Prostate cancer is the most common cancer among U.S. Veterans—more than 200,000 are prostate cancer survivors, and about 15,000 more are newly diagnosed every year.1 Veterans have dedicated their lives to service and deserve the best possible care and support while navigating life after a cancer diagnosis.
As a physician who specializes in treating prostate cancer, it has been my great privilege to care for Veterans with this disease for the past 30 years. In this piece, I discuss some of the unique experiences of Veterans living with prostate cancer, how they and their loved ones can advocate for their care, and a few of the challenges and solutions that the Veterans Administration (VA) healthcare system has faced and implemented as it works to improve prostate cancer care for every Veteran.
A positron-emission tomography (PET) scan is a newer, more accurate way for doctors to check if and where prostate cancer has spread in your body. There are two FDA-approved PET CT scans that are often used in men with prostate cancer: fluciclovine F-18 PET CT (also called an Axumin PET CT scan) and prostate-specific membrane antigen (PSMA) PET CT.
Veterans and prostate cancer risk
Veterans approach life with a different mindset from many civilians. They are people who have made a significant commitment to advancing the greater good of society, often risking their lives to do so. Unfortunately, active military duty sometimes involves exposures to toxins that can increase the risk of developing cancer and other diseases—often years or decades later. For Veterans, relevant toxins include certain herbicides, pesticides, chromium, depleted uranium, industrial solvents, and chemicals and air pollutants associated with burn pits.2
Among these toxins, Agent Orange has been most strongly linked to prostate cancer in Veterans.3,4 During the Vietnam era, approximately 3 million U.S. soldiers were exposed to this herbicide, which is one potential reason why prostate cancer is diagnosed in Veterans nearly twice as often as in the nonmilitary population.5 Importantly, Veterans with prostate cancer who were exposed to Agent Orange during active duty do not have to prove a connection to receive treatment and disability compensation from the VA.6
In 2022, Congress passed the PACT Act, which further expanded VA healthcare and benefit eligibility to Veterans with other toxic exposures, such as burn pits, which were used widely during U.S. military operations in Iraq and Afghanistan. The PACT Act lists more than 20 presumptive conditions, including prostate cancer, to simplify the process of obtaining benefits and care if Veterans develop these diseases after having been exposed to toxic substances during active duty and/or serving during the Vietnam era, Gulf war era, and the post-9/11 era.2 In the two years since the passage of the PACT Act, the number of Veterans enrolling in VA health care has risen by 33%.7 More than half these enrollees come from the PACT Act population—they are Vietnam, Gulf War, and Post-9/11 era Veterans.
The PACT Act is one of several recent steps that the VA has taken to improve care for Veterans. The following covers other topics of relevance to Veterans and changes made by the VA to improve prostate cancer care.
Active surveillance for low-risk prostate cancer
Any cancer diagnosis can be frightening—and can trigger a great deal of uncertainty. Veterans who are diagnosed with prostate cancer may have many questions about prognosis, treatment, and follow-up. If prostate cancer has already spread outside the prostate or has other high-risk features, then prompt treatment is important.
However, about 50% to 75% of prostate cancers start out as slow-growing, low-grade tumors that are unlikely to rapidly grow or spread. If a patient’s biopsy shows that a prostate cancer falls in this category, the patient may be a candidate for conservative management, usually consisting of active surveillance. This means that instead of being treated right away, a patient is monitored regularly to make sure that a low-risk tumor is not growing or changing its behavior. For patients with prostate cancer, active surveillance means regularly rechecking PSA (prostate-specific antigen) levels, digital rectal examinations, and, in some cases, follow-up biopsies.
Active surveillance helps avoid the side effects, complications, and costs of treating a low-risk cancer that is unlikely to affect lifespan or quality of life. Recently, a large study of Veterans and other patients found that active surveillance was safe and appropriate for the vast majority of individuals with low-risk prostate cancer.8 Current clinical guidelines include active surveillance as a recommended option for patients with low-risk prostate cancer.9,10 At the VA, the use of conservative management, such as with active surveillance, has increased dramatically—in 2021, it was used for more than 85% of VA patients with low-risk prostate cancer, compared with only 63% of such patients in 2012.11
The main risk of active surveillance is that the window of opportunity for curative treatment could close before cancer progression is found and stopped. However, the chances that this risk will impact a patient’s life are very low. The risk can be further reduced by attending regular follow-up appointments.8 All patients, including Veterans, should talk with their physician and healthcare team to weigh the benefits and risks of active surveillance for their particular case of prostate cancer.
Advocating for multidisciplinary care
Prostate cancer is a complex disease—the chances that it could have an impact on a patient’s life varies greatly from patient to patient, and sometimes within a single patient over time. Different patients also respond differently to different treatments. To help determine the best management plan, patients with prostate cancer requiring treatment should receive multidisciplinary care—meaning that the treatment plan incorporates input from a team of physicians with expertise in different specialties.
Multidisciplinary care helps ensure that appropriate treatment options are considered, leading to a better plan of care.12,13 For patients with prostate cancer, multidisciplinary care should involve a urologist (who usually is the one who makes the diagnosis, by performing a prostate biopsy), a radiation oncologist, and, for some patients, a medical oncologist. The vast majority of VAs employ all three of these types of specialists. In addition, in 2022, the VA started a National Virtual Tumor Board, which brings together physician experts from across the U.S. to provide guidance on more complex cases of prostate cancer and other cancers.14
Ideally, every Veteran whose prostate cancer needs treatment will receive multidisciplinary care without having to ask for it. However, this may not always be the case, either at the VA or in other healthcare settings. If multidisciplinary care is not offered upfront, a Veteran can advocate for it by starting a conversation with his physician—usually the urologist who diagnosed his prostate cancer. For example, the Veteran might ask, “Are radiation and surgery an option for me? How would I go about getting an opinion to help me understand the advantages and disadvantages of each option?” Asking these questions can help patients with prostate cancer ensure that they are receiving thoughtful, appropriate treatment.
Finding support
Feelings of stress, anxiety, depression, and isolation are common after a cancer diagnosis and are not a sign of weakness. Emotional support from others who have walked the road of dealing with cancer can make a tremendous difference. Many Veterans find support groups to be especially helpful. Whether held online or in person, these groups offer vital comradeship, mutual understanding, information, and practical resources. Many local VAs host support groups for Veterans living with cancer. There are also support groups and one-on-one peer mentoring programs specifically for patients living with prostate cancer.15,16
In addition, national prostate cancer advocacy groups also often have relationships with VAs and may host meetings and support groups in the area where a Veteran lives. Veterans and family members can ask their VA healthcare team for referrals. One-on-one mental health counseling also can be very helpful, both for Veterans and their family members. In many cases, a primary care provider can provide a direct referral to a mental health counselor.
Genetic testing
Genetic testing plays a key role in prostate cancer management, offering valuable information for patients and family members. For patients with advanced prostate cancer, two different types of genetic tests are used: 1) inherited cancer risk gene testing (sometimes known as germline testing, or testing for inherited gene alterations), and 2) somatic (or tumor) testing. Each test provides vital information—and performing both kinds of tests is important for each patient. I will briefly discuss each type.
Inherited cancer risk genes are passed down from a parent to a child. If present, they are found in every cell in the body and can be detected in saliva or a blood sample. For patients with advanced prostate cancer, testing for inherited cancer risk genes helps determine eligibility for certain types of treatments, such as PARP inhibitors. This is an example of precision oncology, in which cancer treatment is customized, or targeted, based on the unique biology of a patient’s tumor. In some cases, targeted cancer treatments are exceptionally effective—that is one reason that inherited cancer risk gene testing is so important.
The second reason is that testing for inherited cancer risk genes helps patients and family members understand if they are at increased risk for some other types of cancer, such as female or male breast cancer, colon cancer, and pancreatic cancer. This knowledge helps guide decisions about enhanced cancer screening, as well as other steps that may help prevent cancer or detect it early, while it is still curable. For this reason, inherited cancer risk gene testing can be lifesaving.
Somatic (tumor) testing is important for a different reason—it looks at the tumor tissue to check for gene alterations that are only present in the tumor. The results can help guide the choice of treatment for patients with advanced prostate cancer—this is another example of precision oncology.
About half of the gene alterations that are used to choose prostate cancer treatment are found by testing for inherited cancer risk genes, while the other half are only found by testing the tumor itself. Therefore, both types of tests are critical for patients with advanced prostate cancer. These tests are free for Veterans—insurance issues are not a barrier. (Note that some genetic tests that can be ordered online do not provide the same information and should not be used to guide prostate cancer treatment decisions.)
Expanding access to precision oncology
Unfortunately, not all patients with advanced prostate cancer receive genetic testing, regardless of whether they are treated at the VA or in other healthcare settings. One barrier is that many physicians—even those who specialize in cancer treatment—do not know which genetic tests are available, or how the results are used to guide treatment. Studies suggest that educating providers on these topics can significantly increase the use of genetic tests for patients with prostate cancer.17
Veterans themselves sometimes decline genetic testing because they are concerned that they will lose their disability benefits if inherited risk genes are found. In response, the VA has updated its Compensation and Pension Manual to state that genetic test results showing an inherited predisposition to a disease are not sufficient to deny or cancel service-connected benefits for conditions presumed to be caused by military exposures.18 The aim is to enable VA physicians to use genetic information that is crucial for screening, diagnosis, and treatment—while also protecting Veterans’ benefits.
Another major step forward has been the creation of the Precision Oncology Program for Cancer of the Prostate (POPCaP). This program began in 2016 in collaboration with the Prostate Cancer Foundation (PCF), which has donated more than $60 million to expand prostate cancer clinical research among Veterans to improve access to cutting-edge care and speed the development of new treatments. Since then, POPCaP has created 21 Precision Oncology Centers of Excellence across the U.S., which are supplemented by regional centers with the aim of making precision oncology care available to every Veteran with advanced prostate cancer, no matter where he lives. In 2024, the POPCaP network oversaw more than 380,000 clinic visits for more than 9,000 Veterans with prostate cancer. So far, more than 1,300 Veterans have had their prostate cancer care guided by genetic testing.
Clinical trials not only support the development of new cancer treatments, but they also help patients access high-quality care. Through the POPCaP network, Veterans with prostate cancer can enroll in clinical trials coordinated through the Prostate cancer Analysis for Therapy Choice (PATCH) program. To date, more than 600 Veterans have enrolled in these studies. As a direct outgrowth of the POPCaP effort, the VA is working to expand genetic and molecular testing for Veterans with other types of cancers.20
The Cleland-Dole Act, passed in 2022, aims to comprehensively improve healthcare and benefits for Veterans.21 Improving prostate cancer care is a key focus. The Act bolsters the POPCaP program to increase access to genetic testing, precision oncology, and clinical trials. In response to this legislation, the VA has developed clinical pathways to ensure that prostate cancer care across all VA facilities follows established guidelines.20 This helps Veterans with prostate cancer receive appropriate treatment—regardless of where they live. The Act also supports the expansion of tele-oncology to improve access to care for Veterans who live in rural areas or far from academic centers. It also calls for the creation of a national prostate cancer registry to better track and study treatment outcomes, so that further improvements can be made.
Summary
Prostate cancer is the most common cancer diagnosed in Veterans. For most patients, it is a localized, slow-growing disease for which conservative management is a good option. For others, however, prostate cancer is higher risk and requires upfront treatment. Multidisciplinary care is important to ensure the best possible care and outcomes. Veterans can advocate for multidisciplinary care by asking their diagnosing physician if radiation or surgery are appropriate for them, and how they might go about getting opinions from those specialists. Genetic testing—both for inherited cancer risk genes and for somatic (tumor) gene alterations—is essential to help customize (or target) treatments for advanced prostate cancer and help patients and their families understand their risk for other cancers. For Veterans, genetic testing does not affect benefits eligibility and is increasingly available through the POPCaP program. Recently, the federal government has required the VA to take other steps to improve prostate cancer care for Veterans, such as expanding POPCaP, establishing clinical pathways to standardize prostate cancer care across VA facilities, and creating a national prostate cancer registry to track diagnoses and treatment outcomes. To improve even further, the VA will need to work to expand participation in clinical trials for Veterans, which will help them access the newest treatments being developed. By coordinating these approaches, the VA can continue to make progress for Veterans with prostate cancer.
References
1. VA National Oncology Program. Prostate Cancer Care at VA. https://www.cancer.va.gov/prostate.html Accessed January 10, 2025.
2. 2022 PACT ACT: UNDERSTANDING HEALTH CARE ELIGIBILITY AND BENEFITS. https://www.va.gov/files/2022-12/PACT-Act-Understanding-Health-Care-and-Benefits.pdf Accessed January 10, 2025.
3. Kronstedt S, Chiu CB, Wahlstedt E, et al. Should military veterans be classified as high risk for prostate cancer screening? a systematic review and meta-analysis. Urology. 2024 Oct 18:S0090-4295(24)00908-7.
4. Ansbaugh N, Shannon J, Mori M, et al. Agent Orange as a risk factor for high-grade prostate cancer. Cancer. 2013 Jul 1;119(13):2399-404.
5. Zhu K, Devesa SS, Wu H, et al. Cancer incidence in the U.S. military population: comparison with rates from the SEER program. Cancer Epidemiol Biomarkers Prev. 2009;18(6):1740-5.
6. U.S. Department of Veterans Affairs. Prostate Cancer and Agent Orange. https://www.publichealth.va.gov/exposures/agentorange/conditions/prostate_cancer.asp Accessed January 10, 2025.
7. The White House. FACT SHEET: On Second Anniversary, President Biden’s Bipartisan PACT Act Delivers Benefits to More Than 1 Million Veterans and Survivors across all 50 States and U.S. Territories. https://www.whitehouse.gov/briefing-room/statements-releases/2024/08/09/fact-sheet-on-second-anniversary-president-bidens-bipartisan-pact-act-delivers-benefits-to-more-than-1-million-veterans-and-survivors-across-all-50-states-and-u-s-territories/ Accessed January 10, 2025.
8. Newcomb LF, Schenk JM, Zheng Y, et al. Long-term outcomes in patients using protocol-directed active surveillance for prostate cancer. JAMA. 2024;331(24):2084-93.
9. Eastham JA, Auffenberg GB, Barocas DA, et al. Clinically localized prostate cancer: AUA/ASTRO guideline, part II: principles of active surveillance, principles of surgery, and follow-up. J Urol. 2022;208(1):19-25.
10. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines). Prostate Cancer. Version 1.2025— December 4, 2024. https://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf Accessed January 10, 2025.
11. Elaimy AL, Rose BS, Garrway I, et al. Increasing use of conservative management of low-risk prostate cancer in the Veterans Affairs System from 2012 to 2021. Int J Rad Oncol Biol Phys. 2023;117(2_s1):e381.
12. Sciarra A, Gentile V, Panebianco V. Multidisciplinary management of prostate cancer: how and why. Am J Clin Exp Urol. 2013;1(1):12-7.
13. Tang C, Hoffman KE, Allen PK, et al. Contemporary prostate cancer treatment choices in multidisciplinary clinics referenced to national trends. Cancer. 2020;126(3):506-14.
14. Veterans Administration. VA’s National Virtual Tumor Board. https://www.cancer.va.gov/assets/pdf/education/expanded/nopvirtualtumorboardfinal508.pdf Accessed January 10, 2025.
15. Prostate Cancer Foundation. Support groups. https://www.pcf.org/patient-resources/patient-navigation/support-groups/ Accessed January 10, 2025.
16. ZERO Prostate Cancer. Online Peer Support. https://zerocancer.org/help-and-support/online-peer-support Accessed January 10, 2025.
17. Moody E, Larson M, Greenberg S, et al. Impact of provider education on prostate cancer genetic counseling referrals. J Clin Oncol. 2022;40(6_suppl):59.
18. Kwon DH, Scheuner MT, McPhaul M, et al. Germline testing for veterans with advanced prostate cancer: concerns about service-connected benefits. JNCI Cancer Spectr. 2024;8(5):pkae079.
19. Montgomery B, Rettig M, Kasten J, et al. The Precision Oncology Program for Cancer of the Prostate (POPCaP) Network: a Veterans Affairs/Prostate Cancer Foundation collaboration. Fed Pract. 2020;37(Suppl 4):S48-S53.
20. VA News. Press release: VA announces steps to increase life-saving screening, access to benefits for Veterans with cancer. Published March 8, 2024. https://news.va.gov/press-room/va-expands-health-care-benefits-veterans-cancer Accessed January 10, 2025.
21. VA News. Provisions of the Comprehensive Cleland-Dole Act. https://news.va.gov/118470/provisions-of-comprehensive-cleland-dole-act/ Accessed January 10, 2025.