VA Articles of Interest
Prostate Cancer Prostatic Dis. 2020 Jun;23(2):252-259.
doi: 10.1038/s41391-019-0178-6. Epub 2019 Oct 17.
Tobacco smoking and death from prostate cancer in US veterans
Paul Riviere 1 2, Abhishek Kumar 1 2, Elaine Luterstein 1, Lucas K Vitzthum 1 2, Vinit Nalawade 1 2, Reith R Sarkar 1 2, Alex K Bryant 1 2, John P Einck 1, Arno J Mundt 1, James D Murphy 1 2, Brent S Rose 3 4
Affiliations
1Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA.
2VA San Diego Health Care System, La Jolla, CA, USA.
3Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA. bsrose@ucsd.edu.
4VA San Diego Health Care System, La Jolla, CA, USA. bsrose@ucsd.edu.
Abstract
Background: Cigarette smoking is a risk factor for mortality in several genitourinary cancers, likely due to accumulation of carcinogens in urine. However, in prostate cancer (PC) the link has been less studied. We evaluated differences in prostate cancer-specific mortality (PCSM) between current smokers, past smokers, and never smokers diagnosed with PC.
Methods: This was a retrospective cohort study of PCSM in men diagnosed with PC between 2000 and 2015 treated in the US Veterans Affairs health care system, using competing risk regression analyses.
Results: The cohort included 73,668 men (current smokers: 22,608 (30.7%), past smokers: 23,695 (32.1%), and never smokers: 27,365 (37.1%)). Median follow-up was 5.9 years. Current smoker patients were younger at presentation (median age current: 63, never: 66; p < 0.001), and had more advanced disease stage (stage IV disease current: 5.3%, never: 4.3%; p < 0.04). The 10-year incidence of PCSM was 5.2%, 4.8%, and 4.5% for current, past, and never smokers, respectively. On competing risk regression, current smoking was associated with increased PCSM (subdistribution hazard ratio: 1.14, 95% confidence interval: (1.05-1.24), p = 0.002), whereas past smoking was not. Hierarchical regression suggests that this increased risk was partially attributable to tumor characteristics.
Conclusions: Smoking at the time of diagnosis is associated with a higher risk of dying from PC as well as other causes of death. In contrast, past smoking was not associated with PCSM suggesting that smoking may be a modifiable risk factor. PC diagnosis may be an important opportunity to discuss smoking cessation.
Clin J Oncol Nurs. 2020 Jun 1;24(3):331-334.
doi: 10.1188/20.CJON.331-334.
Veterans With Cancer: Providing Care in the Community
Mary Laudon Thomas
Affiliation
VA Palo Alto Health Care System.
Abstract
Cancer is more prevalent in the military veteran population than in the general population and is often associated with radiation and chemical exposures encountered while in service. Veterans with cancer may have complex comorbidities, including mental health conditions and social challenges, that can interfere with successful cancer treatment. As more veterans receive their cancer care in the community outside the Veterans Health Administration (VHA), oncology nurses must be aware of these issues and provide appropriate interventions to increase the likelihood that positive cancer treatment outcomes are realized for these patients.
Psychooncology. 2021 Apr;30(4):581-590.
doi: 10.1002/pon.5605. Epub 2020 Dec 13.
Posttraumatic stress disorder and suicide among veterans with prostate cancer
Maya Aboumrad 1, Brian Shiner 1 2, Lorelei Mucci 3, Nabin Neupane 1, Florian R Schroeck 1 2, Zachary Klaassen 4, Stephen J Freedland 5 6, Yinong Young-Xu 1 2
Affiliations
1White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.
2Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
3Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
4Medical College of Georgia at Augusta University, Augusta, Georgia, USA.
5Cedars-Sinai Medical Center, Los Angeles, California, USA.
6Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.
Abstract
Objective: To evaluate the effect of a preexisting posttraumatic stress disorder (PTSD) diagnosis on suicide and non-suicide mortalities among men with newly diagnosed prostate cancer, and examine potential mediating factors for the relationship between PTSD and suicide.
Methods: We used patient-level data from Veterans Health Administration electronic medical records to identify men (age ≥40 years) diagnosed with prostate cancer between 2004 and 2014. We used Fine and Gray regression model to estimate the risk for competing mortality outcomes (suicide, non-suicide, and alive). We used structural equation models to evaluate the mediating factors.
Results: Our cohort comprised 214,649 men with prostate cancer, of whom 12,208 (5.7%) had a preexisting PTSD diagnosis. Patients with PTSD compared to those without utilized more healthcare services and had lower risk cancer at diagnosis. Additionally, they experienced more suicide deaths (N = 26, 0.21% vs. N = 269, 0.13%) and fewer non-suicide deaths (N = 1399, 11.5% vs. N = 45,625, 22.5%). On multivariable analysis, PTSD was an independent suicide risk factor (HR = 2.35; 95% CI: 1.16, 4.78). Depression, substance use disorder, and any definitive prostate cancer treatment were partial mediators. However, PTSD was associated with lower non-suicide mortality risk (HR = 0.86; 95% CI: 0.77, 0.96).
Conclusion: Patients with PTSD experienced greater suicide risk even after adjusting for important mediators. They may have experienced lower non-suicide mortality risk due to favorable physical health resulting from greater healthcare service use and early diagnosis of lower risk cancer. Our findings highlight the importance of considering psychiatric illnesses when treating patients with prostate cancer and the need for interventions to ameliorate suicide risk.
Mil Med. 2020 Mar 2;185(3-4):512-518.
doi: 10.1093/milmed/usz291.
Breast Cancer Risk Assessment and Chemoprevention Use Among Veterans Affairs Primary Care Providers: A National Online Survey
Balmatee Bidassie 1, Amanda Kovach 1, Marissa A Vallette 1, Joseph Merriman 2 3, Yeun-Hee Anna Park 4 5, Anita Aggarwal 6, Sarah Colonna 3
Affiliations
1Clinical Partnerships in Healthcare Transformation (CPHT), VA-Center for Applied Systems Engineering (VA-CASE), Veterans Engineering Resource Center (VERC), 2669 Cold Springs Road, Building 9, Indianapolis, IN 46222.
2Vanderbilt Ingram Cancer Center, 1301 Medical Center Dr #1710, Nashville, TN 37232.
3Huntsman Cancer Institute 1950, 2000 Cir of Hope Dr, Salt Lake City, UT 84112, George E Wahlen VA 500 Foothill Dr Salt Lake City, UT 84148.
4James J. Peters VA Medical Center, 130 W Kingsbridge Rd The Bronx, NY 10468.
5Columbia University Division of Hematology/Oncology, 116th St & Broadway, New York, NY 10027.
6Washington D.C. VA Medical Center, 50 Irving St NW, Washington, DC 20422.
Abstract
Introduction: Breast cancer is the most common cancer diagnosed among women and the second most common cause of cancer death among women. There are ways to reduce a woman's risk of breast cancer; however, most eligible women in the United States are neither offered personalized screening nor chemoprevention. Surveys have found that primary care providers are largely unaware of breast cancer risk assessment models or chemoprevention. This survey aims to investigate Veterans Health Administration primary care providers' comfort level, practice patterns, and knowledge of breast cancer risk assessment and chemoprevention.
Materials and methods: An online, Research Electronic Data Capture-generated survey was distributed to VHA providers in internal medicine, family medicine, and obstetrics/gynecology. Survey domains were provider demographics, women's health experience, comfort level, practice patterns, barriers to using risk models and chemoprevention, and knowledge of chemoprevention.
Results: Of the 167 respondents, 33.1% used the Gail model monthly or more often and only 2.4% prescribed chemoprevention in the past 2 years. Most VHA primary care providers did not answer chemoprevention knowledge questions correctly. Designated women's health providers were more comfortable with risk assessment (P < 0.018) and chemoprevention (P < 0.011) and used both breast cancer risk models (P < 0.0045) and chemoprevention more often (P < 0.153). Reported barriers to chemoprevention were lack of education and provider time.
Conclusions: VHA providers and women Veterans would benefit from a system to ensure that women at increased risk of breast cancer are identified with risk modeling and that risk reduction options, such as chemoprevention, are offered when appropriate. VHA providers requested risk reduction education, which could improve primary care provider comfort level with chemoprevention.
J Womens Health (Larchmt). 2019 Feb;28(2):268-275.
doi: 10.1089/jwh.2018.6936. Epub 2018 Jun 19.
Cancer Among Women Treated in the Veterans Affairs Healthcare System
Leah L Zullig 1 2, Karen M Goldstein 1 3, Kellie J Sims 4, Christina D Williams 4 5, Michael Chang 6, Dawn Provenzale 4 7, Michael J Kelley 5 8 9 10
Affiliations
11 Center for Health Services Research in Primary Care , Durham Veterans Affairs Health Care System, Durham, North Carolina.
22 Department of Population Health Sciences, Duke University Medical Center , Durham, North Carolina.
33 Division of General Internal Medicine, Duke University Medical Center , Durham, North Carolina.
44 VA Cooperative Studies Program Epidemiology Center , Durham Veterans Affairs Health Care System, Durham, North Carolina.
55 Division of Medical Oncology, Duke University Medical Center , Durham, North Carolina.
66 Radiation Oncology Service, Richmond Veterans Affairs Medical Center , Richmond, Virginia.
77 Division of Gastroenterology, Duke University Medical Center , Durham, North Carolina.
88 Departments of Psychiatry and School of Nursing Duke University , Durham, North Carolina.
99 Department of Veterans Affairs, Specialty Care Services , Washington, District of Columbia.
1010 Hematology-Oncology Service, Durham Veterans Affairs Health Care System , Durham, North Carolina.
Abstract
Background: The Veterans Affairs (VA) healthcare system is a high-volume provider of cancer care. Women are the fastest growing patient population using VA healthcare services. Quantifying the types of cancers diagnosed among women in the VA is a critical step toward identifying needed healthcare resources for women Veterans with cancer.
Materials and methods: We obtained data from the VA Central Cancer Registry for cancers newly diagnosed in calendar year 2010. Our analysis was limited to women diagnosed with invasive cancers (e.g., stages I-IV) between January 1, 2010, and December 31, 2010, in the VA healthcare system. We evaluated frequency distributions of incident cancer diagnoses by primary anatomical site, race, and geographic region. For commonly occurring cancers, we reported distribution by stage.
Results: We identified 1,330 women diagnosed with invasive cancer in the VA healthcare system in 2010. The most commonly diagnosed cancer among women Veterans was breast (30%), followed by cancers of the respiratory (16%), gastrointestinal (12%), and gynecological systems (12%). The most commonly diagnosed cancers were similar for white and minority women, except white women were significantly more likely to be diagnosed with respiratory cancers (p < 0.01) and minority women were significantly more likely to be diagnosed with gastrointestinal cancers (p = 0.03).
Conclusions: Understanding cancer incidence among women Veterans is important for healthcare resource planning. While cancer incidence among women using the VA healthcare system is similar to U.S civilian women, the geographic dispersion and small incidence relative to male cancers raise challenges for high quality, well-coordinated cancer care within the VA.
Semin Oncol. Aug-Oct 2019;46(4-5):321-326.
doi: 10.1053/j.seminoncol.2019.10.001. Epub 2019 Oct 24.
Utilization of the Veterans Affairs Central Cancer Registry to evaluate lung cancer outcomes
Mark Klein 1, George Scaria 2, Apar Kishor Ganti 3
Affiliations
1Hematology/Oncology Section, Primary Care Service Line, Minneapolis VA Health Care System, Minneapolis, Minnesota; Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota, Minneapolis, Minnesota. Electronic address: mark.klein2@va.gov.
2Research Service, Minneapolis VA Health Care System, Minneapolis, Minnesota.
3Division of Oncology, Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska; Hematology/Oncology Section, Omaha VA Medical Center-VA Nebraska-Western Iowa Healthcare System, Omaha, Nebraska.
Abstract
Lung cancer is one of the most common and difficult to treat cancers. Veterans are disproportionately affected by lung cancer, as approximately 20% of all cancers diagnosed within the Veteran Affairs health system are lung cancers. Many Veterans have extensive comorbidities, and thus they are often excluded from clinical trials based on this and other eligibility criteria. Thus, while clinical trials are the gold standard to guide treatment decisions, many Veterans' clinical situations will not align with clinical trial criteria. The Department of Veterans Affairs has established a Central Cancer Registry to aid in evaluation of cancer outcomes and other studies, and data in the registry date back to 1995. This has provided a rich source of data for outcome-based and other research. Here, we highlight studies that utilized the Veterans Affairs Central Cancer Registry to analyze lung cancer outcomes in Veterans treated within the Veterans Affairs health system.