Fewer Doses

The VA’s focus on quality patient care may transform prostate cancer treatment around the U.S. through other means, as well.

The nation’s largest integrated healthcare system has moved away from conventional radiation treatment for prostate cancer over the past decade. Historically, radiation therapy was delivered in low doses over an eight-week period.

“It’s been clear for the last seven years that hypofraction, a four-week course with higher doses, is just as effective. Not only is it associated with no increase in toxicity, it may actually decrease toxicity,” Hagan said.

More recently, the VA has moved to increased use of stereotactic body radiation therapy, which typically requires just five but can need as few as three doses.

“Michael Chang, MD, the service chief in Richmond, is putting together a protocol for two fractions,” Hagan added.

For many veterans, the shorter schedules make radiation doable.

The new schedules transform “a very inconvenient treatment that is particularly difficult for rural veterans who may be the only caretaker at home and could be taking care of livestock and fields. They can get away for three to five days of treatment, they’re used to that, but leaving for eight weeks dramatically affects their quality of life,” Hagan noted. It could even destroy their livelihoods.

Despite the wide adoption of shorter treatment schedules in the VA, “we observe that, when veterans receive care in the community, virtually all of them are given weeks of treatment. They are rarely offered anything else,” Hagan said. Yet, research consistently shows that the shorter schedules are superior to the eight-week standard.

The persistence of the longer treatment time frame reflects the volume-based reimbursement of most care. “The more treatment, the higher the reimbursement,” Hagan noted, “so it’s hard to get community providers to shorten their treatment course and cut their reimbursement in half or thirds.”

That puts the VA into a bit of a bind. As long as the care in the community is not inferior to that in the VA, the department has to pay for it. The new quality metrics offer a way to ensure community providers are providing high quality care, including hypofractionation and SBRT.

“We currently have eight quality metrics that we can see and compare that show that community providers are OK but not at the level of quality metrics we see in the VA,” Hagan observed. “It could be because all VA centers are required to have American College of Radiology accreditation, so they all pass a very high bar every three years. Most community practices are not accredited and are not evaluated against any national set of standards.”

The quality data could enable the VA to establish a system of preferred providers based on the established metrics. “Then, when we’re looking where to send a veteran, it will be clear who is providing quality data and providing quality care. It’s a much better way to bring the community along by offering a carrot instead of a stick.”