office of Research and Development, and there's several initiatives that are ongoing. First of all, it was set out to create centers of excellence at VAs across the country, where they're recruiting the best and brightest, hopefully, physicians, scientists who are also usually providers in the VA. There's an academic affiliation with these VAs. For example, in Los Angeles, where I care for my veterans, it's in the greater Los Angeles VA, we have an affiliation with UCLA, which is where I am a professor of urology. So, it's an amazing thing. We can basically have the infrastructure that comes with these academic affiliations, that long-term infrastructure that allows us to stand up these trials and also make sure that we're offering the standard of care and the state of the art to the veterans.

It allows us to have that in place and across the VA. You get all this input and it builds this network. So, all of a sudden, you have a built-in network of potential collaborators and partners from all across the country. We can leverage that to really work together to open new trials and accrue to these new trials and raise awareness of making sure our patients are getting sequencing, telling tips and tricks on how to get them sequenced and how to really make sure that is accessible to everyone. It's been a really amazing partnership, I think, not only for the patients, but also for the investigators to build their network and I don't know, just leverage everything to make discovery possible.

Samuel Washington: You mentioned several exciting components or outcomes from this partnership and you're doing so many amazing things in general.

Isla Garraway: Thank you.

Samuel Washington: Are there specific things you'd like to highlight coming out of the VA through this partnership?

Isla Garraway: Yeah, I think so. As you mentioned, African-American patients have in general, if you look across the country, worse outcomes with prostate cancer. They have a higher incidence of prostate cancer, they get more aggressive prostate cancer, they're more likely to have metastatic prostate cancer, and they're more likely to die of prostate cancer. So, one thing that we have always noticed in the VA system, or noticed more recently, is that all of these disparities are really not evident in veterans and probably, that's due in large part to the fact that the VA is a relatively open access or equal access system. If you're a veteran, you pretty much can get veteran care, and so that's been amazing.

What we see is that although there is still a huge disparity in terms of incidence of prostate cancer, so African-American individuals have a higher rate of being diagnosed with prostate cancer in the VA, once they're diagnosed and they get treated, the outcomes really are not that disparate. They're not that different from white patients or patients of other races. So, there is something about VA care that's really alleviating some of these disparities. However, there's still a lot we can learn, especially related to incidents and how to best screen these individuals, so that we can make sure we get early detection and they get treatment, if they opt for treatment and if they are indicated to have treatment with a more aggressive cancer, so that we can prevent that metastasis and death from prostate cancer.

Samuel Washington: Now, across all the VAs, there's just so much coverage across the country. It's exciting to know how each place will have the opportunity to be involved in this type of research. Will there be opportunities for each of the VA sites to be included?

Isla Garraway: Oh, yeah. I'm always on the phone trying to recruit fellow urologists to be a part of some of the larger study efforts that we have. First of all, there's always the clinical trials, which we want to have multi-site and try to make sure we can recruit for, especially for precision oncology. The variants are still rare that we're looking for for precision oncology. So, you need a lot of patients to participate in order to make sure you can accrue for that trial. We definitely need participation. You don't even have to be an academic affiliate. Anybody is welcome to join the network and be a part of it, especially from the clinical trial perspective.

We have a large biobanking effort, which I have the pleasure of leading. That's another one which we really welcome anyone from across the VAs. It's a centralized, standardized collection procedure from our patients who are... Anybody who is coming in for a biopsy or going in for prostate cancer treatment can participate if they want and they can opt in and give samples along their treatment course if they want. So, it's totally voluntary. The patients don't have to do it, but it's just a wonderful way to build a resource, so that we can really learn from these amazing patients.

Samuel Washington: The VA has such a strong infrastructure already built that a lot of research institutions and other groups are trying to replicate for research in this space. Because the VA is a few steps ahead in all of these aspects, where do you see these efforts going or the big picture goal over the next five, 10 years?

Isla Garraway: Well, I think the big picture goal for the VA specifically, and maybe also I'm sure others, non-VA centers would love to learn from this is, again, continuing to make sure we can expand access and instead of really focusing on having the patients come to us, being able to have a way to go to the patients. So, one way to do that is really using more or implementing more of the telehealth that we were able to really stand up in the face of COVID. All this infrastructure was put in place to do video visits and telephone visits, and so that's going to really make a huge difference in terms of, I mean, even consenting patients for trials. The fact that we're now able to do that remotely is a huge step, so that you don't have to always have a patient drive in or find a way transporting and to sign off on these forms. So, I think really using those tools to make sure that we can really reach veterans where they are.

Samuel Washington: Very exciting. It'll be great to see the VA lead in this area.

Isla Garraway: Yes, I think so.

Samuel Washington: Especially with how things may vary based on healthcare system or others to be able to have that reached geographically across the country. In terms of areas of investigation, you've talked about genomics, we've talked about tissue from social determinants side. What other information is being gathered?

Isla Garraway: That's a really exciting area of research that I think a lot of our colleagues are very interested in really trying to understand. We talked about how in the VA system, a lot of the disparities in outcome are mitigated, but at the same time, we're learning from a lot of studies that where you live, your neighborhood, your ZNA, your zip code, are having such an impact on outcomes in general. So, where is the intersection of that with the VA? Because the VA, again, it's a relatively open access system, does that mitigate a lot of these factors that we're seeing in non-veterans?

The nice thing is we can actually do these amazing comparisons. The veterans, because we know most of the time they're geographic residents, we can take measurements again of their ZNA. We can measure the factors in their neighborhood, how well-resourced their neighborhood, or how basically socioeconomically deprived their neighborhood might be based on their geographic location. And then, we can factor that in in our models to see how is that impacting their outcomes and their survival or whatever factor you want to look at. What we have seen when we started taking some of these measurements, which is totally in stark contrast to what we see in non-veterans, is that the neighborhood really doesn't matter so much.

You can come from a really deprived neighborhood, but your outcome is going to be the same as if you come from the wealthiest neighborhood. Really, that might just be a measure again of the value of equal access care. The individual socioeconomic status still matters, as in our early studies. We see that basically, if we look at just generally income level, those with a lower income still tend to have worse outcomes so far, but at least at the neighborhood level, that seems to be mitigated by VA care. But we still have more work to do to really confirm that and look further across the country. We've really only focused on our California population so far, but it's a really exciting area that we hope to see that maybe this is true, that the VA really can mitigate some of these social determinant measures.

Samuel Washington: Yeah, it's exciting to see the VA lead and have the infrastructure, the data, to really look at this multi-level network-

Isla Garraway: Exactly.

Samuel Washington: Of factors that are interacting.

Isla Garraway: Yes.

Samuel Washington: Well, I just want to say thank you for taking the time.

Isla Garraway: Great.

Samuel Washington: Always exciting to talk about-

Isla Garraway: Yes, always great to talk to you too.

Samuel Washington: All the things you're doing.

Isla Garraway: Thank you.