Improving Prostate Cancer Screening with Health System-Wide Microsimulation

About This Grant

Significance to VA: Every year, nearly 2 million Veterans undergo prostate-specific antigen (PSA) screening for prostate cancer within VHA. Despite widespread use, current screening practices are inconsistent and inefficient, leading to unnecessary biopsies, overtreatment, and missed opportunities for early intervention. These inefficiencies stem from the uncoordinated nature of the screening care cascade—a series of complex, multistep decisions involving screening timing, follow-up imaging, biopsies, and treatment choices. Prior attempts to improve PSA screening in VHA have focused on isolated steps within the cascade, missing critical interdependencies and failing to identify where improvement is most needed. To optimize outcomes, a comprehensive understanding of the entire care cascade is essential. One promising alternative approach is microsimulation, which simulates millions of patients as they undergo screening, diagnosis, and treatment for prostate cancer (i.e., the entire care cascade), allowing analysis of complex care decisions in an integrated, system-wide context. This approach is widely used to inform national cancer screening guidelines for this very reason. The overall objective of this proposal is to develop a VHA-specific microsimulation model of prostate cancer care, enabling rigorous identification of potential improvement opportunities, development of high-impact strategies tailored to VHA, and a detailed accounting of benefits and harms. This work is significant because it would be an enormous leap forward in VHA's ability to identify, analyze, and address opportunities to improve complex, multi-step cancer care pathways through microsimulation. This would result in a methodological toolbox that could be applied to other cancer care pathways and produce concrete benefits for the millions of Veterans undergoing PSA screening each year. Innovation and Impact: The research in this CDA is innovative because it would be the first use of microsimulation to identify opportunities for improvement in a VHA cancer care pathway and develop evidence- backed strategies to address them. This work has the potential to revolutionize how VHA develops and prioritizes cancer screening quality improvement initiatives by enabling VHA to identify the highest-impact strategies and allocate scarce resources accordingly. Specific Aims: Aim 1: Describe facility-level variation and potential improvement opportunities in PSA screening care cascades. Aim 2: Adapt an established microsimulation model to reflect current VHA prostate cancer care. Aim 3: Develop and refine high-impact strategies to improve PSA screening cascades. Methodology: Aim 1 will explore facility-level variation of key steps in contemporary VHA screening cascades, assessing drivers of this variation and focusing on patterns indicating potential overscreening of low-benefit Veterans, underscreening of higher-benefit Veterans, and inefficiencies in biopsy and treatment practices. This will identify potential opportunities for improvement and direct Aim 3 intervention assessments. Aim 2 will adapt an established, NCI-funded microsimulation model to reflect VHA-specific prostate cancer care, incorporating facility-level differences and unique Veteran risk factors and enabling simulation of improvement strategies. Aim 3 will use the VHA-specific microsimulation model to test and refine strategies, such as adjusting screening intensity by age and risk level or using pre-biopsy MRI. To ensure they are impactful and feasible, the most promising strategies will then be refined through a modified Delphi expert panel of multidisciplinary stakeholders, Path to Translation/Implementation: The project will yield a set of evidence-based strategies for improving screening efficiency and patient outcomes, tailored to address the specific inefficiencies in current VHA care cascades. These insights will be disseminated through professional channels, including through multiple research publications and presentations, seeding an effort to establish a VHA prostate cancer screening learning community focused on implementation and iterative refinement of model-informed interventions.