Education, Telehealth, and Access Initiatives Aim to Improve Cancer Care for Veterans

Despite having the option of cancer care through the Veterans Affairs (VA) health network, veterans with cancer still experience economic, social, and geographic barriers to receiving high-quality care. This has prompted investigators to develop several interventions to better serve these patients.

“Veterans have higher rates of lung cancer [compared with] civilian populations; prostate and bladder cancer [rates] are also pronounced [among] veterans, [and we also see] higher rates of melanoma, [all] largely due to exogenous exposure risk,” Manali I. Patel, MD, MPH, MS, said in an interview with OncologyLive. “One of the biggest barriers [to cancer care] for veterans is the lack of system level resources that can ensure veterans understand the diagnosis and treatment options, such that veterans receive care that is concordant with their goals, preferences, and values. Cancer care is quite complex and trying to not only coordinate care but explain the nuances in plain language is challenging. Having resources [available] that proactively assist veterans in their understanding and support them through cancer care is what is most needed to improve patient outcomes.”

Patel is an associate professor in the Division of Oncology at Stanford University School of Medicine, a staff oncologist at the VA Palo Alto Health Care System in Palo Alto, California, and directs the Partnerships to Advance Cancer Care lab.

Lingering Barriers to Cancer Care

Beyond these issues that Patel identified, which are also prevalent among nonveteran patient populations, she explained that veteran patients with cancer face unique barriers to receiving high-quality cancer care, especially when receiving care in non-VA community settings where appropriate and tailored health care, including mental health care, may be lacking, as well as other veteran-directed resources. This is especially challenging for veterans who may lack social support to help them advocate and navigate through the system.

“Many veteran [patients with cancer] have limited social support, which we know is important in helping people navigate through their cancer care, advocate for treatments that are aligned with their goals, and help to manage aspects of their care, especially as they’re nearing the end of life. The VA is especially aware of these issues in their approach to deliver cancer care. Specifically in the VA setting, there are many interventions that address these key barriers,” Patel noted.

In a qualitative study of veteran patients with lung cancer published in JCO Oncology Practice, Patel et al interviewed 24 patients with lung cancer who were receiving cancer treatment at the VA Palo Alto Health Care System. The median one-way distance to the facility for the study population was 82 miles (range, 45-300), and patients had stage I (12.5%), II (12.5%), III (37.5%), or IV (37.5%) disease at diagnosis. The study objective aimed to “assess veterans’ perspectives regarding their lung cancer care with a specific focus on identifying modifiable barriers to evidence-based care delivery.”¹

Findings from the study showed that social and economic disadvantages were hindering the delivery of cancer care, fragmented care delivery was contributing to diminished mental health and emotional well-being, and there was a lack of health system–level interventions to address limited health literacy. Patients noted that this lack of health literacy negatively impacted shared decision-making regarding treatment options and end-of-life care.

Respondents cited long commute times, travel-related financial concerns, job retention, and wage loss as social and economic disadvantages limiting their access to care. Although VA transportation options such as shuttle buses and fuel mileage reimbursements were available and utilized, patients often found these stressful.

Furthermore, as Patel noted, mental health concerns, which are prevalent among veteran patients, have been associated with increased mortality among people with cancer. But interventions have been shown to have a positive impact on outcomes for these patients. For example, findings from a retrospective population-based cohort study of patients in the Veterans Affairs Central Cancer Registry with newly diagnosed non–small cell lung cancer (n = 55,315) showed that patients with a preexisting mental health disorder (n = 18,229) experienced a lower likelihood of being diagnosed with cancer in a late stage when they participated in a mental health treatment program vs when they did not (OR, 0.62; 95% CI, 0.58-0.66; P < .001). Patients who participated in a mental health treatment program also experienced an increased likelihood of receiving stage-appropriate treatment (OR, 1.55; 95% CI, 1.26-1.89; P < .001), lower all-cause mortality (adjusted HR, 0.74; 95% CI, 0.72-0.77; P < .001), and lower lung cancer–specific mortality (adjusted HR, 0.77; 95% CI, 0.74-0.80; P < .001) compared with those who did not.²

Patel noted that care administered within the VA setting has been associated with better outcomes among veterans than care received in non-VA settings. This is largely due to the tailored and veteran-specific care that veterans receive in VA settings.³ Thus, interventions are being developed to ensure that veteran patients can more easily access this care as well as better collaboration with non-VA settings where veterans may seek care.

“Our studies and others have consistently shown that when veterans receive care in non-VA settings for cancer, their outcomes, including survival, are not as [favorable]. Also, [in terms of] end-of-life [care], there are significant hospitalizations and acute care use that occur for veterans [who] may receive care in non-VA settings,” Patel added.

Overcoming Obstacles to Cancer Care

To address the barriers to quality precision care that veteran patients with cancer may face, Patel and other investigators have employed several interventions, with many more in the development and rollout phases. During the 2024 American Society of Clinical Oncology Annual Meeting, investigators presented findings from an interventional study (NCT05795959) that examined the impact of a multilevel intervention led by a community health worker or veteran volunteer.⁴ During the 1-month program, the community health worker or veteran volunteer provided veteran-tailored education regarding molecular testing in adult patients with newly diagnosed lung cancer and alerted physicians via a secure messaging system if tumor samples were not tested.

All patients included in the study completed baseline and 1-month follow-up assessments via a 3-question validated precision medicine knowledge questionnaire and a 13-question validated patient activation measure. Molecular testing was measured via chart review at 6-month follow-up. The primary objective was patient knowledge of precision medicine; patient activation in their care and receipt of molecular testing were secondary objectives.

At 1 month of follow-up, data from the randomized clinical trial revealed that patients who received the intervention (n = 23) experienced increased mean knowledge scores with a mean score of 2.30 (+/– 0.97) compared with 1.16 (+/– 1.15) among patients in the control group who received usual care alone (n = 23; P = .014). Additionally, patient activation scores increased more in the intervention group (46.7 +/– 11.3) compared with the control arm (37.6 +/– 9.26, P = .002). Patients in the investigational arm experienced a molecular testing rate of 95.6% vs 86.9% in the control arm; this difference was not deemed statistically significant (P = .62).

“We had high rates of molecular testing overall across both the intervention and the usual care group. However, veterans had a better understanding of the tests that should have been performed before they started treatment, and they were trained on how to advocate for care that matched their goals,” Patel said. “Patients reported education, satisfaction, and activation changes, and we saw a statistically significant reduction in the time to first course of treatment.”

Telehealth interventions have also been a key factor in improving cancer care for patients, according to Patel. Approximately 38% of Veterans Health Administration patients reside in rural areas, and just 44% of rural counties have an oncologist, prompting the Veterans Health Administration to establish the National TeleOncology Service.⁵

“We have a lot of provider shortage areas across the US that impact all patient populations,” Patel said. “What’s unique for veteran populations is that they can still access the VA through these new initiatives developed through the National TeleOncology Program.”

To better determine how social determinants of health affect the use of telehealth services, the National Cancer Institute–funded center Telehealth Research and Innovation for Veterans with Cancer (THRIVE) was established in 2023. THRIVE consists of 4 core areas that act synergistically to research telehealth equity: the Administrative Core, Research and Methods Core, Clinical Practice Network, and Pragmatic Trial. As of October 2023, THRIVE reviewed 20 pilot studies and funded 3 studies to address telehealth access for patients in rural communities and veterans experiencing homelessness, as well as the effects of automated texting protocols on cancer screening adherence.⁵

Another strategy to reduce the burden of travel for patients with cancer while ensuring they have the option to receive care from the VA is the Close to Me Novel Infusion Care Delivery service, launched in 2022 by the VA’s National Oncology Program. The service offers anticancer therapy at community-based outpatient clinics, mobile infusion units, and patients’ homes. The program was initiated at community-based outpatient clinics in the Pittsburgh, Pennsylvania area, with 12 VA facilities nationwide being selected to implement 8 community-based outpatient clinic care models, 3 home care models, and 1 mobile infusion site in early 2023.⁶

In July 2024, the VA announced that the program had expanded to 22 new sites. A planned expansion will provide services for an additional 9000 patients with cancer across 30 locations by the end of October 2025.⁷

Approximately 500 patients with cancer have been treated across the community-based outpatient clinic locations, reducing their travel by a total of over 200,000 miles. Notably, the treatment adherence rate for patients treated via the Close to Me Novel Infusion Care Delivery service is 99%.⁸

“This is better overall for veterans who may not want or have the ability to travel long distances for care,” Patel said. “This helps to keep care within VA settings while also improving their experiences.”

References

1. Lopez C, Murillo A, Das M, Patel MI. Understanding barriers and facilitators to high-quality cancer care among veterans with lung cancer: a qualitative study. JCO Oncol Pract. 2023;19(12):1153-1159. doi:10.1200/OP.23.00228
2. Berchuck JE, Meyer CS, Zhang N, et al. Association of mental health treatment with outcomes for US veterans diagnosed with non-small cell lung cancer. JAMA Oncol. 2020;6(7):1055-1062. doi:10.1001/jamaoncol.2020.1466
3. Thomas M, Gonzalez H, Agrawal M, Das M, Patel MI. Ensuring precision medicine for veterans with lung cancer: a randomized clinical trial. J Clin Oncol. 2024;42(suppl 16):1501. doi:10.1200/JCO.2024.42.16_suppl.1501
4. Zullig LL, Makarov D, Becker D, et al. Telehealth Research and Innovation for Veterans with Cancer: the THRIVE Center. J Natl Cancer Inst Monogr. 2024;2024(64):70-75. doi:10.1093/jncimonographs/lgae019
5. Franchio C. VA launches Close to Me Novel Infusion Care Delivery service. VA News. March 16, 2023. Accessed October 22, 2024. bit.ly/40eblSI
6. Shields J. Advancing cancer treatment access with 22 new ‘Close to Me’ sites. VA News. July 18, 2024. Accessed October 22, 2024. bit.ly/4eKoiZ3
7. VA’s oncology services and tools. VA National Oncology Program. Accessed October 22, 2024. bit.ly/3NBmfuh