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Ruchika Talwar: Hi, everyone. Welcome back to UroToday's Health Policy Center of Excellence. As always, my name is Ruchika Talwar, and I'm a urologic oncologist in Nashville, Tennessee. Today in our Center of Excellence, we're continuing our special series on prostate cancer patient costs, and I'm joined today by Dr. Dan Lee, who's an assistant professor of urology at the University of Pennsylvania, and he's a senior fellow affiliated with the Leonard Davis Institute of Healthcare Economics. He's going to be chatting with us today about patient-facing costs within the VA Health Care System for advanced prostate cancer. Dr. Lee, thank you so much for joining us.

Daniel Lee: And thank you so much for the opportunity to talk about this really, really important topic here. Thank you again for the opportunity to present about this very interesting topic, but also very worthwhile to discuss, to talk about some of the patient costs for advanced prostate cancer, specifically in the VA Health Care system, as Dr. Talwar had introduced before. So I am one of the assistant professors of urology over at the University of Pennsylvania. I'm also one of the staff surgeons at the Corporal Michael J. Crescenz VA Medical Center, which is in Philadelphia, Pennsylvania. I don't have any disclosures relevant to this. I'm a consultant for Verona Health, but not relevant to this discussion.

What I really want to go over is some of the outlines that we have here for this in terms of discussing prostate cancer costs. What does that mean? What does it imply? And what are some of the things that we can see in how it impacts patients?

First off, we want to discuss how prostate cancer treatment itself is quite costly to our patients in multiple different ways. The VA Health Care System does provide many services specifically for advanced prostate cancer that does improve the quality of care and accessibility for some high level of treatment options, but there are still other costs to consider, and those are some of the considerations that we'll have here today.

First off, prostate cancer treatment is very costly, as Dr. Talwar, but also some of our other colleagues, Dr. Joyce and Dr. Michael, have gone through before. Prostate cancer treatment, especially for advanced prostate cancer, is exceedingly costly, especially the newer oral anti-androgens that are on the market today are about 18 times the cost of older medications. The median cost can be upwards of $700 per month, and this is after adjusting for insurance coverage, meaning out-of-pocket costs. So when we consider that for our patients and for our individuals that are undergoing prostate cancer, specifically under advanced prostate cancer treatments where they're on these agents for years or several months, you can see that these per month costs—again, these are out-of-pocket costs—can add up quite substantially.

These higher costs may also lead to lower adherence or compliance with these medications. Again, if it's more costly to afford these newer medications, it may be hard to stay on these treatments. But there are also indirect costs that we have to account for, for example, lost wages and travel time for these medications and to receive each of these medications in the clinics. These indirect costs can also be costly; it can add up to almost $4,000 per month. So again, we're talking about something that can cost the patient, again, out of pocket, both in terms of the medication cost and also in terms of the travel and time spent upwards of several thousand per month. We also have to consider secondary treatments that patients may need for some of the side effects from their primary treatments, whether it be surgery, radiation, or even the androgen deprivation therapy itself.

In terms of the services that the VA provides for advanced prostate cancer, there are several that really have made a substantial change in terms of affordability and access to care. First off, the Cleland-Dole Act from 2022 was really influential in terms of providing different advanced services for our patients. First off, it provided pretty streamlined prostate cancer clinical pathways, and what that does is that it does several things. Number one, it provides guideline-concordant care and at least a steady process for individuals and for providers to follow so that patients, no matter where they are or where they may be located, can receive care that's concurrent with the most recent guidelines.

The National Tele-Oncology Program also is exceedingly helpful, especially for folks where there are significant access to care barriers, for folks who are in rural locations, or where there's not already an academic center available. Through this National Tele-Oncology program, you can receive excellent quality of care just by having access to video conferencing or over telemedicine as well.

The Precision Oncology Program for the Cancer of the Prostate, also known as POPCaP, also has really broadened not just the access to quality care, but access to a lot of the other secondary treatment options, but also options, for example, as germline mutational testing, and also access to research and clinical trials as well. This all fits under the National Precision Oncology Program, and there's been a really tight partnership with the Prostate Cancer Foundation in terms of advancing prostate cancer-related research and access to clinical trials for our veterans.

The other big component of improving access to care through the VA Medical Health Care System is fewer and lower co-pays. This is actually taken from one of their brochures on the VA website, and when you look, especially even at the tier three—so for all these different medications that fit into tier one, tier two, tier three, and there are different tier levels that are involved with the different medications that are prescribed—but for even the most advanced and newest anti-androgens, even the most expensive medications that we have, the most that our veterans would pay out of pocket for those causes upwards of $11 per month, which is definitely different than what our commercial insurers or payers would have. And there's also a $700 medication co-payment cap that patients would have for the year. So overall, this is actually one of the biggest benefits for our veterans is the affordability of the medications.

There's also a low-income exemption that is readily available and quite easy to apply for any of our veterans. They're able to coordinate with any of the nurse navigators that are available through the VA system. It's quite an easy process to apply for.

Even though the medications are quite affordable and there are all these programs that are available for our veterans with prostate cancer, there have been a couple of recent studies that have shown that there still are some other costs that our veterans have to take into account when thinking about prostate cancer, especially advanced prostate cancer care.

One of the biggest ones is going to be cardiovascular risk. Now, there is a recent study that showed we do know that anybody who's on advanced androgen deprivation therapy, we do have to watch and monitor and account for the cardiovascular risks, and especially in the veteran population where the cardiovascular risks will be higher than the non-veteran population, this is something that's quite significant and has to be accounted for. So half of the patients on androgen deprivation therapy had uncontrolled cardiovascular risk factors. This is a paper that came out from our group here at Penn where we looked at—I forget the exact number, but it was a large number, a large cohort of men undergoing androgen deprivation therapy looking at their cardiovascular risk factors. And of that cohort, up to a third of them were not receiving the medications to help decrease or alleviate that risk. So talking about, or at least accounting for, the cardiovascular risks and costs that are associated with that has to be part of the discussion.

Travel and time spent on care is still a significant burden, especially for our veterans who may be traveling quite a distance to be able to get to the different centers of excellence. This is where home administration of some of our androgen deprivation therapy can be game-changing. I know at Penn and some of our other facilities, we are trialing a home administration, for example, of Lupron and some of our other medications, so this is something also that we're hoping to advance.

Another one, this is coming out of the Jefferson group where they looked at, again, veterans and did qualitative surveys of some of their burdens and costs, and they found that over a third of veterans reported—even after accounting for the lower co-pays of the medications—that over a third of them reported still not having enough money after treatments. So we still know that there are some other indirect costs that need to be substantiated and accounted for.

So overall, again, in conclusion, our prostate cancer treatments for advanced prostate cancer are quite costly. The VA can provide androgen deprivation and some of these newer anti-androgens at a much more affordable cost, but there are still other costs and things that we have to consider, and hopefully in the future with future collaborations and research we can really get to the bottom of this and really improve the care for our veterans and for our patients here. Thank you.

Ruchika Talwar: Thank you so much, Dr. Lee. Really important points, and I love that you stress the fact that there are indirect costs that we need to continue to explore, understand, and potentially discuss with our patients, even though the cost of the medications themselves may still be covered. So as we wrap up here, I'm curious, what is your advice to the population of urologists who interface with folks who may be getting their prostate cancer care at the VA? How can we initiate these sorts of conversations?

Daniel Lee: Well, I think you said it perfectly. It's just having that conversation. As most of you know, Dr. Pence would love to say, "You can't improve what you can't measure," and so that's one of the biggest things that I would really strongly encourage to our listeners and to the rest of our providers here. Asking those questions is so important because, number one, it's so important for the patients to know that you care, that we care about these things, that we really want to improve these things. But we also can't improve it unless we know what are the different barriers that our patients are facing. And speaking to that, I think a lot of us, even the best of us, still make assumptions, there's still biases that we internally have, and I think it's so important that we bring this up to the forefront and just be honest with our patients about what they may be experiencing at their homes.

How are they doing with these costs? What are the different things that they have to do? And really understand their perspective from what it is. There are different cost measures that we can use. I know that you've also published on this, but other folks and myself, we like using the COST measure, which is quite simple and quite quick to be able to quickly assess where patients are in terms of their affordability. But just even asking the simple question, "How much are these costs costing you per month and where are you in terms of your finances?" Those are just two real quick questions that I think we could all ask to get to the bottom line of that.

Ruchika Talwar: Yeah, and I think another thing that we potentially don't do enough is consider coordinating care. So as you mentioned, patients who seek care at the VA are often coming from pretty far away, so being a little more thoughtful in consolidating those specialty appointments I think is another avenue by which we can alleviate some of that burden.

Daniel Lee: Yeah. And I really do hope the initial results from our home care delivery services—Penn has a couple of programs now where we're developing home delivery of different cancer treatments, Lupron, androgen deprivation therapy, but also some chemotherapy—and just being able to bring those treatments to a home setting has shown to really alleviate or decrease the burden of those indirect costs. So I do think that different innovations in that space could really change the ballgame.

Ruchika Talwar: Absolutely. Well, we look forward to your future work in that space, and thank you so much for spending some time with us today.

Daniel Lee: Great. Thank you so much for the opportunity.

Ruchika Talwar: And to our audience, thanks, as always, for joining. We'll see you next time.