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Pace R, Goldstein KM, Williams AR, Clayton-Stiglbauer K, Meernik C, Shepherd-Banigan M, Chawla N, Moss H, Skalla LA, Colonna S, Kelley MJ, Zullig LL. The Landscape of Care for Women Veterans with Cancer: An Evidence Map. J Gen Intern Med 2024; 39:2300-2316. [PMID: 38965201 PMCID: PMC11347519 DOI: 10.1007/s11606-024-08903-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2024] [Accepted: 06/17/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Women are the fastest growing veteran group in the US and the number of women veterans (WVs) with cancer is rising; however, little is known about this population. Cancer care for WVs is complex and it is essential to understand their unique needs and care coordination challenges to provide evidence-based care. The purpose of this review is to map the quantity, distribution, and characteristics of literature describing cancer and its treatment among WVs. METHODS We searched MEDLINE (via PubMed), Embase (Elsevier), and Web of Science Core Collection (Clarivate) from inception through January, 2024. Publications were eligible that reported gender-specific data on any aspect of cancer care among WVs. Data was abstracted by a single investigator with over-reading. RESULTS Forty-six reports were included; 44 were observational and 19 had a women-only sample. There were no interventional reports and no qualitative reports had a patient sample. Breast cancer was the most commonly addressed (n = 19). There were six additional reports on sex-specific cancers. Many reports used large VA databases or previous trial data, creating the potential for patient overlap between reports. Among VA-specific areas of interest, only three reports evaluated the potential implications of racial differences and only two included a transgender population. No reports examined the effects of toxic exposures on cancer. Within the NCI Cancer Control Continuum, crosscutting areas were more commonly represented; over half (25) of the reports addressed epidemiology. There were few reports on focus areas and little overlap between focus and crosscutting areas. DISCUSSION Existing literature provides an inadequate understanding of the population of WVs with cancer. There is scant information regarding the population of WVs with cancer, their care preferences or experiences, or how to best identify and address unmet healthcare needs. It is imperative to expand research to provide evidence-based care for this population.
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Affiliation(s)
- Rachel Pace
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA.
| | - Karen M Goldstein
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA
- Division of General Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - April R Williams
- Division of Hematology and Oncology, Durham VA Healthcare System, Durham, NC, USA
- Cooperative Studies Program Epidemiology Center, Durham VA Healthcare System, Durham, NC, USA
- Million Veteran Program, Boston Coordinating Center, Boston, MA, USA
| | | | | | - Megan Shepherd-Banigan
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
- Duke-Margolis Institute for Health Policy, Duke University, Durham, NC, USA
- Mid-Atlantic Mental Illness Research Education and Clinical Center (MIRECC), Durham VA Healthcare System, Durham, NC, USA
| | - Neetu Chawla
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Haley Moss
- Division of Hematology and Oncology, Durham VA Healthcare System, Durham, NC, USA
- Department of Obstetrics and Gynecology, Duke University Healthcare System, Durham, NC, USA
| | - Lesley A Skalla
- Duke University Medical Center Library and Archives, Duke University School of Medicine, Durham, NC, USA
| | | | - Michael J Kelley
- Division of Hematology and Oncology, Durham VA Healthcare System, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
- National Oncology Program, Department of Veterans Affairs, Washington, DC, USA
| | - Leah L Zullig
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
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Fefferman A, Beaulieu-Jones BR, Shewmaker G, Zhang T, Sachs T, Merrill A, Ko NY, Cassidy MR. Association of Race, Ethnicity, Insurance, and Language and Rate of Breast-Conserving Therapy Among Women With Nonmetastatic Breast Cancer at an Urban, Safety-Net Hospital. J Surg Res 2023; 291:403-413. [PMID: 37517348 DOI: 10.1016/j.jss.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 05/20/2023] [Accepted: 06/13/2023] [Indexed: 08/01/2023]
Abstract
INTRODUCTION Breast-conserving therapy (BCT), specifically breast-conserving surgery (BCS) and adjuvant radiation, provides an equivalent alternative to mastectomy for eligible patients. However, previous studies have shown that BCT is underused in the United States, particularly among marginalized demographic groups. In this study, we examine the association between race, ethnicity, insurance, and language and rate of BCS among patients treated at an academic, safety-net hospital. MATERIALS AND METHODS We conducted a retrospective cohort study of 520 women with nonmetastatic breast cancer diagnosed and treated at an academic, safety-net hospital (2009-2014). We assessed eligibility for BCT and then differences in the rate of BCT among eligible patients by race, ethnicity, insurance, and language. Reasons for not undergoing BCT were documented. RESULTS Median age was 60 y; 55.9% were non-White, 31.9% were non-English-speaking, 15.6% were Hispanic, and 47.4% were Medicaid/uninsured. Three hundred seventy one (86.3%) underwent BCS; within this group, 324 (87.3%) completed adjuvant radiation. Among patients undergoing mastectomy, 30 patients (36.7%) were eligible for BCT; within this group, reasons for mastectomy included patient preference (n = 28) and to avoid possible re-excision or adjuvant radiation in patients with significant comorbidities (n = 2). Eligibility for BCT varied by ethnicity (Hispanic [100%], Non-Hispanic [92%], P = 0.02), but not race, language, or insurance. Among eligible patients, rate of BCS varied by age (<50 y [84.9%], ≥50 y [92.9%], P = 0.01) and ethnicity (Hispanic [98.5%], Non-Hispanic [91.3%], P = 0.04), but not race, language, or insurance. CONCLUSIONS At our safety-net hospital, the rate of BCS among eligible patients did not vary by race, language, or insurance. Excluding two highly comorbid patients, all patients who underwent mastectomy despite being eligible for BCT were counseled regarding BCS and expressed a preference for mastectomy. Further research is needed to understand the value of BCT in the treatment of breast cancer, to ensure informed decision-making, address potential misconceptions regarding BCT, and advance equitable care for all patients.
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Affiliation(s)
- Ann Fefferman
- Boston University School of Medicine, Boston, Massachusetts
| | - Brendin R Beaulieu-Jones
- Boston University School of Medicine, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | | | - Tina Zhang
- Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Teviah Sachs
- Boston University School of Medicine, Boston, Massachusetts; Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, Massachusetts
| | - Andrea Merrill
- Boston University School of Medicine, Boston, Massachusetts; Section of Hematology & Oncology, Boston Medical Center, Boston University, Boston, Massachusetts
| | - Naomi Y Ko
- Boston University School of Medicine, Boston, Massachusetts; Section of Hematology & Oncology, Boston Medical Center, Boston University, Boston, Massachusetts
| | - Michael R Cassidy
- Boston University School of Medicine, Boston, Massachusetts; Section of Surgical Oncology, Boston Medical Center, Boston University, Boston, Massachusetts.
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Jeon CY, Kim S, Lin YC, Risch HA, Goodarzi MO, Nuckols TK, Freedland SJ, Pandol SJ, Pisegna JR. Prediction of Pancreatic Cancer in Diabetes Patients with Worsening Glycemic Control. Cancer Epidemiol Biomarkers Prev 2022; 31:242-253. [PMID: 34728468 PMCID: PMC8759109 DOI: 10.1158/1055-9965.epi-21-0712] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/25/2021] [Accepted: 10/22/2021] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Worsening glycemic control indicates elevated risk of pancreatic ductal adenocarcinoma (PDAC). We developed prediction models for PDAC among those with worsening glycemic control after diabetes diagnosis. METHODS In 2000-2016 records within the Veterans Affairs Health System (VA), we identified three cohorts with progression of diabetes: (i) insulin initiation (n = 449,685), (ii) initiation of combination oral hypoglycemic medication (n = 414,460), and (iii) hemoglobin A1c (HbA1c) ≥8% with ≥Δ1% within 15 months (n = 593,401). We computed 12-, 36-, and 60-month incidence of PDAC and developed prediction models separately for males and females, with consideration of >30 demographic, behavioral, clinical, and laboratory variables. Models were selected to optimize Akaike's Information Criterion, and performance for predicting 12-, 36-, and 60-month incident PDAC was evaluated by bootstrap. RESULTS Incidence of PDAC was highest for insulin initiators and greater in males than in females. Optimism-corrected c-indices of the models for predicting 36-month incidence of PDAC in the male population were: (i) 0.72, (ii) 0.70, and (iii) 0.71, respectively. Models performed better for predicting 12-month incident PDAC [c-index (i) 0.78, (ii) 0.73, (iii) 0.76 for males], and worse for predicting 60-month incident PDAC [c-index (i) 0.69, (ii) 0.67, (iii) 0.68 for males]. Model performance was lower among females. For subjects whose model-predicted 36-month PDAC risks were ≥1%, the observed incidences were (i) 1.9%, (ii) 2.2%, and (iii) 1.8%. CONCLUSIONS Sex-specific models for PDAC can estimate risk of PDAC at the time of progression of diabetes. IMPACT Our models can identify diabetes patients who would benefit from PDAC screening.
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Affiliation(s)
- Christie Y. Jeon
- Cedars-Sinai Cancer, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Epidemiology, UCLA Fielding School of Public Health, Los Angeles, California.,Corresponding Author: Christie Y. Jeon, Department of Medicine, Cedars-Sinai Medical Center, 700 N San Vicente Boulevard, Pacific Design Center G596, West Hollywood, CA 90069. Phone: 310-423-6345; E-mail:
| | - Sungjin Kim
- Cedars-Sinai Cancer, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yu-Chen Lin
- Cedars-Sinai Cancer, Cedars-Sinai Medical Center, Los Angeles, California
| | - Harvey A. Risch
- Department of Epidemiology, Yale School of Public Health, Los Angeles, California
| | - Mark O. Goodarzi
- Division of Endocrinology, Diabetes and Metabolism, Cedars-Sinai Medical Center, Los Angeles, California
| | - Teryl K. Nuckols
- Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Stephen J. Freedland
- Cedars-Sinai Cancer, Cedars-Sinai Medical Center, Los Angeles, California.,Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California.,Section of Urology, Durham VA Medical Center, Durham, North Carolina
| | - Stephen J. Pandol
- Cedars-Sinai Cancer, Cedars-Sinai Medical Center, Los Angeles, California.,Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joseph R. Pisegna
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
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Danan ER, Krebs EE, Ensrud K, Koeller E, MacDonald R, Velasquez T, Greer N, Wilt TJ. An Evidence Map of the Women Veterans' Health Research Literature (2008-2015). J Gen Intern Med 2017; 32:1359-1376. [PMID: 28913683 PMCID: PMC5698220 DOI: 10.1007/s11606-017-4152-5] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Revised: 06/08/2017] [Accepted: 07/27/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Women comprise a growing proportion of Veterans seeking care at Veterans Affairs (VA) healthcare facilities. VA initiatives have accelerated changes in services for female Veterans, yet the corresponding literature has not been systematically reviewed since 2008. In 2015, VA Women's Health Services and the VA Women's Health Research Network requested an updated literature review to facilitate policy and research planning. METHODS The Minneapolis VA Evidence-based Synthesis Program performed a systematic search of research related to female Veterans' health published from 2008 through 2015. We extracted study characteristics including healthcare topic, design, sample size and proportion female, research setting, and funding source. We created an evidence map by organizing and presenting results within and across healthcare topics, and describing patterns, strengths, and gaps. RESULTS We identified 2276 abstracts and assessed each for relevance. We excluded 1092 abstracts and reviewed 1184 full-text articles; 750 were excluded. Of 440 included articles, 208 (47%) were related to mental health, particularly post-traumatic stress disorder (71 articles), military sexual trauma (37 articles), and substance abuse (20 articles). The number of articles addressing VA priority topic areas increased over time, including reproductive health, healthcare organization and delivery, access and utilization, and post-deployment health. Three or fewer articles addressed each of the common chronic diseases: diabetes, hypertension, depression, or anxiety. Nearly 400 articles (90%) used an observational design. Eight articles (2%) described randomized trials. CONCLUSIONS Our evidence map summarizes patterns, progress, and growth in the female Veterans' health and healthcare literature. Observational studies in mental health make up the majority of research. A focus on primary care delivery over clinical topics in primary care and a lack of sex-specific results for studies that include men and women have contributed to research gaps in addressing common chronic diseases. Interventional research using randomized trials is needed.
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Affiliation(s)
- Elisheva R Danan
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA. .,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA.
| | - Erin E Krebs
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Kristine Ensrud
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Eva Koeller
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Roderick MacDonald
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Tina Velasquez
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Nancy Greer
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA
| | - Timothy J Wilt
- VA HSR&D Center for Chronic Disease Outcomes Research, Minneapolis VA Healthcare System, 1 Veterans Drive (152), Minneapolis, MN, 55417, USA.,Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
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Women with breast cancer in the Veterans Health Administration: demographics, breast cancer characteristics, and trends. Med Care 2015; 53:S149-55. [PMID: 25767969 DOI: 10.1097/mlr.0000000000000299] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An increasing number of women are being cared for within the Veterans Health Administration (VA). However, the demographics and trends of women with breast cancer at the VA has not been documented. We describe the demographics and breast cancer characteristics of the 4445 women enrolled in the VA and reported to the Department of Veterans Affairs Central Cancer Registry diagnosed with breast cancer from 1995 to 2012. The cases of breast cancer per year increased over time to 365 in 2012. Black women represented only 16% of women diagnosed with breast cancer in the VA in 1995-1999 but increased to 25% by 2010-2012 (P<0.001). The median age at diagnosis in 1995-1999 was 58.4 and decreased to 56.8 by 2010-2012 (P<0.02). The fraction of breast cancers that were node negative was 45% in 1995-1999 and increased to 64% in 2010-2012; correspondingly, women presented at an earlier stage in more recent years (P<0.001). Urban women with breast cancer cared for within the VA are more likely to be younger (P=0.04) and nonwhite (P<0.001) compared with rural women, but the breast tumor characteristics appear similar. Oncology physicians at the VA must be prepared to care for breast cancer among women as the number of cases is growing. With only 365 women diagnosed with breast cancer at the VA as per year 2012 and nearly 150 treating VA facilities, the number of breast cancer patients seen by a particular physician could be quite low, and this fact suggests a need for an evaluation of the quality and outcomes of breast cancer care at the VA.
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Bielawski MP, Goldstein KM, Mattocks KM, Bean-Mayberry B, Yano EM, Bastian LA. Improving care of chronic conditions for women veterans: identifying opportunities for comparative effectiveness research. J Comp Eff Res 2014; 3:155-66. [PMID: 24645689 DOI: 10.2217/cer.14.4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
This article aims to critically analyze research focused on the findings for five chronic conditions: chronic pain, diabetes, cardiovascular disease, HIV and cancer among women veterans to identify opportunities for comparative effectiveness research. We provide a descriptive analysis from the relevant articles in prior systematic reviews. In order to identify potential gaps in research for these specific conditions, we also conducted a literature search to highlight studies focusing on women veterans published since the last systematic review. While the scientific knowledge base has grown for these chronic conditions among women veterans, the vast majority of the published literature remains descriptive and/or observational, with only a few studies examining gender differences and even fewer clinical trials. There is a need to conduct comparative effectiveness research on chronic conditions among women veterans to improve health and healthcare.
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Affiliation(s)
- Mark P Bielawski
- Center of Excellence, VA Connecticut Healthcare System, Newington, CT, USA
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