Enhancing Personalized Cancer Treatment and Increasing Appropriate Screening

May 20, 2026

Takeaway: Three studies conducted by HSR investigators demonstrate the advances VA is making in both increasing personalized cancer treatment and appropriate screening. In one study, investigators reduced the cost of an expensive anticancer drug by personalizing the dosage, saving more than $138,000 since June 2024. Another study developed and evaluated the Lung Cancer Screening (LCS) Decision Tool for use by patients before a clinic visit, while additional research helped contribute toward national LCS guidelines and a new national VHA directive for LCS programs.

Background

Cancer is the second most common cause of death in the United States, behind heart disease. The American Cancer Society estimated there would be more than two million new cancer cases in 2024, excluding certain skin cancers (i.e., basal cell, squamous cell). VA estimates that more than 50,000 Veterans are diagnosed with cancer annually; moreover, Veterans may be at increased risk of cancer due to exposure to certain carcinogens during their service (e.g., fumes from burn pits).

Personalized Cancer Drug Dosing

Immune checkpoint inhibitors, a class of drugs used in approximately 40 unique cancer indications, are a sizable part of the economic burden of cancer care. For example, baseline annual VA spending for these drugs is approximately $537 million. One advancement in the treatment of cancer is the use of precision or personalized medicine, which means finding out which medicines-at what doses-work best for individuals. Pembrolizumab is a costly anticancer drug typically administered as a one-size-fits-all dose, despite originally having been FDA-approved for personalized dosage. Building upon previous work,^1,2Garth Strohbehn, MD, an oncologist and HSR researcher, and colleagues launched a quality improvement pilot program at the VA Ann Arbor Healthcare System using weight-based dosing of pembrolizumab for Veterans with cancer. Between June 2024 and June 2025, the program has saved more than $138,000 while promoting patient-friendly dosing, environmental stability, and improved operational efficiency.

Immune checkpoint inhibitors are a type of immunotherapy for certain cancers that helps the body's immune system recognize and attack cancer cells. They work by blocking specific proteins-"checkpoints"-on immune cells (T cells) or cancer cells that normally turn off immune responses, allowing them to remain active and kill cancer cells.

Lung Cancer Screening Decision Tool for VA Patients

Lung cancer is the second most commonly diagnosed cancer among men and women in both VA and general US populations; however, greater comorbidity burden among Veterans compared with the US general population may increase the effect of harms related to lung cancer screening (LCS). For example, the higher incidence of mental health disorders could heighten the anxiety associated with false-positive test results, as well as the risk associated with radiation exposure. In a randomized clinical study funded by HSR, Marilyn Schapira, MD, MPH, and colleagues developed and evaluated the impact of an LCS Decision Tool (LCSDecTool) on the quality of decision-making and LCS uptake. The decision tool was designed to be used independently by a patient before a clinic visit. The LCS tool includes an overview of lung cancer screening, a pictograph representing LCS outcomes, smoking cessation advice, mental health resources, and the option to request a referral to a smoking cessation clinic or to a behavioral health clinician. Study findings suggest the LCS decision tool intervention improved LCS knowledge without increasing general anxiety or lung cancer worry. The LCSDecTool will be updated and made more accessible outside of the study.³

Developing LCS National Guidelines

Despite national guidelines recommending low-dose computed tomography (CT) lung cancer screening for individuals meeting age and smoking criteria since 2013, less than 20% of eligible persons are screened. Lung cancer screening is especially important for those with the most to gain-individuals at high risk of lung cancer (i.e., ex-smokers, Veterans exposed to carcinogens), and those with high life expectancy (10 years+). Building upon a decade of VA research on LCS and shared decision-making, HSR investigator Tanner Caverly, MD, participated in developing national guidelines and a new national VHA directive for LCS programs, as part of a QUERI initiative. This work included personalizing LCS conversations based on a Veteran's unique risk factors, and more strongly encouraging screening for those with higher predicted lung cancer risk and potentially larger health gains with LCS. Following his work on national guidelines, Dr. Caverly helped develop the first VHA directive for lung cancer screening in 2024.⁴

Implications

The research conducted by HSR investigators demonstrates the advances VA is making in both increasing personalized cancer treatment and appropriate screening. In one study, investigators reduced the cost of an expensive anticancer drug by personalizing the dosage, saving more than $138,000 since June 2024. Another study developed and evaluated the Lung Cancer Screening (LCS) Decision Tool for use by patients before a clinic visit, while additional research helped contribute toward national LCS guidelines and a new national VHA directive for LCS programs.

Investigators

HSR Career Development Awardee Garth Strohbehn, MD, MPhil, and Tanner Caverly, MD, are core investigators with HSR's Center for Clinical Management Research (CCMR); Marilyn Schapira, MD, MPH, is Associate Director of HSR's Center for Healthcare Evaluation, Research, and Promotion (CHERP).

Citations

1. Strohbehn G, Holleman R, Burns J, et al. Adoption of extended-interval dosing of single-agent pembrolizumab and comparative effectiveness vs standard dosing in time-to-treatment discontinuation. JAMA Oncology. 2022;8(11):1663-1667.
2. Bryant A, Chopra Z, Edwards D, et al., and Strohbehn G. Adopting weight-based dosing with pharmacy-level stewardship strategies could reduce cancer drug spending by millions. Health Affairs. July 2023:42(7):946-955.
3. Schapira M, Hubbard R, Whittle J, et al. Lung cancer screening decision aid designed for a primary care setting: A randomized clinical trial. JAMA Network Open. 2023;6(8):e2330452.
4. Caverly T, Weiner R Kumbier K, et al. Prediction-augmented shared decision-making and lung cancer screening uptake. JAMA Network Open. July 1, 2024;7(7):e2419624.