Navigating Care in the VA: Dr. Stacy Loeb & Dr. Maneesh Jain

Dr. Stacy Loeb:

We're here today to discuss navigating prostate cancer care in the VA. I'm Dr. Stacy Loeb. I'm a urologist at the Manhattan VA at New York University, Langone Health. I became interested in prostate cancer due to my grandfather, who was a veteran and going through his journey with prostate cancer. So, I became very passionate about prostate cancer care in veterans.

Dr. Maneesh Jain:

Hi, I'm Maneesh Jain. I am an associate professor of medicine at George Washington University. I also have been working at the Washington DC VA Medical Center for the last eight years. I'm very interested in prostate cancer because majority of my oncology clinics are involving veterans with prostate cancer.

Dr. Stacy Loeb:

So, the goal of today's session is really to talk about navigating prostate cancer care in the VA. And I think this is a really important topic, just because prostate cancer is the most common cancer in veterans. It's also more common among African-American males, and it is associated with certain exposures, like Agent Orange, in the veteran population. So, very timely and important topic. 

Dr. Maneesh Jain:

Dr. Loeb, I wanted to start by asking you about diagnosis because most veterans are diagnosed with a prostate cancer by a urologist, such as yourself. How do men start their prostate cancer journey at the VA?

Dr. Stacy Loeb:

Great question. So, most of the time, what happens is that veterans are having their PSA checked. PSA is prostate-specific antigen. This is the blood test that's used for prostate cancer screening. So, many veterans are referred to us in urology because they were found to have an elevated PSA that might be suspicious. The way that we check whether they have prostate cancer is to do a biopsy. So, the biopsy is done by urology.

Now, there are some other tests that can be done that can help sort this out, such as an MRI. Many VAs have prostate MRI or, if not, the VA will make it possible to get it at an outside facility. And so, once the veteran has a biopsy, then we find out if there's cancer present. If there is, the next goal is staging, figuring out, is it a low risk cancer, is it still within the prostate, has it spread? And once we figure that out, we can help determine next steps in terms of possible treatment.

Dr. Maneesh Jain:

Can you also discuss, when the veteran comes and sees you, who's the quarterback directing their care? 

Dr. Stacy Loeb:

The quarterback is the urologist for the initial diagnosis of prostate cancer. Urology is the one that does the biopsy and diagnoses the cancer, and also who will typically direct any kind of staging evaluation that's needed. What I mean by staging is if there's any other imaging tests. For example, PSMA PET is a new type of imaging test, which is available in the VA system, that can be used to determine if the cancer has spread to other organs. Other options are imaging tests like CT scans, bone scans, and all of these can be obtained within the VA system, if needed.

Now, if the prostate cancer has not spread, then the patient can be counseled on different options, some of which are done by urology, where the patient would remain with urology. And these include active surveillance. If it's a very low-risk cancer and we're just going to watch the cancer over time, the patient can remain under the urologist's care to monitor the cancer. Or urologists also do prostate surgery. So, if the patient has a significant cancer and opts to proceed with surgery, we can remove the patient's prostate, which is curative for many people.

However, another gold standard treatment option for patients whose prostate cancer has not spread is radiation therapy, and that's done by a different set of doctors from radiation oncology. This is also available within the VA system at some VAs. We actually don't have radiation oncology yet at the Manhattan VA, where I work. So, our patients go to another VA nearby if they're receiving radiation therapy. But everything can easily be coordinated within the VA system.

Now, how about you? So, as a medical oncologist, you're managing advanced prostate cancer. So, can you talk a little bit more about the journey for patients whose prostate cancer is more advanced or maybe has spread beyond the prostate?

Dr. Maneesh Jain:

Yeah, no, that's a great question. So, what happens is a lot of veterans go and see their primary care doctor, or they might come in the hospital and then you find out that they have an extremely elevated PSA. So, any time a PSA is greater than four, there's a level of concern. And certainly, when the PSA is greater than 10, you're concerned that maybe the cancer has spread to the bones.

So, sometimes you'll see these patients in the hospital, where the PSA will be several hundred or up to a thousand. Or they'll see their urologist or radiation oncologist, as you stated, and when they get the PSMA scan or conventional CT scans and bone scan, they'll notice that the cancer has spread outside of the prostate. The most common site of metastasis for prostate cancer is to the bones, but also, prostate cancer can also spread to the liver and the lung in certain situations.

So, once the prostate cancer has been diagnosed to be metastatic disease, the urologist, the radiation oncologist, or the primary care provider will refer the patient to the medical oncologist. At that time, physicians like myself will take over the care and be the quarterback. The standard of care at that point, once you diagnose somebody with advanced prostate cancer, is to make sure that you do next generation sequencing, which I know you'll get into in a second. But you want to make sure that that gets done because, at some point, it's going to help direct therapy moving forward.

Dr. Stacy Loeb:

So, how does a veteran come to see you as a medical oncologist? And then, what types of tests should a veteran with advanced prostate cancer ask an oncologist about?

Dr. Maneesh Jain:

You want to make sure that you have properly done staging so you know that a patient has metastatic prostate cancer. So, you want to assess where is it spread, and is it high volume or low volume disease? So, high volume would mean more than four or more bone lesions, or if they have visceral metastasis, which just basically means liver lesions or lung lesions, or something like that.

So, first step is, we want to make sure that we've gotten the conventional imaging done to assess what is the burden of disease. And then, as I mentioned before, you want to make sure that you're doing next generation sequencing, and that includes somatic and germline testing, because you want to see, are they a potential candidate for therapies up front or maybe in subsequent lines of therapy. You also want to get this testing done because you want to see, are they going to be eligible for clinical trials?

Dr. Stacy Loeb:

And that's a great segue to talk a little bit about the VA Centers of Excellence and how veterans can get the most up-to-date prostate cancer care and access to clinical trials.

Dr. Maneesh Jain:

Yes. So, I want to give a little bit of a background. I'm affiliated with George Washington University, and I work at the DC VA Medical Center, and we were a POPCaP Center of Excellence since 2019, 2020. And what that allowed us to do is to build the infrastructure to get that testing and sequencing done for veterans and to allow us, as a network, to open clinical trials for veterans.

So, there are investigators, like Bruce Montgomery in Puget Sound or Matt Reddick in LA, where they have opened their own concept of their trials, looking at BRCA mutations or PALB2 or CHEK2. So, there were certain mutations that they were looking at, and they were opening those trials across the VA. The center of excellence now have moved forward, where now the VA is funding what they call clinical research centers.

So, all of us, you work in Manhattan, I work in DC, we are all part of different VISN numbers. So, the thought process was after these centers of excellence that the Prostate Cancer Foundation funded, the VA has taken over, and they want each VISN to have these clinical research centers in a focus area, including GU and prostate cancer. And this will allow veterans to have access to cutting-edge clinical trials moving forward.

Dr. Stacy Loeb:

So, can you discuss some of these clinical trials at a higher level, and maybe a bit more information about what you mean by the genetic testing and how that plays in for the veteran?

Dr. Maneesh Jain:

When you've gotten that sequencing information done, you are now able to see what trials are they a candidate for. We know in the frontline setting, if you have advanced prostate cancer, that is pretty routine. We know that there are doublet or triplet regimens that you can try, that you use two drugs or three drugs to get their disease under control. Based on that genetic sequencing and the second line, or after they fail the frontline treatment, then you can see, what do I have to do next?

And as mentioned, the other thing that the clinical research center is doing is trying to make sure that rural veterans have access to clinical trials. So, where I live is, I live in DC, and certainly Baltimore is the neighboring center, but there are other VAs in our region and our VISN that might not have access to the testing, or might not have access to these clinical trials.

We feel like what the Prostate Cancer Foundation support, and clearly, the VA, moving forward with these clinical research centers, now veterans that are living in smaller areas in my VISN. They could be in Martinsburg, or they could be in other parts of rural Virginia. And it's important that they get the information out, that they can go to PCF.org, or they can go to these clinical research center websites, and be aware that they have to get the testing done, and then they have to see if they can be part of these clinical trials.

Dr. Loeb, after a veteran receives a diagnosis of prostate cancer, what types of healthcare providers will they see?

Dr. Stacy Loeb:

Well, it really could be a mix. Of course, there's the urologist, typically, who is doing the biopsy to diagnose the prostate cancer. The patient may have to go to radiology doctors to have some imaging tests to determine the stage of the cancer, if it is spread anywhere else. And then, depending on the patient's grade and stage of cancer, they may need to see a radiation oncologist or a medical oncologist to find out about other types of therapies.

And, of course, there's also a lot of other supporting services available. For example, patients who have surgery, who are trying to work on their urinary control, they may end up seeing pelvic floor physical therapy. Many VAs also have, within the urology department, sexual medicine expertise to help with penile rehabilitation therapy, or help with recovering sexual function after prostate cancer treatment, which can span everything from pills up through learning how to do injection therapy for erections.

And so, lots of different options, all the way through from the time of diagnosis to really survivorship care for people and helping to manage some side effects that might occur after prostate cancer treatment. The VA has a lot of other programs that could be helpful, like the MOVE! program, to help people with lifestyle modification, which is very important as part of any cancer survivorship journey.

Many of these services may be available at your local VA, but if not, it's possible to do interfacility consults. We certainly see a lot of veterans from other VAs around our region if we offer some specialty services that are not at their local VA. And there's the possibility as well of community care consults for something that is not available at our VA for somebody to receive consultation in the community.

So, bottom line, I think it's really a great place to receive prostate cancer care because such a comprehensive suite of services is available within the VA system, as well as access to all of these top-notch clinical trial opportunities. And then, I know you also had some thoughts regarding services for mental health and other options within the VA system.

Dr. Maneesh Jain: 

Yeah, no, thank you for bringing that up. When veterans come and see us, when they have advanced prostate cancer, and they come see me in clinic, they also have access to other services, including nutrition support. They can see social worker. They can also see somebody like a health psychologist. The health psychologist can organize groups and meetings, where they have support groups for veterans with prostate cancer.

So, it allows veterans to have access across the suite, as you stated, where they come in, and whatever they need, whether it's social worker, health psychology, support groups, they have access to all of that. And I feel like that really allows them to focus on their treatment and allow them to get better with their family and other support that they have at home.

Dr. Stacy Loeb:

Absolutely. I think the VA is a fantastic place to get prostate cancer care. And also, just wanted to mention that the Prostate Cancer Foundation has a lot of information for veterans on prostate cancer with a lot more detail than we were able to go into today. So, you can find that at PCF.org. So, thank you, Dr. Jain, for chatting with me. Do you have any final thoughts?

Dr. Maneesh Jain:

I just wanted to say that the Prostate Cancer Foundation has been monumental for patients with advanced prostate cancer. With that organization of having those Centers of Excellence, it's really jumpstarted that program. Now, we have multiple clinical trials, on the order of eight, nine trials, that have started from that network.

I think that has allowed veterans to stay within the VA system, allow them to get cutting-edge care, as they fail one, two lines of therapy, so that they know that they can get the right care and that they get access to any sort of novel or cutting-edge therapy. I feel like Prostate Cancer Foundation is the impetus for us to be where we are, and so I give a lot of credit to that organization. But thank you again for a great conversation.