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Brooks RT, Luedders B, Wheeler A, Johnson TM, Yang Y, Roul P, Ganti AK, Singh N, Sauer BC, Cannon GW, Baker JF, Mikuls TR, England BR. The Risk of Lung Cancer in Rheumatoid Arthritis and Rheumatoid Arthritis-Associated Interstitial Lung Disease. Arthritis Rheumatol 2024. [PMID: 39073264 DOI: 10.1002/art.42961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/24/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE We aimed to evaluate lung cancer risk in patients with rheumatoid arthritis (RA) and RA-interstitial lung disease (ILD). METHODS We performed a retrospective, matched cohort study of RA and RA-ILD within the Veterans Health Administration (VA) between 2000 and 2019. Patients with RA and RA-ILD were identified with validated administrative-based algorithms, then matched (up to 1:10) on age, gender, and VA enrollment year to individuals without RA. Lung cancers were identified from a VA oncology database and the National Death Index. Conditional Cox regression models assessed lung cancer risk adjusting for race, ethnicity, smoking status, Agent Orange exposure, and comorbidity burden among matched individuals. Several sensitivity analyses were performed. RESULTS We matched 72,795 patients with RA with 633,937 patients without RA (mean age 63 years; 88% male). Over 4,481,323 patient-years, 17,099 incident lung cancers occurred. RA was independently associated with an increased lung cancer risk (adjusted hazard ratio [aHR] 1.58 [95% confidence interval (CI) 1.52-1.64]), which persisted in never smokers (aHR 1.65 [95% CI 1.22-2.24]) and in those with incident RA (aHR 1.54 [95% CI 1.44-1.65]). Compared to non-RA controls, prevalent RA-ILD (n = 757) was more strongly associated with lung cancer risk (aHR 3.25 [95% CI 2.13-4.95]) than RA without ILD (aHR 1.57 [95% CI 1.51-1.64]). Analyses of both prevalent and incident RA-ILD produced similar results (RA-ILD vs non-RA aHR 2.88 [95% CI 2.45-3.40]). CONCLUSION RA was associated with a >50% increased risk of lung cancer, and those with RA-ILD represented a particularly high-risk group with an approximate three-fold increased risk. Increased lung cancer surveillance in RA, and especially RA-ILD, may be a useful strategy for reducing the burden posed by the leading cause of cancer death.
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Affiliation(s)
| | - Brent Luedders
- The Department of Veterans Affairs Nebraska-Western Iowa Health Care System and the University of Nebraska Medical Center, Omaha
| | - Austin Wheeler
- The Department of Veterans Affairs Nebraska-Western Iowa Health Care System and the University of Nebraska Medical Center, Omaha
| | - Tate M Johnson
- The Department of Veterans Affairs Nebraska-Western Iowa Health Care System and the University of Nebraska Medical Center, Omaha
| | - Yangyuna Yang
- The Department of Veterans Affairs Nebraska-Western Iowa Health Care System and the University of Nebraska Medical Center, Omaha
| | - Punyasha Roul
- The Department of Veterans Affairs Nebraska-Western Iowa Health Care System and the University of Nebraska Medical Center, Omaha
| | - Apar Kishor Ganti
- The Department of Veterans Affairs Nebraska-Western Iowa Health Care System and the University of Nebraska Medical Center, Omaha
| | | | - Brian C Sauer
- Salt Lake City Department of Veterans Affairs and the University of Utah
| | - Grant W Cannon
- Salt Lake City Department of Veterans Affairs and the University of Utah
| | - Joshua F Baker
- Corporal Michael J. Crescenz Department of Veterans Affairs and the University of Pennsylvania, Philadelphia
| | - Ted R Mikuls
- The Department of Veterans Affairs Nebraska-Western Iowa Health Care System and the University of Nebraska Medical Center, Omaha
| | - Bryant R England
- The Department of Veterans Affairs Nebraska-Western Iowa Health Care System and the University of Nebraska Medical Center, Omaha
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Zhao J, Dong Y, Clark E, Garcia JM, White DL, Kramer JR, Mazul AL, Hartman C, Chiao EY. Risk and predictors of penile cancer in US Veterans with HIV. AIDS 2024; 38:1395-1401. [PMID: 38652491 DOI: 10.1097/qad.0000000000003914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
OBJECTIVES People with HIV (PWH) may have an increased burden of penile cancer. We aimed to evaluate the risk of penile cancer in PWH compared with that of the general population. DESIGN We conducted a nationwide retrospective matched cohort study of penile cancer incidence among veterans with HIV (VWH) compared with veterans without HIV. METHODS We compared penile cancer incidence rates in 44 173 VWH to those of veterans without HIV ( N = 159 443; 4 : 1 matched in age). We used Cox regression models to estimate hazard ratios and 95% confidence intervals (CIs) for associations with HIV infection and for penile cancer risk factors. RESULTS HIV positivity was associated with an increased risk of penile cancer, with adjusted hazard ratios of 2.63 (95% CI 1.64-4.23) when adjusting for age, race/ethnicity, baseline BMI, smoking and alcohol use, economic means test, and history of condyloma. The risk increased to hazard ratio = 4.25 (95% CI 2.75-6.57) when adjusting for all factors except history of condyloma. Risk factors for penile cancer in VWH included lower nadir CD4 + count, less than 50% of follow-up time with undetectable HIV viral load, and history of condyloma. CONCLUSION VWH - particularly those with low CD4 + counts, detectable HIV viral loads, or history of condyloma - are at increased risk of penile cancer, suggesting the penile cancer prevention activities are needed in this population.
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Affiliation(s)
- Jing Zhao
- Section of Epidemiology and Population Sciences, Department of Medicine, Dan L. Duncan Comprehensive Cancer Center, Baylor College of Medicine
| | - Yongquan Dong
- Health Services Research, Michael E. DeBakey Center for Innovations in Quality, Effectiveness, and Safety (IQuESt)
- Section of Health Services Research, Department of Medicine
| | - Eva Clark
- Health Services Research, Michael E. DeBakey Center for Innovations in Quality, Effectiveness, and Safety (IQuESt)
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, TX
| | - Jose M Garcia
- Geriatric Research, Education and Clinical Center (GRECC), VA Puget Sound Healthcare System and Division of Gerontology & Geriatric Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Donna L White
- Health Services Research, Michael E. DeBakey Center for Innovations in Quality, Effectiveness, and Safety (IQuESt)
- Section of Health Services Research, Department of Medicine
- Dan L. Duncan Cancer Center, Baylor College of Medicine
- Texas Medical Center Digestive Disease Center, Baylor College of Medicine, Houston, TX
| | - Jennifer R Kramer
- Health Services Research, Michael E. DeBakey Center for Innovations in Quality, Effectiveness, and Safety (IQuESt)
- Section of Health Services Research, Department of Medicine
- Dan L. Duncan Cancer Center, Baylor College of Medicine
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine
| | - Angela L Mazul
- Department of Otolaryngology-Head and Neck Surgery, Washington University
- Division of Public Health Science, Department of Surgery, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christine Hartman
- Health Services Research, Michael E. DeBakey Center for Innovations in Quality, Effectiveness, and Safety (IQuESt)
| | - Elizabeth Y Chiao
- Division of Cancer Prevention and Population Sciences, Department of Epidemiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Zullig LL, Makarov D, Becker D, Dardashti N, Guzman I, Kelley MJ, Melnic I, Juarez Padilla J, Rojas S, Thomas J, Tumminello C, Sherman SE. Telehealth Research and Innovation for Veterans with Cancer: the THRIVE Center. J Natl Cancer Inst Monogr 2024; 2024:70-75. [PMID: 38924789 PMCID: PMC11207852 DOI: 10.1093/jncimonographs/lgae019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/10/2024] [Accepted: 04/09/2024] [Indexed: 06/28/2024] Open
Abstract
BACKGROUND In recent years the US health-care system has witnessed a substantial increase in telehealth use. Telehealth enhances health-care access and quality and may reduce costs. However, there is a concern that the shift from in-person to telehealth care delivery may differentially improve cancer care access and quality in certain clinical settings and for specific patient populations while potentially exacerbating disparities in care for others. Our National Cancer Institute-funded center, called Telehealth Research and Innovation for Veterans with Cancer (THRIVE), is focused on health equity for telehealth-delivered cancer care. We seek to understand how social determinants of telehealth-particularly race and ethnicity, poverty, and rurality-affect the use of telehealth. METHODS THRIVE draws from the Health Disparities Research Framework and the Consolidated Framework for Implementation Research. THRIVE consists of multiple cores that work synergistically to assess and understand health equity for telehealth-delivered cancer care. These include the Administrative Core, Research and Methods Core, Clinical Practice Network, and Pragmatic Trial. RESULTS As of October 2023, we identified and trained 5 THRIVE scholars, who are junior faculty beginning a research career. We have reviewed 20 potential pilot studies, funding 6. Additionally, in communication with our funders and advisory boards, we have adjusted our study design and analytic approach, ensuring feasibility while addressing our operational partners' needs. CONCLUSIONS THRIVE has several key strengths. First, the Veterans Health Administration's health-care system is large and diverse regarding health-care setting type and patient population. Second, we have access to longitudinal data, predating the COVID-19 pandemic, about telehealth use. Finally, equitable access to high-quality care for all veterans is a major tenet of the Veterans Health Administration health-care mission. As a result of these advantages, THRIVE can focus on isolating and evaluating the impact of social determinants of telehealth on equity in cancer care.
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Affiliation(s)
- 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, Durham, NC, USA
| | - Danil Makarov
- VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Daniel Becker
- VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Navid Dardashti
- VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Ivonne Guzman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA
| | - Michael J Kelley
- Department of Veterans Affairs, National Oncology Program, Washington, DC, USA
- Division of Medical Oncology, Duke University Medical Center, Durham, NC, USA
- Division of Hematology-Oncology, Durham Veterans Affairs Healthcare System, Durham, NC, USA
| | - Irina Melnic
- VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Janeth Juarez Padilla
- VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Sidney Rojas
- VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Jerry Thomas
- VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Christa Tumminello
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Healthcare System, Durham, NC, USA
| | - Scott E Sherman
- VA New York Harbor Healthcare System, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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Shah SC, Camargo MC, Lamm M, Bustamante R, Roumie CL, Wilson O, Halvorson AE, Greevy R, Liu L, Gupta S, Demb J. Impact of Helicobacter pylori Infection and Treatment on Colorectal Cancer in a Large, Nationwide Cohort. J Clin Oncol 2024; 42:1881-1889. [PMID: 38427927 DOI: 10.1200/jco.23.00703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 11/04/2023] [Accepted: 12/18/2023] [Indexed: 03/03/2024] Open
Abstract
PURPOSE Helicobacter pylori is the most common cause of infection-associated cancer worldwide. We aimed to evaluate the impact of H. pylori infection and treatment on colorectal cancer (CRC) incidence and mortality. PATIENTS US Veterans who completed H. pylori testing between 1999 and 2018. METHODS We conducted a retrospective cohort analysis among adults within the Veterans Health Administration who completed testing for H. pylori. The primary exposures were (1) H. pylori test result (positive/negative) and (2) H. pylori treatment (untreated/treated) among H. pylori-positive individuals. The primary outcomes were CRC incidence and mortality. Follow-up started at the first H. pylori testing and continued until the earliest of incident or fatal CRC, non-CRC death, or December 31, 2019. RESULTS Among 812,736 individuals tested for H. pylori, 205,178 (25.2%) tested positive. Being H. pylori-positive versus H. pylori-negative was associated with higher CRC incidence and mortality. H. pylori treatment versus no treatment was associated with lower CRC incidence and mortality (absolute risk reduction 0.23%-0.35%) through 15-year follow-up. Being H. pylori-positive versus H. pylori-negative was associated with an 18% (adjusted hazard ratio [adjusted HR], 1.18 [95% CI, 1.12 to 1.24]) and 12% (adjusted HR, 1.12 [95% CI, 1.03 to 1.21]) higher incident and fatal CRC risk, respectively. Individuals with untreated versus treated H. pylori infection had 23% (adjusted HR, 1.23 [95% CI, 1.13 to 1.34]) and 40% (adjusted HR, 1.40 [95% CI, 1.24 to 1.58]) higher incident and fatal CRC risk, respectively. The results were more pronounced in the analysis restricted to individuals with nonserologic testing. CONCLUSION H. pylori positivity may be associated with small but statistically significant higher CRC incidence and mortality; untreated individuals, especially those with confirmed active infection, appear to be most at risk.
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Affiliation(s)
- Shailja C Shah
- Division of Gastroenterology, VA San Diego Healthcare System, San Diego, CA
- Division of Gastroenterology, University of California, San Diego, San Diego, CA
| | - M Constanza Camargo
- Division of Cancer Epidemiology and Genetics, National Cancer Institute, National Institutes of Health, Rockville, MD
| | - Mark Lamm
- Division of Gastroenterology, VA San Diego Healthcare System, San Diego, CA
| | - Ranier Bustamante
- Division of Gastroenterology, VA San Diego Healthcare System, San Diego, CA
- Division of Gastroenterology, University of California, San Diego, San Diego, CA
| | - Christianne L Roumie
- Department of Medicine, VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, TN
- Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
- Department of Medicine, VA Geriatrics Research Education and Clinical Center (GRECC), VA Tennessee Valley Health System, Nashville, TN
| | - Otis Wilson
- Department of Medicine, VA Tennessee Valley Healthcare System, Clinical Services Research and Development, Nashville, TN
| | - Alese E Halvorson
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Robert Greevy
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Lin Liu
- Division of Biostatistics and Bioinformatics, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, San Diego, CA
| | - Samir Gupta
- Division of Gastroenterology, VA San Diego Healthcare System, San Diego, CA
- Division of Gastroenterology, University of California, San Diego, San Diego, CA
| | - Joshua Demb
- Division of Gastroenterology, University of California, San Diego, San Diego, CA
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Mezzacappa C, Larki NR, Skanderson M, Park LS, Brandt C, Hauser RG, Justice A, Yang YX, Wang L. Development and Validation of Case-Finding Algorithms to Identify Pancreatic Cancer in the Veterans Health Administration. Dig Dis Sci 2024; 69:1507-1513. [PMID: 38453743 DOI: 10.1007/s10620-024-08324-w] [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: 09/12/2023] [Accepted: 01/29/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND Survival in pancreatic ductal adenocarcinoma (PDAC) remains poor due to late diagnosis. Electronic Health Records (EHRs) can be used to study this rare disease, but validated algorithms to identify PDAC in the United States EHRs do not currently exist. AIMS To develop and validate an algorithm using Veterans Health Administration (VHA) EHR data for the identification of patients with PDAC. METHODS We developed two algorithms to identify patients with PDAC in the VHA from 2002 to 2023. The algorithms required diagnosis of exocrine pancreatic cancer in either ≥ 1 or ≥ 2 of the following domains: (i) the VA national cancer registry, (ii) an inpatient encounter, or (iii) an outpatient encounter in an oncology setting. Among individuals identified with ≥ 1 of the above criteria, a random sample of 100 were reviewed by three gastroenterologists to adjudicate PDAC status. We also adjudicated fifty patients not qualifying for either algorithm. These patients died as inpatients and had alkaline phosphatase values within the interquartile range of patients who met ≥ 2 of the above criteria for PDAC. These expert adjudications allowed us to calculate the positive and negative predictive value of the algorithms. RESULTS Of 10.8 million individuals, 25,533 met ≥ 1 criteria (PPV 83.0%, kappa statistic 0.93) and 13,693 individuals met ≥ 2 criteria (PPV 95.2%, kappa statistic 1.00). The NPV for PDAC was 100%. CONCLUSIONS An algorithm incorporating readily available EHR data elements to identify patients with PDAC achieved excellent PPV and NPV. This algorithm is likely to enable future epidemiologic studies of PDAC.
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Affiliation(s)
- Catherine Mezzacappa
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06520, USA
| | - Navid Rahimi Larki
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06520, USA
| | | | - Lesley S Park
- Department of Epidemiology and Population Health, Stanford School of Medicine, Stanford, CA, USA
| | - Cynthia Brandt
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Ronald G Hauser
- VA Connecticut Healthcare System, West Haven, CT, USA
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Amy Justice
- VA Connecticut Healthcare System, West Haven, CT, USA
- Section of General Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- School of Public Health, Yale University, New Haven, CT, USA
| | - Yu-Xiao Yang
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Louise Wang
- Section of Digestive Diseases, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, 06520, USA.
- VA Connecticut Healthcare System, West Haven, CT, USA.
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Ramos K, King HA, Gladney MN, Woolson SL, Coffman C, Bosworth HB, Porter LS, Hastings SN. Understanding veterans' experiences with lung cancer and psychological distress: A multimethod approach. Psychol Serv 2024:2024-59433-001. [PMID: 38436646 PMCID: PMC11371941 DOI: 10.1037/ser0000839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2024]
Abstract
Psychological distress while coping with cancer is a highly prevalent and yet underrecognized and burdensome adverse effect of cancer diagnosis and treatment. Left unaddressed, psychological distress can further exacerbate poor mental health, negatively influence health management behaviors, and lead to a worsening quality of life. This multimethod study primarily focused on understanding veterans' psychological distress and personal experiences living with lung cancer (an underrepresented patient population). In a sample of 60 veterans diagnosed with either nonsmall cell lung cancer (NSCLC) or small cell lung cancer (SCLC), we found that distress is common across clinical psychology measures of depression (37% [using the Patient Health Questionnaire, PHQ-9 measure]), anxiety (35% [using the Generalized Anxiety Disorder, GAD-7 measure]), and cancer-related posttraumatic stress (13% [using the Posttraumatic Stress Symptom Checklist measure]). A total of 23% of the sample endorsed distress scores on two or more mental health screeners. Using a broader cancer-specific distress measure (National Comprehensive Cancer Network), 67% of our sample scored above the clinical cutoff (i.e., ≥ 3), and in the follow-up symptom checklist of the National Comprehensive Cancer Network measure, a majority endorsed feeling sadness (75%), worry (73%), and depression (60%). Qualitative analysis with a subset of 25 veterans highlighted that psychological distress is common, variable in nature, and quite bothersome. Future research should (a) identify veterans at risk for distress while living with lung cancer and (b) test supportive mental health interventions to target psychological distress among this vulnerable veteran population. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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Affiliation(s)
- Katherine Ramos
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Heather A King
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Micaela N Gladney
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Sandra L Woolson
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Cynthia Coffman
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham VA Health Care System
| | - Hayden B Bosworth
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Laura S Porter
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - S Nicole Hastings
- Geriatric Research, Education, and Clinical Center, Durham VA Health Care System
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Lovejoy LA, Shriver CD, Ellsworth RE. Cancer Incidence and Etiology in the Active Duty Population of U.S. Military. Mil Med 2024; 189:e58-e65. [PMID: 36239575 DOI: 10.1093/milmed/usac297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 08/09/2022] [Accepted: 09/19/2022] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION As members of the military, all active duty service members (ADS) must meet physical fitness requirements and are provided with equal-access healthcare through the DoD. In addition, 92% of ADS are ≤40 years of age. Together, these characteristics suggest that ADS represent a healthy population that may have a low risk of cancer. Each year, however, >800 ADS are diagnosed with cancer and the resulting in time off for treatment, reassignment, or medical retirement may significantly impact force readiness. MATERIAL AND METHODS Relevant literature was identified by searching the PubMed database using search terms ACTIVE DUTY and CANCER. Only articles written in English were included. RESULTS Melanoma is the most common cancer in ADS, while testicular cancer is the most common cancer in males and breast cancer is the most common in females. Cancer incidence patterns in ADS differ from those in the general U.S. population and from military veterans. Tumor etiology in ADS may be influenced by military-enriched exposures such as prolonged use of oral contraceptives, suboptimal use of sunscreen, exposure to volatile organic compounds, or germline predisposition/family history. CONCLUSIONS The etiology of cancer within ADS remains largely unknown. A number of new research programs may provide the means to improve understanding of the etiology of cancer in ADS. Together, these efforts will improve prevention, early detection, and clinical management, thus improving the outcomes of ADS and preserving force readiness.
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Affiliation(s)
- Leann A Lovejoy
- Clinical Breast Care Project, Chan Soon-Shiong Institute for Molecular Medicine at Windber, Windber, PA 15963, USA
| | - Craig D Shriver
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
| | - Rachel E Ellsworth
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20889, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Windber, PA 15963, USA
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Zullig LL, Jazowski SA, Chawla N, Williams CD, Winski D, Slatore CG, Clary A, Rasmussen KM, Ticknor LM, Kelley MJ. Summary of Veterans Health Administration Cancer Data Sources. JOURNAL OF REGISTRY MANAGEMENT 2024; 51:21-28. [PMID: 38881982 PMCID: PMC11178113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/18/2024]
Abstract
Objectives The Veterans Health Administration (VHA) is a leader in generating transformational research across the cancer care continuum. Given the extensive body of cancer-related literature utilizing VHA data, our objectives are to: (1) describe the VHA data sources available for conducting cancer-related research, and (2) discuss examples of published cancer research using each data source. Methods We identified commonly used data sources within the VHA and reviewed previously published cancer-related research that utilized these data sources. In addition, we reviewed VHA clinical and health services research web pages and consulted with a multidisciplinary group of cancer researchers that included hematologist/oncologists, health services researchers, and epidemiologists. Results Commonly used VHA cancer data sources include the Veterans Affairs (VA) Cancer Registry System, the VA Central Cancer Registry (VACCR), the Corporate Data Warehouse (CDW)-Oncology Raw Domain (subset of data within the CDW), and the VA Cancer Care Cube (Cube). While no reference standard exists for cancer case ascertainment, the VACCR provides a systematic approach to ensure the complete capture of clinical history, cancer diagnosis, and treatment. Like many population-based cancer registries, a significant time lag exists due to constrained resources, which may make it best suited for historical epidemiologic studies. The CDW-Oncology Raw Domain and the Cube contain national information on incident cancers which may be useful for case ascertainment and prospective recruitment; however, additional resources may be needed for data cleaning. Conclusions The VHA has a wealth of data sources available for cancer-related research. It is imperative that researchers recognize the advantages and disadvantages of each data source to ensure their research questions are addressed appropriately.
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Affiliation(s)
- Leah L. Zullig
- Durham VA Health Care System, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Shelley A. Jazowski
- Duke University School of Medicine, Durham, North Carolina
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Neetu Chawla
- Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), VA Greater Los Angeles, Los Angeles, California
| | - Christina D. Williams
- Durham VA Health Care System, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - David Winski
- Durham VA Health Care System, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Christopher G. Slatore
- VA Portland Health Care System, Portland, Oregon
- Oregon Health & Science University, Portland, Oregon
| | - Alecia Clary
- Durham VA Health Care System, Durham, North Carolina
| | | | | | - Michael J. Kelley
- Durham VA Health Care System, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
- Department of Veterans Affairs, Washington, DC
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Tohmasi S, Eaton DB, Heiden BT, Rossetti NE, Rasi V, Chang SH, Yan Y, Gopukumar D, Patel MR, Meyers BF, Kozower BD, Puri V, Schoen MW. Inhaled medications for chronic obstructive pulmonary disease predict surgical complications and survival in stage I non-small cell lung cancer. J Thorac Dis 2023; 15:6544-6554. [PMID: 38249867 PMCID: PMC10797395 DOI: 10.21037/jtd-23-1273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 10/20/2023] [Indexed: 01/23/2024]
Abstract
Background Lung function is routinely assessed prior to surgical resection for non-small cell lung cancer (NSCLC). Further assessment of chronic obstructive pulmonary disease (COPD) using inhaled COPD medications to determine disease severity, a readily available metric of disease burden, may predict postoperative outcomes and overall survival (OS) in lung cancer patients undergoing surgery. Methods We retrospectively evaluated clinical stage I NSCLC patients receiving surgical treatment within the Veterans Health Administration from 2006-2016 to determine the relationship between number and type of inhaled COPD medications (short- and long-acting beta2-agonists, muscarinic antagonists, or corticosteroids prescribed within 1 year before surgery) and postoperative outcomes including OS using multivariable models. We also assessed the relationship between inhaled COPD medications, disease severity [measured by forced expiratory volume in 1 second (FEV1)], and diagnosis of COPD. Results Among 9,741 veterans undergoing surgery for clinical stage I NSCLC, patients with COPD were more likely to be prescribed inhaled medications than those without COPD [odds ratio (OR) =5.367, 95% confidence interval (CI): 4.886-5.896]. Increased severity of COPD was associated with increased number of prescribed inhaled COPD medications (P<0.0001). The number of inhaled COPD medications was associated with prolonged hospital stay [adjusted OR (aOR) =1.119, 95% CI: 1.076-1.165), more major complications (aOR =1.117, 95% CI: 1.074-1.163), increased 90-day mortality (aOR =1.088, 95% CI: 1.013-1.170), and decreased OS [adjusted hazard ratio (aHR) =1.061, 95% CI: 1.042-1.080]. In patients with FEV1 ≥80% predicted, greater number of prescribed inhaled COPD medications was associated with increased 30-day mortality (aOR =1.265, 95% CI: 1.062-1.505), prolonged hospital stay (aOR =1.130, 95% CI: 1.051-1.216), more major complications (aOR =1.147, 95% CI: 1.064-1.235), and decreased OS (aHR =1.058, 95% CI: 1.022-1.095). When adjusting for other drug classes and covariables, short-acting beta2-agonists were associated with increased 90-day mortality (aOR =1.527, 95% CI: 1.120-2.083) and decreased OS (aHR =1.087, 95% CI: 1.005-1.177). Conclusions In patients with early-stage NSCLC, inhaled COPD medications prescribed prior to surgery were associated with both short- and long-term outcomes, including in patients with FEV1 ≥80% predicted. Routine assessment of COPD medications may be a simple method to quantify operative risk in early-stage NSCLC patients.
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Affiliation(s)
- Steven Tohmasi
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel B. Eaton
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
| | - Brendan T. Heiden
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Nikki E. Rossetti
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Valerio Rasi
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Su-Hsin Chang
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Yan Yan
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Deepika Gopukumar
- Department of Health and Clinical Outcomes Research, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Mayank R. Patel
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Benjamin D. Kozower
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
| | - Martin W. Schoen
- Veterans Affairs St. Louis Health Care System, St. Louis, MO, USA
- Division of Hematology and Medical Oncology, Department of Internal Medicine, Saint Louis University School of Medicine, St. Louis, MO, USA
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10
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Englum BR, Sahoo S, Mayorga-Carlin M, Hayssen H, Siddiqui T, Turner DJ, Sorkin JD, Lal BK. Growing Deficit in New Cancer Diagnoses 2 Years Into the COVID-19 Pandemic: A National Multicenter Study. Ann Surg Oncol 2023; 30:8509-8518. [PMID: 37695458 PMCID: PMC10939008 DOI: 10.1245/s10434-023-14217-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023]
Abstract
BACKGROUND Large decreases in cancer diagnoses were seen early in the COVID-19 pandemic. However, the evolution of these deficits since the end of 2020 and the advent of widespread vaccination is unknown. METHODS This study examined data from the Veterans Health Administration (VA) from 1 January 2018 through 28 February 2022 and identified patients with screening or diagnostic procedures or new cancer diagnoses for the four most common cancers in the VA health system: prostate, lung, colorectal, and bladder cancers. Monthly procedures and new diagnoses were calculated, and the pre-COVID era (January 2018 to February 2020) was compared with the COVID era (March 2020 to February 2022). RESULTS The study identified 2.5 million patients who underwent a diagnostic or screening procedure related to the four cancers. A new cancer was diagnosed for 317,833 patients. During the first 2 years of the pandemic, VA medical centers performed 13,022 fewer prostate biopsies, 32,348 fewer cystoscopies, and 200,710 fewer colonoscopies than in 2018-2019. These persistent deficits added a cumulative deficit of nearly 19,000 undiagnosed prostate cancers and 3300 to 3700 undiagnosed cancers each for lung, colon, and bladder. Decreased diagnostic and screening procedures correlated with decreased new diagnoses of cancer, particularly cancer of the prostate (R = 0.44) and bladder (R = 0.27). CONCLUSION Disruptions in new diagnoses of four common cancers (prostate, lung, bladder, and colorectal) seen early in the COVID-19 pandemic have persisted for 2 years. Although reductions improved from the early pandemic, new reductions during the Delta and Omicron waves demonstrate the continued impact of the COVID-19 pandemic on cancer care.
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Affiliation(s)
- Brian R Englum
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shalini Sahoo
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Minerva Mayorga-Carlin
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Hilary Hayssen
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Tariq Siddiqui
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - Douglas J Turner
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA
| | - John D Sorkin
- Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Brajesh K Lal
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA.
- Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA.
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11
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Rubenstein JH, Fontaine S, MacDonald PW, Burns JA, Evans RR, Arasim ME, Chang JW, Firsht EM, Hawley ST, Saini SD, Wallner LP, Zhu J, Waljee AK. Predicting Incident Adenocarcinoma of the Esophagus or Gastric Cardia Using Machine Learning of Electronic Health Records. Gastroenterology 2023; 165:1420-1429.e10. [PMID: 37597631 PMCID: PMC11013733 DOI: 10.1053/j.gastro.2023.08.011] [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: 03/13/2023] [Revised: 07/11/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND & AIMS Tools that can automatically predict incident esophageal adenocarcinoma (EAC) and gastric cardia adenocarcinoma (GCA) using electronic health records to guide screening decisions are needed. METHODS The Veterans Health Administration (VHA) Corporate Data Warehouse was accessed to identify Veterans with 1 or more encounters between 2005 and 2018. Patients diagnosed with EAC (n = 8430) or GCA (n = 2965) were identified in the VHA Central Cancer Registry and compared with 10,256,887 controls. Predictors included demographic characteristics, prescriptions, laboratory results, and diagnoses between 1 and 5 years before the index date. The Kettles Esophageal and Cardia Adenocarcinoma predictioN (K-ECAN) tool was developed and internally validated using simple random sampling imputation and extreme gradient boosting, a machine learning method. Training was performed in 50% of the data, preliminary validation in 25% of the data, and final testing in 25% of the data. RESULTS K-ECAN was well-calibrated and had better discrimination (area under the receiver operating characteristic curve [AuROC], 0.77) than previously validated models, such as the Nord-Trøndelag Health Study (AuROC, 0.68) and Kunzmann model (AuROC, 0.64), or published guidelines. Using only data from between 3 and 5 years before index diminished its accuracy slightly (AuROC, 0.75). Undersampling men to simulate a non-VHA population, AUCs of the Nord-Trøndelag Health Study and Kunzmann model improved, but K-ECAN was still the most accurate (AuROC, 0.85). Although gastroesophageal reflux disease was strongly associated with EAC, it contributed only a small proportion of gain in information for prediction. CONCLUSIONS K-ECAN is a novel, internally validated tool predicting incident EAC and GCA using electronic health records data. Further work is needed to validate K-ECAN outside VHA and to assess how best to implement it within electronic health records.
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Affiliation(s)
- Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan.
| | - Simon Fontaine
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, Michigan
| | - Peter W MacDonald
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, Michigan
| | - Jennifer A Burns
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Richard R Evans
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Maria E Arasim
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Elizabeth M Firsht
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan
| | - Sarah T Hawley
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ji Zhu
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, Michigan
| | - Akbar K Waljee
- Veterans Affairs Center for Clinical Management Research, Lieutenant Colonel Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan
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12
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Ostrom QT, Price M, Neff C, Cioffi G, Waite KA, Kruchko C, Barnholtz-Sloan JS. CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2016-2020. Neuro Oncol 2023; 25:iv1-iv99. [PMID: 37793125 PMCID: PMC10550277 DOI: 10.1093/neuonc/noad149] [Citation(s) in RCA: 101] [Impact Index Per Article: 101.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023] Open
Abstract
The Central Brain Tumor Registry of the United States (CBTRUS), in collaboration with the Centers for Disease Control and Prevention and the National Cancer Institute, is the largest population-based registry focused exclusively on primary brain and other central nervous system (CNS) tumors in the United States (US) and represents the entire US population. This report contains the most up-to-date population-based data on primary brain tumors available and supersedes all previous CBTRUS reports in terms of completeness and accuracy. All rates are age-adjusted using the 2000 US standard population and presented per 100,000 population. The average annual age-adjusted incidence rate (AAAIR) of all malignant and non-malignant brain and other CNS tumors was 24.83 per 100,000 population (malignant AAAIR=6.94 and non-malignant AAAIR=17.88). This overall rate was higher in females compared to males (27.85 versus 21.62 per 100,000) and non-Hispanic persons compared to Hispanic persons (25.24 versus 22.61 per 100,000). Gliomas accounted for 26.3% of all tumors. The most commonly occurring malignant brain and other CNS histopathology was glioblastoma (14.2% of all tumors and 50.9% of all malignant tumors), and the most common predominantly non-malignant histopathology was meningioma (40.8% of all tumors and 56.2% of all non-malignant tumors). Glioblastomas were more common in males, and meningiomas were more common in females. In children and adolescents (ages 0-19 years), the incidence rate of all primary brain and other CNS tumors was 6.13 per 100,000 population. There were 86,030 deaths attributed to malignant brain and other CNS tumors between 2016 and 2020. This represents an average annual mortality rate of 4.42 per 100,000 population and an average of 17,206 deaths per year. The five-year relative survival rate following diagnosis of a malignant brain and other CNS tumor was 35.7%, for a non-malignant brain and other CNS tumor the five-year relative survival rate was 91.8%.
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Affiliation(s)
- Quinn T Ostrom
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, NC, USA
| | - Mackenzie Price
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Corey Neff
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
| | - Gino Cioffi
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, MD, USA
| | - Kristin A Waite
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, MD, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, IL, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, MD, USA
- Center for Biomedical Informatics & Information Technology (CBIIT), National Cancer Institute, Bethesda, MD, USA
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13
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Thanawala SU, Kaplan DE, Falk GW, Beveridge CA, Schaubel D, Serper M, Yang YX. Antibiotic Exposure is Associated With a Risk of Esophageal Adenocarcinoma. Clin Gastroenterol Hepatol 2023; 21:2817-2824.e4. [PMID: 36967101 PMCID: PMC10518027 DOI: 10.1016/j.cgh.2023.03.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 03/02/2023] [Accepted: 03/10/2023] [Indexed: 04/23/2023]
Abstract
BACKGROUND & AIMS Antibiotic exposure leads to changes in the gut microbiota. Our objective was to evaluate the association between antibiotic exposure and esophageal adenocarcinoma (EAC) risk. METHODS We performed a nested case-control study using data from the Veterans Health Administration from 2004 through 2020. The case group consisted of patients who received an incident diagnosis of EAC. For each case, up to 20 matched controls were selected using incidence density sampling. Our primary exposure of interest was any oral or intravenous antibiotic use. Our secondary exposures included cumulative number of days of exposure and classification of antibiotics by various subgroups. Conditional logistic regression was used to estimate the crude and adjusted odds ratios (aORs) for the risk of EAC associated with antibiotic exposure. RESULTS The case-control analysis included 8226 EAC cases and 140,670 matched controls. Exposure to any antibiotic was associated with an aOR for EAC of 1.74 (95% confidence interval [CI], 1.65-1.83) vs no antibiotic exposure. Compared with no antibiotic exposure, the aOR for EAC was 1.63 (95% CI, 1.52-1.74; P < .001) for cumulative exposure to any antibiotic for 1 to 15 days; 1.77 (95% CI, 1.65-1.89; P < 0 .001) for 16 to 47 days; and 1.87 (95% CI, 1.75-2.01; P < .001) for ≥48 days, respectively (P for trend < .001). CONCLUSION Exposure to any antibiotic is associated with an increased risk of EAC, and this risk increases as the cumulative days of exposure increase. This novel finding is hypothesis-generating for potential mechanisms that may play a role in the development or progression of EAC.
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Affiliation(s)
- Shivani U Thanawala
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.
| | - David E Kaplan
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Veterans Health Administration, Philadelphia, Pennsylvania
| | - Gary W Falk
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Claire A Beveridge
- Department of Gastroenterology, Hepatology, and Nutrition, Digestive Diseases and Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Douglas Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marina Serper
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Veterans Health Administration, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Yu-Xiao Yang
- Division of Gastroenterology and Hepatology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Division of Gastroenterology, Veterans Health Administration, Philadelphia, Pennsylvania; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Casey Y, Demb J, Enwerem N, Liu L, Jackson C, Earles A, Bustamante R, Mahata S, Shah S, Gupta S. Risk of Incident and Fatal Colorectal Cancer After Young-Onset Adenoma Diagnosis: A National Cohort Study. Am J Gastroenterol 2023; 118:1656-1663. [PMID: 37053557 PMCID: PMC10524098 DOI: 10.14309/ajg.0000000000002296] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 03/27/2023] [Indexed: 04/15/2023]
Abstract
INTRODUCTION Colorectal cancer (CRC) incidence and mortality rates are increasing in adults aged <50 years. Young-onset adenoma (YOA)-adenoma detected in adults younger than 50 years-may signify increased CRC risk, but this association has not been widely studied. Our aim was to compare the risk of incident and fatal CRC in adults aged <50 years with YOA diagnosis compared with those with a normal colonoscopy. METHODS We conducted a cohort study of US Veterans aged 18-49 years who received colonoscopy between 2005 and 2016. The primary exposure of interest was YOA. Primary outcomes included incident and fatal CRC. We used Kaplan-Meier curves to calculate cumulative incident and fatal CRC risk and Cox models to examine relative CRC risk. RESULTS The study cohort included 54,284 Veterans aged <50 years exposed to colonoscopy, among whom 13% (n = 7,233) had YOA at start of follow-up. Cumulative 10-year CRC incidence was 0.11% (95% confidence interval [CI]: 0.00%-0.27%) after any adenoma diagnosis, 0.18% (95% CI: 0.02%-0.53%) after advanced YOA diagnosis, 0.10% (95% CI: 0.00%-0.28%) after nonadvanced adenoma diagnosis, and 0.06% (95% CI: 0.02%-0.09%) after normal colonoscopy. Veterans with advanced adenoma had 8-fold greater incident CRC risk than those with normal colonoscopy (hazard ratio: 8.0; 95% CI: 1.8-35.6). Across groups, no differences in fatal CRC risk were observed. DISCUSSION Young-onset advanced adenoma diagnosis was associated with 8-fold increased incident CRC risk compared with normal colonoscopy. However, cumulative CRC incidence and mortality at 10 years among individuals with either young onset non-advanced or advanced adenoma diagnosis were both relatively low.
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Affiliation(s)
- Yas Casey
- VA Loma Linda Healthcare System, Loma Linda, CA, USA
- Herbert Wertheim School of Public Health and Human Longevity Science.University of California, San Diego, La Jolla, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Joshua Demb
- Herbert Wertheim School of Public Health and Human Longevity Science.University of California, San Diego, La Jolla, CA, USA
- Jennifer Moreno VA San Diego Healthcare System, San Diego, CA, USA
| | | | - Lin Liu
- Herbert Wertheim School of Public Health and Human Longevity Science.University of California, San Diego, La Jolla, CA, USA
- Jennifer Moreno VA San Diego Healthcare System, San Diego, CA, USA
| | - Christian Jackson
- VA Loma Linda Healthcare System, Loma Linda, CA, USA
- Loma Linda University School of Medicine, Loma Linda, CA, USA
| | - Ashley Earles
- Jennifer Moreno VA San Diego Healthcare System, San Diego, CA, USA
| | - Ranier Bustamante
- Herbert Wertheim School of Public Health and Human Longevity Science.University of California, San Diego, La Jolla, CA, USA
- Jennifer Moreno VA San Diego Healthcare System, San Diego, CA, USA
| | | | - Shailja Shah
- Herbert Wertheim School of Public Health and Human Longevity Science.University of California, San Diego, La Jolla, CA, USA
- Jennifer Moreno VA San Diego Healthcare System, San Diego, CA, USA
| | - Samir Gupta
- Herbert Wertheim School of Public Health and Human Longevity Science.University of California, San Diego, La Jolla, CA, USA
- Jennifer Moreno VA San Diego Healthcare System, San Diego, CA, USA
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15
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Hoffman RM, Lang JA, Bailey GJ, Merchant JA, Seaman AS, Newbury EA, Sanchez R, Volk RJ, Lowenstein LM, Averill SL. Implementing a Telehealth Shared Counseling and Decision-Making Visit for Lung Cancer Screening in a Veterans Affairs Medical Center. Fed Pract 2023; 40:S83-S90. [PMID: 38021099 PMCID: PMC10681016 DOI: 10.12788/fp.0403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Background Veterans suffer substantial morbidity and mortality from lung cancer. Lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce mortality. Guidelines recommend counseling and shared decision-making (SDM) to address the benefits and harms of screening and the importance of tobacco cessation before patients undergo screening. Observations We implemented a centralized LCS program at the Iowa City Veterans Affairs Medical Center with a nurse program coordinator (NPC)-led telephone visit. Our multidisciplinary team ensured that veterans referred from primary care met eligibility criteria, that LDCT results were correctly coded by radiology, and that pulmonary promptly evaluated abnormal LDCT. The NPC mailed a decision aid to the veteran and scheduled a SDM telephone visit. We surveyed veterans after the visit using validated measures to assess knowledge, decisional conflict, and quality of decision making. We conducted 105 SDM visits, and 91 veterans agreed to LDCT. Overall, 84% of veterans reported no decisional conflict, and 59% reported high-quality decision making. While most veterans correctly answered questions about the harms of radiation, false-positive results, and overdiagnosis, few knew when to stop screening, and most overestimated the benefit of screening and the predictive value of an abnormal scan. Tobacco cessation interventions were offered to 72 currently smoking veterans. Conclusions We successfully implemented an LCS program that provides SDM and tobacco cessation support using a centralized telehealth model. While veterans were confident about screening decisions, knowledge testing indicated important deficits, and many did not engage meaningfully in SDM. Clinicians should frame the decision as patient centered at the time of referral, highlight the importance of SDM, and be able to provide adequate decision support.
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Affiliation(s)
- Richard M. Hoffman
- Iowa City Veterans Affairs Medical Center, Iowa
- University of Iowa Carver College of Medicine, Iowa City
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City
| | - Julie A. Lang
- Veterans Rural Health Resource Center, Office of Rural Health, Veterans Health Administration, Iowa City, Iowa
| | - George J. Bailey
- Veterans Rural Health Resource Center, Office of Rural Health, Veterans Health Administration, Iowa City, Iowa
| | - James A. Merchant
- Veterans Rural Health Resource Center, Office of Rural Health, Veterans Health Administration, Iowa City, Iowa
| | - Aaron S. Seaman
- Iowa City Veterans Affairs Medical Center, Iowa
- University of Iowa Carver College of Medicine, Iowa City
- Holden Comprehensive Cancer Center, University of Iowa, Iowa City
| | - Elizabeth A. Newbury
- Veterans Rural Health Resource Center, Office of Rural Health, Veterans Health Administration, Iowa City, Iowa
| | - Rolando Sanchez
- Iowa City Veterans Affairs Medical Center, Iowa
- University of Iowa Carver College of Medicine, Iowa City
| | - Robert J. Volk
- The University of Texas MD Anderson Cancer Center, Houston
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Williams SB, Janes JL, Howard LE, Yang R, De Hoedt AM, Baillargeon JG, Kuo YF, Tyler DS, Terris MK, Freedland SJ. Exposure to Agent Orange and Risk of Bladder Cancer Among US Veterans. JAMA Netw Open 2023; 6:e2320593. [PMID: 37368398 DOI: 10.1001/jamanetworkopen.2023.20593] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Abstract
Importance To date, limited data exist regarding the association between Agent Orange and bladder cancer, and the Institute of Medicine concluded that the association between exposure to Agent Orange and bladder cancer outcomes is an area of needed research. Objective To examine the association between bladder cancer risk and exposure to Agent Orange among male Vietnam veterans. Design, Setting, and Participants This nationwide Veterans Affairs (VA) retrospective cohort study assesses the association between exposure to Agent Orange and bladder cancer risk among 2 517 926 male Vietnam veterans treated in the VA Health System nationwide from January 1, 2001, to December 31, 2019. Statistical analysis was performed from December 14, 2021, to May 3, 2023. Exposure Agent Orange. Main Outcomes and Measures Veterans exposed to Agent Orange were matched in a 1:3 ratio to unexposed veterans on age, race and ethnicity, military branch, and year of service entry. Risk of bladder cancer was measured by incidence. Aggressiveness of bladder cancer was measured by muscle-invasion status using natural language processing. Results Among the 2 517 926 male veterans (median age at VA entry, 60.0 years [IQR, 56.0-64.0 years]) who met inclusion criteria, there were 629 907 veterans (25.0%) with Agent Orange exposure and 1 888 019 matched veterans (75.0%) without Agent Orange exposure. Agent Orange exposure was associated with a significantly increased risk of bladder cancer, although the association was very slight (hazard ratio [HR], 1.04; 95% CI, 1.02-1.06). When stratified by median age at VA entry, Agent Orange was not associated with bladder cancer risk among veterans older than the median age but was associated with increased bladder cancer risk among veterans younger than the median age (HR, 1.07; 95% CI, 1.04-1.10). Among veterans with a diagnosis of bladder cancer, Agent Orange was associated with lower odds of muscle-invasive bladder cancer (odds ratio [OR], 0.91; 95% CI, 0.85-0.98). Conclusions and Relevance In this cohort study among male Vietnam veterans, there was a modestly increased risk of bladder cancer-but not aggressiveness of bladder cancer-among those exposed to Agent Orange. These findings suggest an association between Agent Orange exposure and bladder cancer, although the clinical relevance of this was unclear.
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Affiliation(s)
- Stephen B Williams
- Division of Urology, Department of Surgery, The University of Texas Medical Branch at Galveston
- Urology Section, Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Jessica L Janes
- Urology Section, Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Lauren E Howard
- Urology Section, Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Duke Cancer Institute Biostatistics Shared Resource, Durham, North Carolina
| | - Ruixin Yang
- Urology Section, Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Amanda M De Hoedt
- Urology Section, Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina
| | - Jacques G Baillargeon
- Division of Epidemiology, Department of Medicine, Sealy Center on Aging, The University of Texas Medical Branch at Galveston
| | - Yong-Fang Kuo
- Division of Epidemiology, Department of Medicine, Sealy Center on Aging, The University of Texas Medical Branch at Galveston
| | - Douglas S Tyler
- Department of Surgery, The University of Texas Medical Branch at Galveston
| | - Martha K Terris
- Section of Urology, Augusta University, Augusta, Georgia
- Section of Urology, Charlie Norwood Veterans Affairs Medical Center, Augusta, Georgia
| | - Stephen J Freedland
- Urology Section, Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina
- Department of Urology, Cedars-Sinai Medical Center, Los Angeles, California
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Placido D, Yuan B, Hjaltelin JX, Zheng C, Haue AD, Chmura PJ, Yuan C, Kim J, Umeton R, Antell G, Chowdhury A, Franz A, Brais L, Andrews E, Marks DS, Regev A, Ayandeh S, Brophy MT, Do NV, Kraft P, Wolpin BM, Rosenthal MH, Fillmore NR, Brunak S, Sander C. A deep learning algorithm to predict risk of pancreatic cancer from disease trajectories. Nat Med 2023; 29:1113-1122. [PMID: 37156936 PMCID: PMC10202814 DOI: 10.1038/s41591-023-02332-5] [Citation(s) in RCA: 52] [Impact Index Per Article: 52.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/31/2023] [Indexed: 05/10/2023]
Abstract
Pancreatic cancer is an aggressive disease that typically presents late with poor outcomes, indicating a pronounced need for early detection. In this study, we applied artificial intelligence methods to clinical data from 6 million patients (24,000 pancreatic cancer cases) in Denmark (Danish National Patient Registry (DNPR)) and from 3 million patients (3,900 cases) in the United States (US Veterans Affairs (US-VA)). We trained machine learning models on the sequence of disease codes in clinical histories and tested prediction of cancer occurrence within incremental time windows (CancerRiskNet). For cancer occurrence within 36 months, the performance of the best DNPR model has area under the receiver operating characteristic (AUROC) curve = 0.88 and decreases to AUROC (3m) = 0.83 when disease events within 3 months before cancer diagnosis are excluded from training, with an estimated relative risk of 59 for 1,000 highest-risk patients older than age 50 years. Cross-application of the Danish model to US-VA data had lower performance (AUROC = 0.71), and retraining was needed to improve performance (AUROC = 0.78, AUROC (3m) = 0.76). These results improve the ability to design realistic surveillance programs for patients at elevated risk, potentially benefiting lifespan and quality of life by early detection of this aggressive cancer.
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Affiliation(s)
- Davide Placido
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo Yuan
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of MIT and Harvard, Boston, MA, USA
| | - Jessica X Hjaltelin
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Chunlei Zheng
- VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Amalie D Haue
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Piotr J Chmura
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Chen Yuan
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jihye Kim
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Renato Umeton
- Dana-Farber Cancer Institute, Boston, MA, USA
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Massachusetts Institute of Technology, Cambridge, MA, USA
- Weill Cornell Medicine, New York City, NY, USA
| | | | | | - Alexandra Franz
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- Broad Institute of MIT and Harvard, Boston, MA, USA
| | | | | | | | - Aviv Regev
- Broad Institute of MIT and Harvard, Boston, MA, USA
- Genentech, Inc., South San Francisco, CA, USA
| | | | - Mary T Brophy
- VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Nhan V Do
- VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Peter Kraft
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Brian M Wolpin
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Michael H Rosenthal
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - Nathanael R Fillmore
- Harvard Medical School, Boston, MA, USA
- Dana-Farber Cancer Institute, Boston, MA, USA
- VA Boston Healthcare System, Boston, MA, USA
- Boston University School of Medicine, Boston, MA, USA
| | - Søren Brunak
- Novo Nordisk Foundation Center for Protein Research, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
- Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Chris Sander
- Harvard Medical School, Boston, MA, USA.
- Dana-Farber Cancer Institute, Boston, MA, USA.
- Broad Institute of MIT and Harvard, Boston, MA, USA.
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18
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Wheeler AM, Roul P, Yang Y, Brittan KM, Sayles H, Singh N, Sauer BC, Cannon GW, Baker JF, Mikuls TR, England BR. Risk of Prostate Cancer in US Veterans With Rheumatoid Arthritis. Arthritis Care Res (Hoboken) 2023; 75:785-792. [PMID: 35612872 PMCID: PMC9532468 DOI: 10.1002/acr.24890] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/21/2022] [Accepted: 03/31/2022] [Indexed: 11/07/2022]
Abstract
OBJECTIVE Patients with rheumatoid arthritis (RA) have an increased risk of select cancers, including lymphoma and lung cancer. Whether RA influences prostate cancer risk is uncertain. We aimed to determine the risk of prostate cancer in patients with RA compared to patients without RA in the Veterans Health Administration (VA). METHODS We performed a matched (up to 1:5) cohort study of male patients with and without RA in the VA from 2000 to 2018. RA status, as well as covariates, were obtained from national VA databases. Prostate cancer was identified through linked VA cancer databases and the National Death Index. Multivariable Cox models compared prostate cancer risk between patients with RA and patients without RA, including models that accounted for retention in the VA system. RESULTS We included 56,514 veterans with RA and 227,284 veterans without RA. During 2,337,104 patient-years of follow-up, 6,550 prostate cancers occurred. Prostate cancer incidence (per 1,000 patient-years) was 3.50 (95% confidence interval [95% CI] 3.32-3.69) in patients with RA and 2.66 (95% CI 2.58-2.73) in patients without RA. After accounting for confounders and censoring for attrition of VA health care, RA was modestly associated with a higher prostate cancer risk (adjusted HR [HRadj ] 1.12 [95% CI 1.04-1.20]). There was no association between RA and prostate cancer mortality (HRadj 0.92 [95% CI 0.73-1.16]). CONCLUSION RA was associated with a modestly increased risk of prostate cancer, but not prostate cancer mortality, after accounting for relevant confounders and several potential sources of bias. However, even minimal unmeasured confounding could explain these findings.
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Affiliation(s)
- Austin M. Wheeler
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Punyasha Roul
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Yangyuna Yang
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Kaitlyn M. Brittan
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Harlan Sayles
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
- Department of Biostatistics, College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | | | - Brian C. Sauer
- Salt Lake City VA Healthcare System & University of Utah, Salt Lake City, UT
| | - Grant W. Cannon
- Salt Lake City VA Healthcare System & University of Utah, Salt Lake City, UT
| | - Joshua F. Baker
- Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania, Philadelphia, PA
| | - Ted R. Mikuls
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
| | - Bryant R. England
- VA Nebraska-Western Iowa Health Care System, Omaha, NE
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE
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19
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Rubenstein JH, Burns JA, Arasim ME, Firsht EM, Harbrecht M, Widerquist M, Evans RR, Inadomi JM, Chang JW, Hazelton WD, Hur C, Kurlander JE, Lim F, Luebeck G, Macdonald PW, Reddy CA, Saini SD, Tan SX, Waljee AK, Lansdorp-Vogelaar I. Yield of Repeat Endoscopy for Barrett's Esophagus After Normal Index Endoscopy. Am J Gastroenterol 2023:00000434-990000000-00667. [PMID: 36716445 DOI: 10.14309/ajg.0000000000002204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 01/19/2023] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Guidelines suggest 1-time screening with esophagogastroduodenoscopy (EGD) for Barrett's esophagus (BE) in individuals at an increased risk of esophageal adenocarcinoma (EAC). We aimed to estimate the yield of repeat EGD performed at prolonged intervals after a normal index EGD. METHODS We conducted a national retrospective analysis within the U S Veterans Health Administration, identifying patients with a normal index EGD between 2003 and 2009 who subsequently had a repeat EGD. We tabulated the proportion with a new diagnosis of BE, EAC, or esophagogastric junction adenocarcinoma (EGJAC) and conducted manual chart review of a sample. We fitted logistic regression models for the odds of a new diagnosis of BE/EAC/EGJAC. RESULTS We identified 71,216 individuals who had a repeat EGD between 1 and 16 years after an index EGD without billing or cancer registry codes for BE/EAC/EGJAC. Of them, 4,088 had a new billing or cancer registry code for BE/EAC/EGJAC after the repeat EGD. On manual review of a stratified sample, most did not truly have new BE/EAC/EGJAC. A longer duration between EGD was associated with greater odds of a new diagnosis (adjusted odds ratio [aOR] for each 5 years 1.31; 95% confidence interval [CI] 1.19-1.44), particularly among those who were younger during the index EGD (ages 19-29 years: aOR 3.92; 95% CI 1.24-12.4; ages 60-69 years: aOR 1.19; 95% CI 1.01-1.40). DISCUSSION The yield of repeat EGD for BE/EAC/EGJAC seems to increase with time after a normal index EGD, particularly for younger individuals. Prospective studies are warranted to confirm these findings.
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Affiliation(s)
- Joel H Rubenstein
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Jennifer A Burns
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Maria E Arasim
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Elizabeth M Firsht
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Matthew Harbrecht
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - Marilla Widerquist
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Richard R Evans
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - John M Inadomi
- Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - William D Hazelton
- Computational Biology Program, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Chin Hur
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Jacob E Kurlander
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Francesca Lim
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Georg Luebeck
- Computational Biology Program, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Peter W Macdonald
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, Michigan, USA
| | - Chanakyaram A Reddy
- Center for Esophageal Diseases, Baylor, Scott & White Health, Dallas, Texas, USA
| | - Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Sarah Xinhui Tan
- Division of General Medicine, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Akbar K Waljee
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Iris Lansdorp-Vogelaar
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands
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20
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Mutational profiles of head and neck squamous cell carcinomas based upon human papillomavirus status in the Veterans Affairs National Precision Oncology Program. J Cancer Res Clin Oncol 2023; 149:69-77. [PMID: 36117189 DOI: 10.1007/s00432-022-04358-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Accepted: 09/12/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND Patients with advanced head and neck squamous cell carcinoma (HNSCC) associated with human papillomavirus (HPV) demonstrate favorable clinical outcomes compared to patients bearing HPV-negative HNSCC. We sought to characterize the association between HPV status and mutational profiles among patients served by the Veterans Health Administration (VHA). METHODS We performed a retrospective analysis of all Veterans with primary HNSCC tumors who underwent next-generation sequencing (NGS) through the VHA's National Precision Oncology Program between July 2016 and February 2019. HPV status was determined by clinical pathology reports of p16 immunohistochemical staining; gene variant pathogenicity was classified using OncoKB, an online precision oncology knowledge database, and mutation frequencies were compared using Fisher's exact test. RESULTS A total of 79 patients met inclusion criteria, of which 48 (60.8%) had p16-positive tumors. Patients with p16-negative HNSCC were more likely to have mutations in TP53 (p < 0.0001), and a trend towards increased mutation frequency was observed within NOTCH1 (p = 0.032) and within the composite CDK/Rb pathway (p = 0.065). Mutations in KRAS, NRAS, HRAS, and FBXW7 were exclusively identified within p16-positive tumors, and a trend towards increased frequency was observed within the PI3K pathway (p = 0.051). No difference in overall mutational burden was observed between the two groups. CONCLUSIONS In accordance with the previous studies, no clear molecular basis for improved prognosis among patients harboring HPV-positive disease has been elucidated. Though no targeted therapies are approved based upon HPV-status, current efforts to trial PI3K inhibitors and mTOR inhibitors across patients with HPV-positive disease bear genomic rationale based upon the current findings.
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21
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Sahu KK, Johnson ED, Butler K, Li H, Boucher KM, Gupta S. Improving Bone Health in Patients with Metastatic Prostate Cancer with the Use of Algorithm-Based Clinical Practice Tool. Geriatrics (Basel) 2022; 7:133. [PMID: 36547269 PMCID: PMC9778212 DOI: 10.3390/geriatrics7060133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/06/2022] [Accepted: 11/14/2022] [Indexed: 11/27/2022] Open
Abstract
Background: The bone health of patients with locally advanced and metastatic prostate cancer is at risk from treatment-related bone density loss and skeletal-related events from metastatic disease in bones. Evidence-based guidelines recommend using denosumab or zoledronic acid at bone metastasis-indicated dosages in the setting of castration-resistant prostate cancer with bone metastases and at the osteoporosis-indicated dosages in the hormone-sensitive setting in patients with a significant risk of fragility fracture. For the concerns of jaw osteonecrosis, a dental evaluation is recommended before starting bone-modifying agents. The literature review suggests a limited evidence-based practice for bone health with prostate cancer in the real world. Both under-treatment and inappropriate dosing of bone remodeling therapies place additional risks to bone health. An incomplete dental work up before starting bone-modifying agents increases the risk of jaw osteonecrosis. Methods: We created an algorithm-based clinical practice tool to minimize the deviation from evidence-based guidelines at our center and provide appropriate bone health care to our patients by ensuring indication-appropriate dosing and dental screening rates. This order set was incorporated into the electronic medical record system for ordering a bone remodeling agent for prostate cancer. The tool prompts the clinicians to follow the appropriate algorithm in a stepwise manner to ensure a pretreatment dental evaluation and use of the correct dosage of drugs. Results: We analyzed the data from Sept 2019 to April 2022 following the incorporation of this tool. 0/35 (0%) patients were placed on inappropriate bone modifying agent dosing, and dental health was addressed in every patient before initiating treatment. We compared the change in the practice of prescribing and noted a significant difference in the clinician’s practice while prescribing denosumab/zoledronic acid before and after implementation of this tool [incorrect dosing: 24/41 vs. 0/35 (p < 0.00001)]; and an improvement in pretreatment dental checkup before and after implementation of the tool was noted to be [missed dental evaluation:12/41 vs. 0/35 (p < 0.00001)]. Conclusion: We found that incorporating an evidence-based algorithm in the order set while prescribing bone remodeling agents significantly improved our institutional clinical practice of indication-appropriate dosing and dental screening rates, and facilitated high-quality, evidence-based care to our patients with prostate cancer.
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Affiliation(s)
- Kamal Kant Sahu
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84101, USA
| | - Eric D. Johnson
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84101, USA
- Intermountain Health Care, Salt Lake City, UT 84102, USA
| | - Katerina Butler
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA
| | - Haoran Li
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84101, USA
| | - Kenneth M. Boucher
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84101, USA
| | - Sumati Gupta
- George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, UT 84148, USA
- Huntsman Cancer Institute, University of Utah, Salt Lake City, UT 84101, USA
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22
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Qiao EM, Guram K, Kotha NV, Voora RS, Qian AS, Ahn GS, Kalavacherla S, Pindus R, Banegas MP, Stewart TF, Johnson ML, Murphy JD, Rose BS. Association Between Primary Care Use Prior to Cancer Diagnosis and Subsequent Cancer Mortality in the Veterans Affairs Health System. JAMA Netw Open 2022; 5:e2242048. [PMID: 36374497 PMCID: PMC9664263 DOI: 10.1001/jamanetworkopen.2022.42048] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Primary care physicians (PCPs) are significant contributors of early cancer detection, yet few studies have investigated whether consistent primary care translates to improved downstream outcomes. OBJECTIVE To evaluate the association of prediagnostic primary care use with metastatic disease at diagnosis and cancer-specific mortality (CSM). DESIGN, SETTING, AND PARTICIPANTS This cohort study used databases with primary care and referral linkage from multiple Veterans' Affairs centers from 2004 to 2017 and had a 68-month median follow-up. Analysis was completed between July 2021 and September 2022. Participants included veterans older than 39 years who had been diagnosed with 1 of 12 cancers. Inclusion criteria included known clinical staging, survival follow-up, cause of death, and receiving care at the Veterans Affairs health system (VA). EXPOSURES Prediagnostic PCP use, measured in the 5 years prior to diagnosis. PCP visits were binned into none (0 visits), some (1-4 visits), and annual (5 visits). MAIN OUTCOMES AND MEASURES Metastatic disease at diagnosis, cancer-specific mortality (CSM) for entire cohort and stratified by tumor subtype. RESULTS Among 245 425 patients representing 12 tumor subtypes, mean age was 65.8 (9.3) years, and the cohort skewed male (97.6%), and White (76.1%), with higher levels of comorbidity (58.6% with Charlson Comorbidity Index scores ≥2). Compared with no prior visit, some PCP use was associated with 26% decreased odds of metastatic disease at diagnosis (odds ratio [OR], 0.74; 95% CI, 0.71-0.76; P < .001) and 12% reduced risk of CSM (subdistribution hazard ratio [SHR], 0.88; 95% CI, 0.86-0.89; P < .001). Annual PCP use was associated with 39% decreased odds of metastatic disease (OR, 0.61; 95% CI, 0.59-0.63; P < .001) and 21% reduced risk of CSM (SHR, 0.79; 95% CI, 0.77-0.81; P < .001). Among tumor subtypes, prostate cancer had the largest effect size for prior PCP use on metastatic disease at diagnosis (OR for annual use, 0.32; 95% CI, 0.30-0.35; P < .001) and CSM (SHRfor annual use, 0.51; 95% CI, 0.48-0.55; P < .001). CONCLUSIONS AND RELEVANCE In this cohort study, increased primary care use before cancer diagnosis was associated with significant decreases in metastatic disease at diagnosis and cancer-related death, with potentially the greatest difference from annual use. PCPs play a vital role in cancer prevention, and additional resources should be allocated to assist these physicians.
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Affiliation(s)
- Edmund M. Qiao
- VA San Diego Health Care System, La Jolla, California
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Kripa Guram
- VA San Diego Health Care System, La Jolla, California
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Nikhil V. Kotha
- VA San Diego Health Care System, La Jolla, California
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Rohith S. Voora
- VA San Diego Health Care System, La Jolla, California
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Alexander S. Qian
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Grace S. Ahn
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Sandhya Kalavacherla
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Ramona Pindus
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Matthew P. Banegas
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Tyler F. Stewart
- Division of Hematology-Oncology, Department of Internal Medicine, University of California, San Diego, La Jolla
| | - Michelle L. Johnson
- Department of Family Medicine and Public Health, University of California, San Diego, La Jolla
| | - James D. Murphy
- VA San Diego Health Care System, La Jolla, California
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
| | - Brent S. Rose
- VA San Diego Health Care System, La Jolla, California
- Department of Radiation Medicine and Applied Sciences, University of California, San Diego, La Jolla
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Ostrom QT, Price M, Neff C, Cioffi G, Waite KA, Kruchko C, Barnholtz-Sloan J. CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2015-2019. Neuro Oncol 2022; 24:v1-v95. [PMID: 36196752 PMCID: PMC9533228 DOI: 10.1093/neuonc/noac202] [Citation(s) in RCA: 540] [Impact Index Per Article: 270.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The Central Brain Tumor Registry of the United States (CBTRUS), in collaboration with the Centers for Disease Control and Prevention and the National Cancer Institute, is the largest population-based registry focused exclusively on primary brain and other central nervous system (CNS) tumors in the United States (US) and represents the entire US population. This report contains the most up-to-date population-based data on primary brain tumors available and supersedes all previous reports in terms of completeness and accuracy. All rates are age-adjusted using the 2000 US standard population and presented per 100,000 population. The average annual age-adjusted incidence rate (AAAIR) of all malignant and non-malignant brain and other CNS tumors was 24.71 per 100,000 population (malignant AAAIR=7.02 and non-malignant AAAIR=17.69). This overall rate was higher in females compared to males (27.62 versus 21.60 per 100,000) and non-Hispanic persons compared to Hispanic persons (25.09 versus 22.95 per 100,000). The most commonly occurring malignant brain and other CNS histopathology was glioblastoma (14.2% of all tumors and 50.1% of all malignant tumors), and the most common non-malignant histopathology was meningioma (39.7% of all tumors and 55.4% of all non-malignant tumors). Glioblastoma was more common in males, and meningiomas were more common in females. In children and adolescents (ages 0-19 years), the incidence rate of all primary brain and other CNS tumors was 6.20 per 100,000 population. An estimated 93,470 new cases of malignant and non-malignant brain and other CNS tumors are expected to be diagnosed in the US population in 2022 (26,670 malignant and 66,806 non-malignant). There were 84,264 deaths attributed to malignant brain and other CNS tumors between 2015 and 2019. This represents an average annual mortality rate of 4.41 per 100,000 population and an average of 16,853 deaths per year. The five-year relative survival rate following diagnosis of a malignant brain and other CNS tumor was 35.7%, while for non-malignant brain and other CNS tumors the five-year relative survival rate was 91.8%.
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Affiliation(s)
- Quinn T Ostrom
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Cancer Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mackenzie Price
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Corey Neff
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gino Cioffi
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, Maryland, USA
| | - Kristin A Waite
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, Maryland, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, Maryland, USA
- Center for Biomedical Informatics & Information Technology (CBIIT), National Cancer Institute, Bethesda, Maryland, USA
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24
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Bagshaw HP, Arnow KD, Trickey AW, Leppert JT, Wren SM, Morris AM. Assessment of Second Primary Cancer Risk Among Men Receiving Primary Radiotherapy vs Surgery for the Treatment of Prostate Cancer. JAMA Netw Open 2022; 5:e2223025. [PMID: 35900763 PMCID: PMC9335142 DOI: 10.1001/jamanetworkopen.2022.23025] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
IMPORTANCE Shared decision-making is an important part of the treatment selection process among patients with prostate cancer. Updated information is needed regarding the long-term incidence and risk of second primary cancer after radiotherapy vs nonradiotherapy treatments, which may help to inform discussions of risks and benefits for men diagnosed with prostate cancer. OBJECTIVE To assess the current incidence and risk of developing a second primary cancer after receipt of radiotherapy vs nonradiotherapy treatments for prostate cancer. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used the Veterans Affairs Corporate Data Warehouse to identify 154 514 male veterans 18 years and older who had localized prostate cancer (tumor stages T1-T3) diagnosed between January 1, 2000, and December 31, 2015, and no cancer history. A total of 10 628 patients were excluded because of (1) incomplete treatment information for the year after diagnosis, (2) receipt of both radiotherapy and a surgical procedure in the year after diagnosis, (3) receipt of radiotherapy more than 1 year after diagnosis, (4) occurrence of second primary cancer or death within 1 year or less after diagnosis, (5) prostate-specific antigen value greater than 99 ng/mL within 6 months before diagnosis, or (6) no recorded Veterans Health Administration service after diagnosis. The remaining 143 886 patients included in the study had a median (IQR) follow-up of 9 (6-13) years. Data were analyzed from May 1, 2021, to May 22, 2022. MAIN OUTCOMES AND MEASURES Diagnosis of a second primary cancer more than 1 year after prostate cancer diagnosis. RESULTS Among 143 886 male veterans (median [IQR] age, 65 [60-71] years) with localized prostate cancer, 750 (0.5%) were American Indian or Alaska Native, 389 (0.3%) were Asian, 37 796 (26.3%) were Black or African American, 933 (0.6%) were Native Hawaiian or other Pacific Islander, 91 091 (63.3%) were White, and 12 927 (9.0%) were of unknown race; 7299 patients (5.1%) were Hispanic or Latino, 128 796 (89.5%) were not Hispanic or Latino, and 7791 (5.4%) were of unknown ethnicity. A total of 52 886 patients (36.8%) received primary radiotherapy, and 91 000 (63.2%) did not. A second primary cancer more than 1 year after prostate cancer diagnosis was present in 4257 patients (3.0%), comprising 1955 patients (3.7%) in the radiotherapy cohort and 2302 patients (2.5%) in the nonradiotherapy cohort. In the multivariable analyses, patients in the radiotherapy cohort had a higher risk of second primary cancer compared with those in the nonradiotherapy cohort at years 1 to 5 after diagnosis (hazard ratio [HR], 1.24; 95% CI, 1.13-1.37; P < .001), with higher adjusted HRs in the subsequent 15 years (years 5-10: 1.50 [95% CI, 1.36-1.65; P < .001]; years 10-15: 1.59 [95% CI, 1.37-1.84; P < .001]; years 15-20: 1.47 [95% CI, 1.08-2.01; P = .02). CONCLUSIONS AND RELEVANCE In this cohort study, patients with prostate cancer who received radiotherapy were more likely to develop a second primary cancer than patients who did not receive radiotherapy, with increased risk over time. Although the incidence and risk of developing a second primary cancer were low, it is important to discuss the risk with patients during shared decision-making about prostate cancer treatment options.
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Affiliation(s)
- Hilary P. Bagshaw
- Department of Radiation Oncology, Stanford University, Palo Alto, California
| | - Katherine D. Arnow
- Department of Surgery, Stanford University, Palo Alto, California
- Stanford–Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California
| | - Amber W. Trickey
- Department of Surgery, Stanford University, Palo Alto, California
- Stanford–Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California
| | - John T. Leppert
- Department of Urology, Stanford University, Palo Alto, California
- Palo Alto Veterans Health Care System, Palo Alto, California
| | - Sherry M. Wren
- Department of Surgery, Stanford University, Palo Alto, California
- Stanford–Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California
- Palo Alto Veterans Health Care System, Palo Alto, California
| | - Arden M. Morris
- Department of Surgery, Stanford University, Palo Alto, California
- Stanford–Surgery Policy Improvement Research and Education Center, Stanford University, Palo Alto, California
- Palo Alto Veterans Health Care System, Palo Alto, California
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25
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Maurice NM, Tanner NT. Lung cancer screening at the VA: Past, present and future. Semin Oncol 2022; 49:S0093-7754(22)00041-0. [PMID: 35831214 DOI: 10.1053/j.seminoncol.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 06/04/2022] [Indexed: 11/11/2022]
Abstract
Lung cancer is responsible for more deaths annually in the United States than breast, prostate and colon cancers combined. Lung cancer screening with annual low-dose computed tomography reduces lung cancer mortality in high-risk patients through early detection. The incidence of lung cancer is higher in the veteran population compared to the general population due, in part, to the prevalence of tobacco use. Early detection of lung cancer is therefore an important goal of the Veterans Health Administration (VHA), the largest integrated health care system in the United States. The following will review previous and current initiatives undertaken by the VHA to implement and expand access to lung cancer screening and will highlight target areas of interest to improve uptake and quality of lung cancer screening. Through these initiatives and programs, the VHA aims to provide high quality and equitable access to lung cancer screening for all Veterans that incorporates research that will improve outcomes and potentially inform and optimize the practice of Lung cancer screening across the United States.
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Affiliation(s)
- Nicholas M Maurice
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University School of Medicine, Atlanta, GA, U.S.A.; Atlanta Veterans Affairs Health Care System, Decatur, GA.
| | - Nichole T Tanner
- Ralph H. Johnson Veterans Affairs Hospital, Health Equity and Rural Outreach Innovation Center (HEROIC), Charleston, SC, U.S.A.; Medical University of South Carolina, Thoracic Oncology Research Group, Division of Pulmonary and Critical Care, Charleston, SC, U.S.A
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26
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Tessema ST, Mahgoub AE, Nakhleh R. Angiosarcoma: A Rare Malignancy Linked to Chemical Exposures. Cureus 2022; 14:e25289. [PMID: 35755516 PMCID: PMC9224836 DOI: 10.7759/cureus.25289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2022] [Indexed: 11/05/2022] Open
Abstract
Angiosarcoma is an exceptionally rare malignancy that accounts for less than 1% of all sarcomas. This case describes a 90-year-old male veteran who presented with a hematoma from a traumatic head injury. This then progressed to an ulcerated bleeding lesion that measured 2.5 cm in diameter with pearly borders and granulation tissue. CT scan of the head and skin biopsy were consistent with the diagnosis of cutaneous angiosarcoma. The patient may have unique exposures from the military training site Camp Lejeune including tetrachloroethylene (PCE), trichloroethylene (TCE), trans-1,2-dichloroethylene, and vinyl chloride predisposing to angiosarcoma. The patient underwent palliative radiation without obvious complications. This case presents an opportunity for further evaluation and understanding of the effects of these exposures and the implications for the health of veterans and aging populations. Patient outcomes may be improved with earlier diagnosis and aggressive treatment.
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27
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Rubenstein JH, Evans RR, Burns JA, Arasim ME, Zhu J, Waljee AK, Macdonald PW, Adams MA, Chang JW, Firsht EM, Hawley ST, Saini SD, Wallner LP. Patients With Adenocarcinoma of the Esophagus or Esophagogastric Junction Frequently Have Potential Screening Opportunities. Gastroenterology 2022; 162:1349-1351.e5. [PMID: 34942170 PMCID: PMC8934293 DOI: 10.1053/j.gastro.2021.12.255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 12/02/2022]
Affiliation(s)
- Joel H. Rubenstein
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI,Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI,Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Richard R. Evans
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI
| | - Jennifer A. Burns
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI
| | - Maria E. Arasim
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI
| | - Ji Zhu
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Akbar K. Waljee
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI,Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI,Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | | | - Peter W Macdonald
- Department of Statistics, University of Michigan College of Literature, Science, and Arts, Ann Arbor, MI
| | - Megan A Adams
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Joy W Chang
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Elizabeth M Firsht
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI
| | - Sarah T Hawley
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI; Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sameer D Saini
- Veterans Affairs Center for Clinical Management Research, LTC Charles S. Kettles Veterans Affairs Medical Center, Ann Arbor, MI; Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI
| | - Lauren P Wallner
- Rogel Cancer Center, University of Michigan Medical School, Ann Arbor, MI; Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI
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28
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Chang MS, La J, Trepanowski N, Cheng D, Bihn JR, Do N, Brophy M, Fillmore NR, Hartman RI. Increased relative proportions of advanced melanoma among Veterans: a comparative analysis with the SEER registry. J Am Acad Dermatol 2022; 87:72-79. [PMID: 35595121 DOI: 10.1016/j.jaad.2022.02.063] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 02/23/2022] [Accepted: 02/27/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND The Surveillance, Epidemiology, and End Results (SEER) program reflects one-third of the U.S. POPULATION However, SEER may not be generalizable to the Veteran population. Since Veterans comprise a high-risk population, this discrepancy may limit our understanding of melanoma epidemiology in such high-risk populations. OBJECTIVE To assess differences in demographics, tumor characteristics, and melanoma-specific survival in Veterans compared to the general population. METHODS Data were collected from the Veterans Affairs Central Cancer Registry (VACCR) and SEER (18 registries) from 2009 to 2017. RESULTS 15,334 Veterans and 166,265 SEER patients with melanoma were identified. Veterans were more likely to present with regional or distant disease (17.5% vs. 13.0% in SEER). 5-year melanoma specific survival (MSS) was lower across all ages, except those diagnosed at ≥80 years, in VACCR relative to SEER. Similarly, from 2009-2017, MSS by stage was lower across all stages in VACCR. However, for stage IV melanomas diagnosed in 2015-2017, compared to 2011-2014, 2-year MSS increased from 37.8% to 51.5% in VACCR versus 36.4% to 44.8% in SEER. LIMITATIONS Unique Veteran demographics and missing data inherent to VACCR. CONCLUSION Compared to SEER, Veterans with melanoma were diagnosed at later stages, but both exhibited recent improvement in stage IV MSS.
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Affiliation(s)
- Michael S Chang
- Harvard Medical School, Boston, MA; Department of Dermatology, Brigham and Women's Hospital, Boston, MA; Department of Dermatology, VA Integrated Service Network (VISN-1), Jamaica Plain, MA
| | - Jennifer La
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA
| | - Nicole Trepanowski
- Department of Dermatology, Brigham and Women's Hospital, Boston, MA; Department of Dermatology, VA Integrated Service Network (VISN-1), Jamaica Plain, MA; Boston University School of Medicine, Boston, MA
| | - David Cheng
- Harvard Medical School, Boston, MA; Biostatistics Center, Massachusetts General Hospital, Boston, MA
| | - John R Bihn
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA
| | - Nhan Do
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA; Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Mary Brophy
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA; Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Nathanael R Fillmore
- Harvard Medical School, Boston, MA; Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Jamaica Plain, MA
| | - Rebecca I Hartman
- Harvard Medical School, Boston, MA; Department of Dermatology, Brigham and Women's Hospital, Boston, MA; Department of Dermatology, VA Integrated Service Network (VISN-1), Jamaica Plain, MA.
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29
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Englum BR, Prasad NK, Lake RE, Mayorga‐Carlin M, Turner DJ, Siddiqui T, Sorkin JD, Lal BK. Impact of the COVID-19 pandemic on diagnosis of new cancers: A national multicenter study of the Veterans Affairs Healthcare System. Cancer 2022; 128:1048-1056. [PMID: 34866184 PMCID: PMC8837676 DOI: 10.1002/cncr.34011] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Revised: 09/11/2021] [Accepted: 10/07/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND The coronavirus disease 2019 (COVID-19) pandemic caused disruptions in treatment for cancer. Less is known about its impact on new cancer diagnoses, where delays could cause worsening long-term outcomes. This study quantifies decreases in encounters related to prostate, lung, bladder and colorectal cancers, procedures that facilitate their diagnosis, and new diagnoses of those cancers in the COVID era compared to pre-COVID era. METHODS All encounters at Veterans' Affairs facilities nationwide from 2016 through 2020 were reviewed. The authors quantified trends in new diagnoses of cancer and in procedures facilitating their diagnosis, from January 1, 2018 onward. Using 2018 to 2019 as baseline, reductions in procedures and new cancer diagnoses in 2020 were estimated. Calculated absolute and percentage differences in annual volume and observed-to-expected volume ratios were calculated. Heat maps and funnel plots of volume changes were generated. RESULTS From 2018 through 2020, there were 4.1 million cancer-related encounters, 3.9 million relevant procedures, and 251,647 new cancers diagnosed. Compared to the annual averages in 2018 through 2019, colonoscopies in 2020 decreased by 45% whereas prostate biopsies, chest computed tomography scans, and cystoscopies decreased by 29%, 10%, and 21%, respectively. New cancer diagnoses decreased by 13% to 23%. These drops varied by state and continued to accumulate despite reductions in pandemic-related restrictions. CONCLUSION The authors identified substantial reductions in procedures used to diagnose cancer and subsequent reductions in new diagnoses of cancer across the United States because of the COVID-19 pandemic. A nomogram is provided to identify and resolve these unmet health care needs and avoid worse long-term cancer outcomes. LAY SUMMARY The disruptions due to the COVID-19 pandemic have led to substantial reductions in new cancers being diagnosed. This study quantifies those reductions in a national health care system and offers a method for understanding the backlog of cases and the resources needed to resolve them.
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Affiliation(s)
- Brian R. Englum
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
| | - Nikhil K. Prasad
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - Rachel E. Lake
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - Minerva Mayorga‐Carlin
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - Douglas J. Turner
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - Tariq Siddiqui
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
| | - John D. Sorkin
- Geriatrics Research, Education, and Clinical CenterVeterans Affairs Medical CenterBaltimoreMaryland
- Department of MedicineUniversity of Maryland School of MedicineBaltimoreMaryland
| | - Brajesh K. Lal
- Department of SurgeryUniversity of Maryland School of MedicineBaltimoreMaryland
- Surgery ServiceVeterans Affairs Medical CenterBaltimoreMaryland
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30
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Kidwai N. Routine cancer screening delays due to pandemic at veteran affairs. J Natl Med Assoc 2022; 114:12-15. [PMID: 34507828 PMCID: PMC8515360 DOI: 10.1016/j.jnma.2021.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/26/2021] [Accepted: 08/09/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Neiha Kidwai
- UConn Health, Internal Medicine Resident, PGY-2, United States.
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31
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Kotha NV, Kumar A, Qiao EM, Qian AS, Voora RS, Nalawade V, Karim Kader A, McKay RR, Stewart TF, Rose BS. Association of Health-Care System and Survival in African American and Non-Hispanic White Patients With Bladder Cancer. J Natl Cancer Inst 2021; 114:600-608. [PMID: 34918091 PMCID: PMC9002275 DOI: 10.1093/jnci/djab219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/17/2021] [Accepted: 11/29/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND African American patients with bladder cancer have inferior outcomes compared with non-Hispanic White (White) patients. We hypothesize that access to health care is a primary determinant of this disparity. We compared outcomes by race for patients with bladder cancer receiving care within the predominant hybrid-payer health-care model of the United States captured in the Surveillance, Epidemiology, and End Results (SEER) database with those receiving care within the equal-access model of the Veterans' Health Administration (VHA). METHODS African American and White patients diagnosed with bladder cancer were identified in SEER and VHA. Stage at presentation, bladder cancer-specific mortality (BCM), and overall survival (OS) were compared by race within each health-care system. RESULTS The SEER cohort included 122 449 patients (93.7% White, 6.3% African American). The VHA cohort included 36 322 patients (91.0% White, 9.0% African American). In both cohorts, African American patients were more likely to present with muscle-invasive disease and metastases, but the differences between races were statistically significantly smaller in VHA. In SEER multivariable models, African American patients had worse BCM (hazard ratio [HR] = 1.22, 95% confidence interval [CI] = 1.15 to 1.29) and OS (HR = 1.26, 95% CI = 1.20 to 1.31). In contrast within the VHA, African American patients had similar BCM (HR = 0.97, 95% CI = 0.88 to 1.07) and OS (HR = 0.99, 95% CI = 0.93 to 1.05). CONCLUSIONS In this study of contrasting health-care models, receiving medical care in an equal-access system was associated with reduced differences in stage at presentation and eliminated disparities in survival outcomes for African American patients with bladder cancer. Our findings highlight the importance of reducing financial barriers to care to notably improve health equity and oncologic outcomes for African American patients.
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Affiliation(s)
- Nikhil V Kotha
- School of Medicine, University of California San Diego, La Jolla, CA, USA,Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Abhishek Kumar
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Edmund M Qiao
- School of Medicine, University of California San Diego, La Jolla, CA, USA,Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Alex S Qian
- School of Medicine, University of California San Diego, La Jolla, CA, USA,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Rohith S Voora
- School of Medicine, University of California San Diego, La Jolla, CA, USA,Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Vinit Nalawade
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - A Karim Kader
- Department of Urology, University of California San Diego, La Jolla, CA, USA
| | - Rana R McKay
- Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Tyler F Stewart
- Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Brent S Rose
- Correspondence to: Brent S. Rose, MD, Department of Radiation Medicine and Applied Sciences, Altman Clinical and Translational Research Institute, University of California San Diego, 9452 Medical Center Dr, La Jolla, CA 92037, USA (e-mail: )
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32
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Weygandt J, Robling K, Whitaker LA, McPherson K, Hartwell M, Greiner B. Cancer Screening Among Current and Former U.S. Military Personnel Compared to Civilians: A Cross-Sectional Analysis of the Behavioral Risk Factor Surveillance System. Mil Med 2021; 188:usab439. [PMID: 34865108 DOI: 10.1093/milmed/usab439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 08/02/2021] [Accepted: 11/04/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Approximately 3% of invasive U.S. cancer diagnoses are made among veterans in a Veterans Affairs (VA) clinic each year, while VA patients only comprise about 1.9% of the U.S. population. Although some research has shown that veterans have higher incidence rates of cancer compared to civilians, evidence is sparse regarding possible disparities in rates of cancer screening between these populations. Thus, the purpose of this study is to compare differences in rates of screening for colorectal, lung, breast, and cervical cancers between current and former U.S. Military service members and civilians. METHODS Using the data extracted from the Behavioral Risk Factor Surveillance System, we assessed the rates of cancer screening among current and former U.S. Military service members compared to civilians from self-reported surveys assessing when individuals had been screened for colorectal or lung cancer among all participants and breast and cervical cancer among women participants. Persons greater than 25 years of age were included in the cervical cancer screening, 50 years of age for colon cancer screening, and 40 years of age for the breast cancer screening-the latter based on recommendations from the American Cancer Society. We used multivariate logistic regression models to determine the adjusted risk ratios (ARRs) of current and former U.S. Military service members receiving screening compared to civilians, adjusting for age, gender, race, education, and health care coverage. RESULTS Current and former U.S. Military service members accounted for 2.6% of individuals included for the cervical cancer screening analysis, 2.2% for the breast cancer screening analyses, nearly 10% of the lung cancer screening, and 15% of the colorectal cancer (CRC) screening analyses. Prevalence of screening was higher for current and former U.S. Military service members among lung cancer and CRC. When controlling for age, race, education, and health care coverage, current and former U.S. Military service members were statistically more likely to be screened for CRC (ARR: 1.05; 95% confidence interval: 1.04-1.07) and lung cancer (ARR: 1.32; 95% confidence interval: 1.15-1.52). The odds of having completed a cervical or breast cancer screening were not significantly different between groups. CONCLUSION Our study showed that current and former U.S. Military service members were more likely to complete CRC and lung cancer screenings, while no significant difference existed between each population with regard to cervical and breast cancer screenings. This is one of the few studies that have directly compared cancer screening usage among civilians and current and former U.S. Military service members. Although current and former U.S. Military service members were more likely to receive several cancer screenings, improvements can still be made to remove barriers and increase screening usage due to the disproportionate rates of cancer mortality in this population. These solutions should be comprehensive-addressing personal, organizational, and societal barriers-to improve prognosis and survival rates among current and former U.S. Military service members.
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Affiliation(s)
- Jonas Weygandt
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation, Tahlequah, OK 74464, USA
| | - Kristyn Robling
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation, Tahlequah, OK 74464, USA
| | - Liza-Ann Whitaker
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation, Tahlequah, OK 74464, USA
| | - Kristen McPherson
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
- Office of Medical Student Research, Oklahoma State University College of Osteopathic Medicine at the Cherokee Nation, Tahlequah, OK 74464, USA
| | - Micah Hartwell
- Office of Medical Student Research, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
- Department of Psychiatry and Behavioral Sciences, Oklahoma State University Center for Health Sciences, Tulsa, OK 74107, USA
| | - Benjamin Greiner
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX 77555, USA
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Kotha NV, Kumar A, Nelson TJ, Qiao EM, Qian AS, Voora RS, McKay RR, Stewart TF, Rose BS. Treatment Discontinuation in Patients With Muscle-Invasive Bladder Cancer Undergoing Chemoradiation. Adv Radiat Oncol 2021; 7:100836. [PMID: 35071834 PMCID: PMC8767252 DOI: 10.1016/j.adro.2021.100836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
PURPOSE Chemoradiation (CRT) is a definitive treatment option for muscle-invasive bladder cancer (MIBC). Despite its effectiveness, CRT is underused, in part owing to concerns of tolerability and the need for integrated multidisciplinary care. We investigated factors associated with and the impact of treatment discontinuation in patients with MIBC treated with CRT. METHODS AND MATERIALS In the US Veterans Affairs' national database, we identified patients with urothelial histology, MIBC (T2-4a/N0-3/M0) diagnosed between 2000 and 2018 and treated with definitive-intent CRT. The primary endpoint of discontinued radiation was evaluated in a multivariable logistic regression. Secondary endpoints of 30-day and 90-day mortality, overall mortality, and nonbladder cancer mortality were evaluated in multivariable models. RESULTS Of 369 veterans with MIBC who underwent CRT, 30 patients (8.1%) did not complete radiation. The most common reasons for treatment discontinuation included comorbidities or infections necessitating hospital admission (63.3%) and treatment intolerance or declining performance status (26.7%). In multivariable logistic regression, variables associated with radiation discontinuation were creatinine clearance ≤ 50 (odds ratio [OR], 3.93; 95% CI, 1.63-9.50; P = .002), incomplete transurethral resection of bladder tumor (TURBT) (OR, 3.16; 95% CI, 1.15-8.63; P = .02), and nonpreferred chemotherapy (OR, 3.31; 95% CI, 1.31-8.36; P = .01). In the cohort that discontinued radiation, 30-day mortality was 33.3% and 90-day mortality was 50.0%, with the majority of deaths attributed to nonbladder cancer causes. No patient or tumor variables were associated with either endpoint. In the cohort that completed radiation, 30-day mortality was 2.7% and 90-day mortality was 6.8%. In multivariable analysis, radiation discontinuation was associated with worse overall mortality (hazard ratio [HR], 2.48; 95% CI, 1.36-4.50; P = .003) and worse nonbladder cancer mortality (HR, 2.32; 95% CI, 1.24-4.34; P = .008). CONCLUSIONS With a low rate of treatment discontinuation, CRT is an effective and feasible treatment option for the typically elderly and comorbid population of patients with MIBC. In addition to identified predictors of treatment discontinuation (poor renal function, incomplete TURBT, etc.), further research is required to develop evidence-based guidelines for optimal patient selection.
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Affiliation(s)
- Nikhil V. Kotha
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California,Veterans Affairs San Diego Healthcare System, San Diego, California,Corresponding author: Nikhil V. Kotha, BS
| | - Abhishek Kumar
- Veterans Affairs San Diego Healthcare System, San Diego, California,Department of Radiation Oncology, Duke University, Durham, North Carolina
| | - Tyler J. Nelson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California,Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Edmund M. Qiao
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California,Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Alex S. Qian
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California,Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Rohith S. Voora
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California,Veterans Affairs San Diego Healthcare System, San Diego, California
| | - Rana R. McKay
- Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Tyler F. Stewart
- Veterans Affairs San Diego Healthcare System, San Diego, California,Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, California
| | - Brent S. Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California,Veterans Affairs San Diego Healthcare System, San Diego, California
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Kotha NV, Voora RS, Qian AS, Kumar A, Qiao EM, Stewart TF, Rose BS, Orosco RK. Prognostic Utility of Pretreatment Neutrophil-Lymphocyte Ratio in Advanced Larynx Cancer. Biomark Insights 2021; 16:11772719211049848. [PMID: 34658619 PMCID: PMC8512256 DOI: 10.1177/11772719211049848] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 09/03/2021] [Indexed: 12/11/2022] Open
Abstract
Purpose: Neutrophil-lymphocyte ratio has been explored as a prognosticator in several
cancer types, but its association with larynx cancer outcomes is not well
known. We aimed to identify an optimal NLR cutoff point and examine the
prognostic utility of this biomarker in patients with locoregionally
advanced larynx cancer treated with curative intent. Methods: In the Veterans Affairs’ (VA) national database, we identified patients with
locoregionally advanced (T3-4N0-3M0) laryngeal squamous cell carcinoma
diagnosed between 2000 and 2017 and treated with curative intent. NLR cutoff
points were calculated using Contal/O’Quigley’s method. Outcomes of larynx
cancer-specific survival (CSS), overall survival (OS), and non-larynx cancer
survival (NCS) were evaluated in multivariable Cox and Fine-Gray models. Results: In 1047 patients, the optimal pretreatment NLR cutoff was identified as 4.17
- 722 patients with NLR ⩽ 4.17, 325 patients with NLR > 4.17. The
elevated NLR cohort had a higher proportion of T4 disease (39.4% vs 28.4%),
node positive disease (52.3% vs 43.1%), and surgical treatment (43.7% vs
35.2%). In multivariable analysis, NLR > 4.17 was independently
associated with worse OS (HR 1.31, 95% CI 1.12-1.54,
P = .001) and worse CSS (HR 1.46, 95% CI 1.17-1.83,
P < .001), but not with NCS (HR 0.94, 95% CI
0.75-1.18, P = .58). Conclusion: In locoregionally advanced larynx cancer treated with curative intent, we
identified elevated NLR to be associated with inferior OS and CSS. Further
prospective studies are needed to investigate pretreatment NLR and our
identified 4.17 cutoff as a potential larynx cancer-specific marker for this
high risk population.
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Affiliation(s)
- Nikhil V Kotha
- School of Medicine, University of California San Diego, La Jolla, CA, USA.,Veterans Affairs San Diego Healthcare System, San Diego, CA, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Rohith S Voora
- School of Medicine, University of California San Diego, La Jolla, CA, USA.,Veterans Affairs San Diego Healthcare System, San Diego, CA, USA.,Division of Otolaryngology-Head & Neck Surgery, University of California San Diego, La Jolla, CA, USA
| | - Alex S Qian
- School of Medicine, University of California San Diego, La Jolla, CA, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Abhishek Kumar
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA.,Department of Radiation Oncology, Duke University, Durham, NC, USA
| | - Edmund M Qiao
- School of Medicine, University of California San Diego, La Jolla, CA, USA.,Veterans Affairs San Diego Healthcare System, San Diego, CA, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA
| | - Tyler F Stewart
- Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, CA, USA.,Moores Cancer Center at University of California San Diego Health, La Jolla, CA, USA
| | - Brent S Rose
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA.,Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA, USA.,Moores Cancer Center at University of California San Diego Health, La Jolla, CA, USA
| | - Ryan K Orosco
- Veterans Affairs San Diego Healthcare System, San Diego, CA, USA.,Division of Otolaryngology-Head & Neck Surgery, University of California San Diego, La Jolla, CA, USA.,Moores Cancer Center at University of California San Diego Health, La Jolla, CA, USA
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Sutton SS, Magagnoli J, Cummings TH, Hardin JW. Leukotriene inhibition and the risk of lung cancer among U.S. veterans with asthma. Pulm Pharmacol Ther 2021; 71:102084. [PMID: 34662740 DOI: 10.1016/j.pupt.2021.102084] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 09/17/2021] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
Leukotriene inhibition, in vitro and in vivo, is found to suppress tumor growth across a variety of cancer cells. A mouse model of lung cancer revealed that the leukotriene inhibitor montelukast induced lung cancer cell death. Based on the preclinical data we hypothesize that exposure to a leukotriene inhibitor is associated with a lower risk of lung cancer. We conducted a national retrospective cohort study among U.S. Veterans with asthma to explore the relationship between leukotriene inhibition and incident lung cancer. We utilize a variety of statistical techniques, including cox proportional hazards models, propensity score matching and falsification testing to examine the association. A total of 558,466 patients met study criteria consisting of 23,730 patients with leukotriene exposure and 534,736 patients with no leukotriene medication use. Leukotriene inhibitor exposure reduced the risk of lung cancer by 17% (HR = 0.830; 95% CI = (0.757-0.911)) in the unmatched and 22.2% in the matched analysis (HR = 0.778 95% CI = (0.688-0.88)). Falsification testing with appendicitis and rotator cuff injury end points, suggest no evidence of selection bias. However, because treatment was not randomized, residual confounding cannot be ruled out. The pre-clinical data on leukotriene inhibition and lung cancer combined with our database analysis provide intriguing evidence warranting further research into the relationship between leukotrienes and lung cancer.
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Affiliation(s)
- S Scott Sutton
- Dorn Research Institute, Columbia VA Health Care System, Columbia, SC, USA; Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - Joseph Magagnoli
- Dorn Research Institute, Columbia VA Health Care System, Columbia, SC, USA; Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC, USA.
| | - Tammy H Cummings
- Dorn Research Institute, Columbia VA Health Care System, Columbia, SC, USA; Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, SC, USA
| | - James W Hardin
- Dorn Research Institute, Columbia VA Health Care System, Columbia, SC, USA; Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
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Ostrom QT, Cioffi G, Waite K, Kruchko C, Barnholtz-Sloan JS. CBTRUS Statistical Report: Primary Brain and Other Central Nervous System Tumors Diagnosed in the United States in 2014-2018. Neuro Oncol 2021; 23:iii1-iii105. [PMID: 34608945 PMCID: PMC8491279 DOI: 10.1093/neuonc/noab200] [Citation(s) in RCA: 800] [Impact Index Per Article: 266.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The Central Brain Tumor Registry of the United States (CBTRUS), in collaboration with the CDC and NCI, is the largest population-based registry focused exclusively on primary brain and other central nervous system (CNS) tumors in the United States (US) and represents the entire US population. This report contains the most up-to-date population-based data on primary brain tumors available and supersedes all previous reports in terms of completeness and accuracy and is the first CBTRUS Report to provide the distribution of molecular markers for selected brain and CNS tumor histologies. All rates are age-adjusted using the 2000 US standard population and presented per 100,000 population. The average annual age-adjusted incidence rate (AAAIR) of all malignant and non-malignant brain and other CNS tumors was 24.25 (Malignant AAAIR=7.06, Non-malignant AAAIR=17.18). This overall rate was higher in females compared to males (26.95 versus 21.35) and non-Hispanics compared to Hispanics (24.68 versus 22.12). The most commonly occurring malignant brain and other CNS tumor was glioblastoma (14.3% of all tumors and 49.1% of malignant tumors), and the most common non-malignant tumor was meningioma (39% of all tumors and 54.5% of non-malignant tumors). Glioblastoma was more common in males, and meningioma was more common in females. In children and adolescents (age 0-19 years), the incidence rate of all primary brain and other CNS tumors was 6.21. An estimated 88,190 new cases of malignant and non-malignant brain and other CNS tumors are expected to be diagnosed in the US population in 2021 (25,690 malignant and 62,500 non-malignant). There were 83,029 deaths attributed to malignant brain and other CNS tumors between 2014 and 2018. This represents an average annual mortality rate of 4.43 per 100,000 and an average of 16,606 deaths per year. The five-year relative survival rate following diagnosis of a malignant brain and other CNS tumor was 66.9%, for a non-malignant brain and other CNS tumors the five-year relative survival rate was 92.1%.
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Affiliation(s)
- Quinn T Ostrom
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, NC, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, NC, USA
- Duke Cancer Institute, Duke University Medical Center, Durham, NC, USA
| | - Gino Cioffi
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, MD, USA
| | - Kristin Waite
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, MD, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
| | - Jill S Barnholtz-Sloan
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Trans Divisional Research Program (TDRP), Division of Cancer Epidemiology and Genetics (DCEG), National Cancer Institute, Bethesda, MD, USA
- Center for Biomedical Informatics & Information Technology (CBIIT), National Cancer Institute, Bethesda, MD, USA
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Alba PR, Gao A, Lee KM, Anglin-Foote T, Robison B, Katsoulakis E, Rose BS, Efimova O, Ferraro JP, Patterson OV, Shelton JB, Duvall SL, Lynch JA. Ascertainment of Veterans With Metastatic Prostate Cancer in Electronic Health Records: Demonstrating the Case for Natural Language Processing. JCO Clin Cancer Inform 2021; 5:1005-1014. [PMID: 34570630 DOI: 10.1200/cci.21.00030] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE Prostate cancer (PCa) is among the leading causes of cancer deaths. While localized PCa has a 5-year survival rate approaching 100%, this rate drops to 31% for metastatic prostate cancer (mPCa). Thus, timely identification of mPCa is a crucial step toward measuring and improving access to innovations that reduce PCa mortality. Yet, methods to identify patients diagnosed with mPCa remain elusive. Cancer registries provide detailed data at diagnosis but are not updated throughout treatment. This study reports on the development and validation of a natural language processing (NLP) algorithm deployed on oncology, urology, and radiology clinical notes to identify patients with a diagnosis or history of mPCa in the Department of Veterans Affairs. PATIENTS AND METHODS Using a broad set of diagnosis and histology codes, the Veterans Affairs Corporate Data Warehouse was queried to identify all Veterans with PCa. An NLP algorithm was developed to identify patients with any history or progression of mPCa. The NLP algorithm was prototyped and developed iteratively using patient notes, grouped into development, training, and validation subsets. RESULTS A total of 1,144,610 Veterans were diagnosed with PCa between January 2000 and October 2020, among which 76,082 (6.6%) were identified by NLP as having mPCa at some point during their care. The NLP system performed with a specificity of 0.979 and sensitivity of 0.919. CONCLUSION Clinical documentation of mPCa is highly reliable. NLP can be leveraged to improve PCa data. When compared to other methods, NLP identified a significantly greater number of patients. NLP can be used to augment cancer registry data, facilitate research inquiries, and identify patients who may benefit from innovations in mPCa treatment.
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Affiliation(s)
- Patrick R Alba
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Anthony Gao
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Kyung Min Lee
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Tori Anglin-Foote
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Brian Robison
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Evangelia Katsoulakis
- Department of Radiation Oncology, James A. Haley Veterans Affairs Healthcare System, Tampa, FL
| | - Brent S Rose
- VA San Diego Health Care System, La Jolla, CA.,Division of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA
| | - Olga Efimova
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Jeffrey P Ferraro
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Olga V Patterson
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Jeremy B Shelton
- VA Greater Los Angeles Healthcare System, Los Angeles, CA.,University of California, Los Angeles School of Medicine, Los Angeles, CA
| | - Scott L Duvall
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Julie A Lynch
- VA Informatics and Computing Infrastructure, VA Salt Lake City Health Care System, Salt Lake City, UT.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT.,Department of Nursing and Health Sciences, University of Massachusetts, Boston, Boston, MA
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38
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Qiao EM, Voora RS, Nalawade V, Kotha NV, Qian AS, Nelson TJ, Durkin M, Vitzthum LK, Murphy JD, Stewart TF, Rose BS. Evaluating the clinical trends and benefits of low-dose computed tomography in lung cancer patients. Cancer Med 2021; 10:7289-7297. [PMID: 34528761 PMCID: PMC8525167 DOI: 10.1002/cam4.4229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Revised: 07/30/2021] [Accepted: 07/31/2021] [Indexed: 12/19/2022] Open
Abstract
Background Despite guideline recommendations, utilization of low‐dose computed tomography (LDCT) for lung cancer screening remains low. The driving factors behind these low rates and the real‐world effect of LDCT utilization on lung cancer outcomes remain limited. Methods We identified patients diagnosed with non‐small cell lung cancer (NSCLC) from 2015 to 2017 within the Veterans Health Administration. Multivariable logistic regression assessed the influence of LDCT screening on stage at diagnosis. Lead time correction using published LDCT lead times was performed. Cancer‐specific mortality (CSM) was evaluated using Fine–Gray regression with non‐cancer death as a competing risk. A lasso machine learning model identified important predictors for receiving LDCT screening. Results Among 4664 patients, mean age was 67.8 with 58‐month median follow‐up, 95% CI = [7–71], and 118 patients received ≥1 screening LDCT before NSCLC diagnosis. From 2015 to 2017, LDCT screening increased (0.1%–6.6%, mean = 1.3%). Compared with no screening, patients with ≥1 LDCT were more than twice as likely to present with stage I disease at diagnosis (odds ratio [OR] 2.16 [95% CI 1.46–3.20]) and less than half as likely to present with stage IV (OR 0.38 [CI 0.21–0.70]). Screened patients had lower risk of CSM even after adjusting for LDCT lead time (subdistribution hazard ratio 0.60 [CI 0.42–0.85]). The machine learning model achieved an area under curve of 0.87 and identified diagnosis year and region as the most important predictors for receiving LDCT. White, non‐Hispanic patients were more likely to receive LDCT screening, whereas minority, older, female, and unemployed patients were less likely. Conclusions Utilization of LDCT screening is increasing, although remains low. Consistent with randomized data, LDCT‐screened patients were diagnosed at earlier stages and had lower CSM. LDCT availability appeared to be the main predictor of utilization. Providing access to more patients, including those in diverse racial and socioeconomic groups, should be a priority.
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Affiliation(s)
- Edmund M Qiao
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Rohith S Voora
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Nikhil V Kotha
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Alexander S Qian
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Tyler J Nelson
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Michael Durkin
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA
| | - Lucas K Vitzthum
- Department of Radiation Oncology, Stanford University, Stanford, California, USA
| | - James D Murphy
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
| | - Tyler F Stewart
- Division of Hematology-Oncology, Department of Internal Medicine, University of California San Diego, La Jolla, California, USA
| | - Brent S Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, California, USA.,Veterans Health Administration San Diego Health Care System, La Jolla, California, USA
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Liu Y, Chorniak E, Odion R, Etienne W, Nair SK, Maccarini P, Palmer GM, Inman BA, Vo-Dinh T. Plasmonic gold nanostars for synergistic photoimmunotherapy to treat cancer. NANOPHOTONICS 2021; 10:3295-3302. [PMID: 36405500 PMCID: PMC9646244 DOI: 10.1515/nanoph-2021-0237] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 08/07/2021] [Indexed: 05/04/2023]
Abstract
Cancer is the second leading cause of death and there is an urgent need to improve cancer management. We have developed an innovative cancer therapy named Synergistic Immuno Photothermal Nanotherapy (SYMPHONY) by combining gold nanostars (GNS)-mediated photothermal ablation with checkpoint inhibitor immunotherapy. Our previous studies have demonstrated that SYMPHONY photoimmunotherapy not only treats the primary tumor but also dramatically amplifies anticancer immune responses in synergy with checkpoint blockade immunotherapy to treat remote and unresectable cancer metastasis. The SYMPHONY treatment also induces a 'cancer vaccine' effect leading to immunologic memory and prevents cancer recurrence in murine animal models. This manuscript provides an overview of our research activities on the SYMPHONY therapy with plasmonic GNS for cancer treatment.
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Affiliation(s)
- Yang Liu
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
- Department of Chemistry, Duke University, Durham, NC, 27708, USA
- Fitzpatrick Institute of Photonics, Duke University, Durham, NC, 27708, USA
| | - Ericka Chorniak
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Ren Odion
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
- Fitzpatrick Institute of Photonics, Duke University, Durham, NC, 27708, USA
| | - Wiguins Etienne
- Division of Urology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Smita K. Nair
- Department of Surgery, Duke University Medical Center, Durham, NC, 27710, USA
- Department of Pathology, Duke University Medical Center, Durham, NC, 27710, USA
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, 27710, USA
| | - Paolo Maccarini
- Fitzpatrick Institute of Photonics, Duke University, Durham, NC, 27708, USA
- Department of Electrical and Computer Engineering, Duke University, Durham, NC, 27708, USA
| | - Gregory M. Palmer
- Fitzpatrick Institute of Photonics, Duke University, Durham, NC, 27708, USA
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Brant A. Inman
- Fitzpatrick Institute of Photonics, Duke University, Durham, NC, 27708, USA
- Division of Urology, Duke University Medical Center, Durham, NC, 27710, USA
| | - Tuan Vo-Dinh
- Department of Biomedical Engineering, Duke University, Durham, NC, 27708, USA
- Department of Chemistry, Duke University, Durham, NC, 27708, USA
- Fitzpatrick Institute of Photonics, Duke University, Durham, NC, 27708, USA
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Wilkie JR, Lipson R, Johnson MC, Williams C, Moghanaki D, Elliott D, Owen D, Atluri N, Jolly S, Chapman CH. Use and Outcomes of SBRT for Early Stage NSCLC Without Pathologic Confirmation in the Veterans Health Care Administration. Adv Radiat Oncol 2021; 6:100707. [PMID: 34409207 PMCID: PMC8361048 DOI: 10.1016/j.adro.2021.100707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 03/01/2021] [Accepted: 03/18/2021] [Indexed: 11/18/2022] Open
Abstract
Purpose Stereotactic body radiation therapy (SBRT) use has increased among patients without pathologic confirmation (PC) of lung cancer. Empirical SBRT without PC raises concerns about variation in workup and patient selection, but national trends have not been well described. In this study, we assessed patterns of empirical SBRT use, workup, and causes of death among a large national non-small cell lung cancer (NSCLC) cohort. Methods and Materials We identified 2221 patients treated with SBRT for cT1-T2aN0M0 NSCLC in the Veterans Affairs health care system from 2008 to 2015. We reviewed their pretreatment workup and assessed associations between absence of PC and clinical and demographic factors. We compared causes of death between PC and non-PC groups and used Cox proportional hazards modeling to compare overall survival and lung cancer specific survival (LCSS) between these groups. Results Treatment without PC varied from 0% to 61% among Veterans Affairs medical centers, with at least 5 cases of stage I NSCLC. Overall, 14.9% of patients were treated without PC and 8.8% did not have a biopsy attempt. Ten percent of facilities were responsible for almost two-thirds (62%) of cases of treatment without PC. Of non-PC patients, 95.5% had positron emission tomography scans, 40.6% had biopsy procedures attempted, and 12.7% underwent endobronchial ultrasound. Non-PC patients were more likely to have cT1 tumors and live outside the histoplasmosis belt. Age, sex, smoking status, and Charlson comorbidity index were similar between groups. Lung cancer was the most common cause of death in both groups. Overall survival was similar between groups, whereas non-PC patients had better LCSS (hazard ratio = 0.77, P = .031). Conclusions Empirical SBRT use varied widely among institutions and appropriate radiographic workup was consistently used in this national cohort. Future studies should investigate determinants of variation and reasons for higher LCSS among non-PC patients.
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Affiliation(s)
- Joel R. Wilkie
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Rachel Lipson
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
| | | | - Christina Williams
- Cooperative Studies Program Epidemiology Center-Durham, Durham Veterans Affairs Health Care System, Durham, North Carolina
- Department of Medicine, Duke University, Durham, North Carolina
| | - Drew Moghanaki
- Atlanta Veterans Affairs Health Care System, East Point, Georgia
- Winship Cancer Institute of Emory University, Atlanta, Georgia
| | - David Elliott
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Dawn Owen
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
- Mayo Clinic Rochester, Department of Radiation Oncology, Rochester, Minnesota
| | | | - Shruti Jolly
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
| | - Christina Hunter Chapman
- Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Radiation Oncology, University of Michigan, Ann Arbor, Michigan
- Corresponding author: Christina Hunter Chapman, MD, MS
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Yoder AK, Lakomy DS, Dong Y, Raychaudhury S, Royse K, Hartman C, Richardson P, White DL, Kramer JR, Lin LL, Chiao E. The association between protease inhibitors and anal cancer outcomes in veterans living with HIV treated with definitive chemoradiation: a retrospective study. BMC Cancer 2021; 21:776. [PMID: 34225709 PMCID: PMC8256603 DOI: 10.1186/s12885-021-08514-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 06/15/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND The incidence of anal squamous cell carcinoma has been increasing, particularly in people living with HIV (PLWH). There is concern that radiosensitizing drugs, such as protease inhibitors, commonly used in the management of HIV, may increase toxicities in patients undergoing chemoradiation. This study examines treatment outcomes and toxicities in PLWH managed with and without protease inhibitors who are receiving chemoradiation for anal cancer. METHODS Patient demographic, HIV management, and cancer treatment information were extracted from multiple Veterans Affairs databases. Patients were also manually chart reviewed. Among PLWH undergoing chemoradiation for anal carcinoma, therapy outcomes and toxicities were compared between those treated with and without protease inhibitors at time of cancer treatment. Statistical analysis was performed using chi-square, Cox regression analysis, and logistic regression. RESULTS A total of 219 PLWH taking anti-retroviral therapy undergoing chemoradiation for anal cancer were identified and included in the final analysis. The use of protease inhibitors was not associated with any survival outcome including colostomy-free survival, progression-free survival, or overall survival (all adjusted hazard ratio p-values> 0.05). Regarding toxicity, protease inhibitor use was not associated with an increased odds of hospitalizations or non-hematologic toxicities; however, protease inhibitor use was associated with increased hospitalizations for hematologic toxicities, including febrile neutropenia (p < 0.01). CONCLUSION The use of protease inhibitors during chemoradiation for anal carcinoma was not associated with any clinical outcome or increase in non-hematologic toxicity. Their use was associated with increased hospitalizations for hematologic toxicities. Further prospective research is needed to evaluate the safety and efficacy of protease inhibitors for patients undergoing chemoradiation.
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Affiliation(s)
- Alison K Yoder
- University of Texas Health Science Center at Houston, McGovern School of Medicine, Houston, TX, USA
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David S Lakomy
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
- Dartmouth College Geisel School of Medicine, Hanover, NH, USA
| | - Yongquan Dong
- Department of Medicine, Baylor College of Medicine, 1155 Pressler St. Unit, Houston, 1340, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Suchismita Raychaudhury
- Department of Medicine, Baylor College of Medicine, 1155 Pressler St. Unit, Houston, 1340, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Kathryn Royse
- Department of Medicine, Baylor College of Medicine, 1155 Pressler St. Unit, Houston, 1340, USA
| | - Christine Hartman
- Department of Medicine, Baylor College of Medicine, 1155 Pressler St. Unit, Houston, 1340, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Peter Richardson
- Department of Medicine, Baylor College of Medicine, 1155 Pressler St. Unit, Houston, 1340, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Donna L White
- Department of Medicine, Baylor College of Medicine, 1155 Pressler St. Unit, Houston, 1340, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Jennifer R Kramer
- Department of Medicine, Baylor College of Medicine, 1155 Pressler St. Unit, Houston, 1340, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Lilie L Lin
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth Chiao
- Department of Medicine, Baylor College of Medicine, 1155 Pressler St. Unit, Houston, 1340, USA.
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
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Tummalapalli SL, Vittinghoff E, Hoggatt KJ, Keyhani S. Preventive Care Delivery After the Veterans Choice Program. Am J Prev Med 2021; 61:55-63. [PMID: 33820664 PMCID: PMC8217145 DOI: 10.1016/j.amepre.2021.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 01/12/2021] [Accepted: 01/15/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The Veterans Choice Program expanded Veteran access to community care. The Veterans Choice Program may negatively impact the receipt of preventive care services owing to care fragmentation. This study assesses 10 measures of preventive care in Veterans with the Department of Veterans Affairs coverage before and after the Veterans Choice Program. METHODS The study population included Veterans who responded to the National Health Interview Survey during the 2 time periods before and after Veterans Choice Program implementation: January 2011-October 2014 and November 2015-December 2018. Outcomes were preventive care services categorized as cardiovascular risk reduction (cholesterol monitoring, blood pressure monitoring, aspirin use), infectious disease prevention (influenza vaccination and HIV testing), and diabetes care (fasting blood glucose monitoring, podiatry visits, ophthalmology visits, influenza vaccination, and pneumonia vaccination). Two different analyses were conducted: (1) unadjusted and multivariable-adjusted pre-post analysis and (2) difference-in-differences analyses. Analyses were conducted in 2019. RESULTS Measures of cardiovascular risk reduction and influenza vaccination were not statistically different before and after Veterans Choice Program implementation using the 2 different analytic approaches. In unadjusted pre-post analysis, after Veterans Choice Program implementation, Veterans with Veterans Affairs coverage had increased HIV testing (66.1%‒75.4%, p=0.008), podiatry visits (22.4%‒38.3%, p=0.01), and ophthalmology visits (62.2%‒77.2%, p=0.02). Using multivariable adjustment for participant sociodemographic factors, Veterans Choice Program implementation was associated with higher odds of podiatry visits (AOR=2.28, 95% CI=1.24, 4.20, p=0.009) and ophthalmology visits (AOR=2.11, 95% CI=1.13, 3.94, p=0.02) among Veterans with diabetes. In difference-in-differences analyses, Veterans Choice Program implementation was associated with increased podiatry visits (AOR=2.95, 95% CI=1.49, 5.83, p=0.002) among Veterans with diabetes and Veterans Affairs coverage compared with that among those with other coverage types, but no statistically significant effect was observed for ophthalmology visits. CONCLUSIONS Veterans with Veterans Affairs coverage and diabetes had an increase in podiatry visits after Veterans Choice Program implementation. There was no evidence that Veterans Choice Program implementation had a negative impact on the receipt of preventive care services among Veterans with Veterans Affairs coverage.
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Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science & Innovation, Department of Population Health Sciences, Weill Cornell Medicine, New York, New York; Department of Medicine, University of California San Francisco, San Francisco, California.
| | - Eric Vittinghoff
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California
| | - Katherine J Hoggatt
- Department of Medicine, University of California San Francisco, San Francisco, California; San Francisco VA Health Care System, San Francisco, California
| | - Salomeh Keyhani
- Department of Medicine, University of California San Francisco, San Francisco, California; San Francisco VA Health Care System, San Francisco, California
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Caram ME, Burns J, Kumbier K, Sparks JB, Tsao PA, Chapman CH, Bauman J, Hollenbeck BK, Shahinian VB, Skolarus TA. Factors influencing treatment of veterans with advanced prostate cancer. Cancer 2021; 127:2311-2318. [PMID: 33764537 PMCID: PMC8195818 DOI: 10.1002/cncr.33485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/01/2020] [Accepted: 01/20/2021] [Indexed: 11/06/2022]
Abstract
BACKGROUND Treatments for metastatic castration-resistant prostate cancer (CRPC) differ in toxicity, administration, and evidence. In this study, clinical and nonclinical factors associated with the first-line treatment for CRPC in a national delivery system were evaluated. METHODS National electronic laboratory and clinical data from the Veterans Health Administration were used to identify patients with CRPC (ie, rising prostate-specific antigen [PSA] on androgen deprivation) who received abiraterone, enzalutamide, docetaxel, or ketoconazole from 2010 through 2017. It was determined whether clinical (eg, PSA) and nonclinical factors (eg, race, facility) were associated with the first-line treatment selection using multilevel, multinomial logistic regression. The average marginal effects (AMEs) were calculated of patient, disease, and facility characteristics on ketoconazole versus more appropriate CRPC therapy. RESULTS There were 4998 patients identified with CRPC who received first-line ketoconazole, docetaxel, abiraterone, or enzalutamide. After adjustment, increasing age was associated with receipt of abiraterone (adjusted odds ratio [aOR], 1.07; 95% credible interval [CrI], 1.06-1.09) or enzalutamide (aOR, 1.10; 95% CrI, 1.08-1.11) versus docetaxel. Greater preexisting comorbidity was associated with enzalutamide versus abiraterone (aOR, 1.53; 95% CrI, 1.23-1.91). Patients with higher PSA values at the start of treatment were more likely to receive docetaxel than oral agents and less likely to receive ketoconazole than other oral agents. African American men were more likely to receive ketoconazole than abiraterone, enzalutamide, or docetaxel (AME, 2.8%; 95% CI, 0.7%-4.9%). This effect was attenuated when adjusting for facility characteristics (AME, 1.9%; 95% CI, -0.4% to 4.1%). CONCLUSIONS Clinical factors had an expected effect on the first-line treatment selection. Race may be associated with the receipt of a guideline-discordant first-line treatment.
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Affiliation(s)
- Megan E.V. Caram
- Department of Internal Medicine, University of Michigan Medical School
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jennifer Burns
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Kyle Kumbier
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Jordan B. Sparks
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
| | - Phoebe A. Tsao
- Department of Internal Medicine, University of Michigan Medical School
| | - Christina H. Chapman
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Radiation Oncology, University of Michigan Medical School
| | - Jordan Bauman
- Department of Internal Medicine, University of Michigan Medical School
| | | | - Vahakn B. Shahinian
- Department of Internal Medicine, University of Michigan Medical School
- Department of Urology, University of Michigan Medical School
| | - Ted A. Skolarus
- VA Health Services Research & Development, Center for Clinical Management and Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan
- Department of Urology, University of Michigan Medical School
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Fillmore NR, La J, Szalat RE, Tuck DP, Nguyen V, Yildirim C, Do NV, Brophy MT, Munshi NC. Prevalence and Outcome of COVID-19 Infection in Cancer Patients: A National Veterans Affairs Study. J Natl Cancer Inst 2021; 113:691-698. [PMID: 33031532 PMCID: PMC7665587 DOI: 10.1093/jnci/djaa159] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/24/2020] [Accepted: 09/23/2020] [Indexed: 12/15/2022] Open
Abstract
Background Emerging data suggest variability in susceptibility and outcome to coronavirus disease 2019 (COVID-19) infection. Identifying risk factors associated with infection and outcomes in cancer patients is necessary to develop healthcare recommendations. Methods We analyzed electronic health records of the US Veterans Affairs Healthcare System and assessed the prevalence of COVID-19 infection in cancer patients. We evaluated the proportion of cancer patients tested for COVID-19 who were positive, as well as outcome attributable to COVID-19, and stratified by clinical characteristics including demographics, comorbidities, cancer treatment, and cancer type. All statistical tests are 2-sided. Results Of 22 914 cancer patients tested for COVID-19, 1794 (7.8%) were positive. The prevalence of COVID-19 was similar across age. Higher prevalence was observed in African American (15.0%) compared with White (5.5%; P < .001) and in patients with hematologic malignancy compared with those with solid tumors (10.9% vs 7.8%; P < .001). Conversely, prevalence was lower in current smokers and patients who recently received cancer therapy (<6 months). The COVID-19–attributable mortality was 10.9%. Higher attributable mortality rates were observed in older patients, those with higher Charlson comorbidity score, and in certain cancer types. Recent (<6 months) or past treatment did not influence attributable mortality. Importantly, African American patients had 3.5-fold higher COVID-19–attributable hospitalization; however, they had similar attributable mortality as White patients. Conclusion Preexistence of cancer affects both susceptibility to COVID-19 infection and eventual outcome. The overall COVID-19–attributable mortality in cancer patients is affected by age, comorbidity, and specific cancer types; however, race or recent treatment including immunotherapy do not impact outcome.
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Affiliation(s)
- Nathanael R Fillmore
- CSP Informatics Center, MAVERIC, VA Boston Healthcare System, Boston, MA, USA.,Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Jennifer La
- CSP Informatics Center, MAVERIC, VA Boston Healthcare System, Boston, MA, USA
| | - Raphael E Szalat
- Hematology and Oncology Department, VA Boston Healthcare System, Boston, MA, USA.,Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Hematology and Oncology Department, Boston University School of Medicine, Boston, MA, USA
| | - David P Tuck
- Hematology and Oncology Department, VA Boston Healthcare System, Boston, MA, USA
| | - Vinh Nguyen
- CSP Informatics Center, MAVERIC, VA Boston Healthcare System, Boston, MA, USA
| | - Cenk Yildirim
- CSP Informatics Center, MAVERIC, VA Boston Healthcare System, Boston, MA, USA
| | - Nhan V Do
- CSP Informatics Center, MAVERIC, VA Boston Healthcare System, Boston, MA, USA.,Hematology and Oncology Department, Boston University School of Medicine, Boston, MA, USA
| | - Mary T Brophy
- CSP Informatics Center, MAVERIC, VA Boston Healthcare System, Boston, MA, USA.,Hematology and Oncology Department, Boston University School of Medicine, Boston, MA, USA
| | - Nikhil C Munshi
- Hematology and Oncology Department, VA Boston Healthcare System, Boston, MA, USA.,Medical Oncology, Dana-Farber Cancer Institute, Boston, MA, USA.,Hematology and Oncology Department, Boston University School of Medicine, Boston, MA, USA
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Azar I, Al Masalmeh N, Esfandiarifard S, Virk G, Kiwan W, Frank Shields A, Mehdi S, Philip PA. The impact of primary tumor sidedness on survival in early-onset colorectal cancer by stage: A National Veterans Affairs retrospective analysis. Cancer Med 2021; 10:2987-2995. [PMID: 33797856 PMCID: PMC8085929 DOI: 10.1002/cam4.3757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 12/15/2020] [Accepted: 12/26/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The incidence of early-onset colorectal cancer (EOCRC) is rising. Left-sided colorectal cancer (LCC) is associated with better survival compared to right-sided colon cancer (RCC) in metastatic disease. NCCN guidelines recommend the addition of EGFR inhibitors to KRAS/NRAS WT metastatic CRC originating from the left only. Whether laterality impacts survival in locoregional disease and EOCRC is of interest. METHODS 65,940 CRC cases from the National VA Cancer Cube Registry (2001-2015) were studied. EOCRC (2096 cases) was defined as CRC diagnosed at <50 years. Using ICD codes, RCC was defined from the cecum to the hepatic flexure (C18.0-C18.3), and LCC from the splenic flexure to the rectum (C18.5-18.7; C19 and C20). RESULTS EOCRC is more likely to originate from the left side (66.65% LCC in EOCRC vs. 58.77% in CRC). Overall, LCC has better 5-year Overall Survival (OS) than RCC in stages I (61.67% vs. 58.01%) and III (46.1% vs. 42.1%) and better 1-year OS in stage IV (57.79% vs. 49.49%). Stage II RCC has better 5-year OS than LCC (53.39% vs. 49.28%). In EOCRC, there is no statistically significant difference between LCC and RCC in stages I-III. Stage IV EOCRC patients with LCC and RCC have a 1-year OS of 73.23% and 59.84%, respectively. CONCLUSION In EOCRC, LCC is associated with better OS than RCC only stage IV. In the overall population, LCC is associated with better OS in all stages except stage II. The better prognosis of stage II RCC might be due to the high incidence of mismatch repair deficient tumors in this subpopulation.
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Affiliation(s)
- Ibrahim Azar
- Karmanos Cancer InstituteDetroitMIUSA
- Wayne State UniversityDetroitMIUSA
- Albany Medical CollegeAlbanyNYUSA
| | | | | | | | | | | | - Syed Mehdi
- Stratton Veterans’ Affairs Medical CenterAlbanyNYUSA
| | - Philip A. Philip
- Karmanos Cancer InstituteDetroitMIUSA
- Wayne State UniversityDetroitMIUSA
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England BR, Campany M, Sayles H, Roul P, Yang Y, Ganti AK, Sokolove J, Robinson WH, Reimold AM, Kerr GS, Cannon GW, Sauer BC, Baker JF, Thiele GM, Mikuls TR. Associations of serum cytokines and chemokines with the risk of incident cancer in a prospective rheumatoid arthritis cohort. Int Immunopharmacol 2021; 97:107719. [PMID: 33933845 DOI: 10.1016/j.intimp.2021.107719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/20/2021] [Accepted: 04/21/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES We aimed to assess whether serum cytokine/chemokine concentrations predict incident cancer in RA patients. METHODS Data from cancer-free enrollees in the Veterans Affairs Rheumatoid Arthritis (VARA) Registry were linked to a national VA oncology database and the National Death Index (NDI) to identify incident cancers. Seventeen serum cytokines/chemokines were measured from enrollment serum and an overall weighted cytokine/chemokine score (CK score) was calculated. Associations of cytokines/chemokines with all-site, lung, and lymphoproliferative cancers were assessed in Cox regression models accounting for relevant covariates including age, sex, RA disease activity, and smoking. RESULTS In 1216 patients, 146 incident cancers (42 lung and 23 lymphoproliferative cancers) occurred over 10,072 patient-years of follow-up with a median time of 4.6 years from enrollment (cytokine/chemokine measurement) to cancer incidence. In fully adjusted models, CK score was associated with a higher risk of all-site (aHR 1.32, 95% CI 1.01-1.71, p < 0.001), lung (aHR 1.81, 1.40-2.34, p = 0.001), and lung/lymphoproliferative (aHR 1.54 [1.35-1.75], p < 0.001) cancer. The highest quartile of CK score was associated with a higher risk of all-site (aHR 1.91, 0.96-3.81, p = 0.07; p-trend = 0.005), lung (aHR 8.18, 1.63-41.23, p = 0.01; p-trend < 0.001), and lung/lymphoproliferative (aHR 4.56 [1.84-11.31], p = 0.001; p-trend < 0.001) cancer. Thirteen of 17 individual analytes were associated with incident cancer risk. CONCLUSION Elevated cytokine/chemokine concentrations are predictive of future cancer in RA patients, particularly lung and lymphoproliferative cancers. These results suggest that the measurement of circulating cytokines/chemokines could be informative in cancer risk stratification and could provide insight into future cancer prevention strategies in RA, and possibly individuals without RA.
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Affiliation(s)
- Bryant R England
- VA Nebraska-Western Iowa Healthcare System, Omaha, NE, USA; Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA.
| | - Megan Campany
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Harlan Sayles
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Punyasha Roul
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Yangyuna Yang
- Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Apar Kishor Ganti
- VA Nebraska-Western Iowa Healthcare System, Omaha, NE, USA; Division of Oncology-Hematology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Jeremy Sokolove
- Division of Immunology and Rheumatology, Stanford University, Stanford, CA, and the Department of Veterans Affairs, Palo Alto, CA, USA; GlaxoSmithKline, Collegeville, PA, USA(1)
| | - William H Robinson
- Division of Immunology and Rheumatology, Stanford University, Stanford, CA, and the Department of Veterans Affairs, Palo Alto, CA, USA
| | - Andreas M Reimold
- Dallas VA and University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Gail S Kerr
- Washington D.C. VA, Howard University, and Georgetown University, Washington D.C., USA
| | - Grant W Cannon
- Salt Lake City VA & University of Utah, Salt Lake City, UT, USA
| | - Brian C Sauer
- Salt Lake City VA & University of Utah, Salt Lake City, UT, USA
| | - Joshua F Baker
- Corporal Michael J. Crescenz VA Medical Center & University of Pennsylvania, Philadelphia, PA, USA
| | - Geoffrey M Thiele
- VA Nebraska-Western Iowa Healthcare System, Omaha, NE, USA; Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
| | - Ted R Mikuls
- VA Nebraska-Western Iowa Healthcare System, Omaha, NE, USA; Division of Rheumatology & Immunology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, NE, USA
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Jazowski SA, Sico IP, Lindquist JH, Smith VA, Bosworth HB, Danus S, Provenzale D, Kelley MJ, Zullig LL. Transportation as a barrier to colorectal cancer care. BMC Health Serv Res 2021; 21:332. [PMID: 33849524 PMCID: PMC8045363 DOI: 10.1186/s12913-021-06339-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 03/31/2021] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Transportation barriers limit access to cancer care services and contribute to suboptimal clinical outcomes. Our objectives were to describe the frequency of Veterans reporting and the factors associated with transportation barriers to or from colorectal cancer (CRC) care visits. METHODS Between November 2015 and September 2016, Veterans with incident stage I, II, or III CRC completed a mailed survey to assess perceived barriers to recommended care. Participants who reported difficulty with transportation to or from CRC care appointments were categorized as experiencing transportation barriers. We assessed pairwise correlations between transportation barriers, transportation-related factors (e.g., mode of travel), and chaotic lifestyle (e.g., predictability of schedules), and used logistic regression to examine the association between the reporting of transportation difficulties, distance traveled to the nearest Veterans Affairs (VA) facility, and life chaos. RESULTS Of the 115 Veterans included in this analysis, 18% reported experiencing transportation barriers. Distance to the VA was not strongly correlated with the reporting of transportation barriers (Spearman's ρ = 0.12, p = 0.19), but chaotic lifestyle was both positively and significantly correlated with experiencing transportation barriers (Spearman's ρ = 0.22, p = 0.02). Results from the logistic regression model modestly supported the findings from the pairwise correlations, but were not statistically significant. CONCLUSIONS Transportation is an important barrier to or from CRC care visits, especially among Veterans who experience greater life chaos. Identifying Veterans who experience chaotic lifestyles would allow for timely engagement in behavioral interventions (e.g., organizational skills training) and with support services (e.g., patient navigation).
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Affiliation(s)
- Shelley A Jazowski
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, 27701, USA
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Isabelle P Sico
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, 27701, USA
| | - Jennifer H Lindquist
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Valerie A Smith
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, 27701, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, 27701, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
- School of Nursing, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
| | - Susanne Danus
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
| | - Dawn Provenzale
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA
- Department of Medicine, Division of Gastroenterology, Duke University School of Medicine, Durham, NC, USA
- Cooperative Studies Program Epidemiology Center, Durham, NC, USA
| | - Michael J Kelley
- Department of Veterans Affairs, Specialty Care Services, Washington, DC, USA
- Durham Veterans Affairs Health Care System, Durham, NC, USA
- Division of Medical Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Leah L Zullig
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, 27701, USA.
- Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, Durham, NC, USA.
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Kotha NV, Cherry DR, Bryant AK, Nalawade V, Stewart TF, Rose BS. Prognostic utility of pretreatment neutrophil-lymphocyte ratio in survival outcomes in localized non-small cell lung cancer patients treated with stereotactic body radiotherapy: Selection of an ideal clinical cutoff point. Clin Transl Radiat Oncol 2021; 28:133-140. [PMID: 33997320 PMCID: PMC8089768 DOI: 10.1016/j.ctro.2021.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/18/2021] [Accepted: 03/28/2021] [Indexed: 12/25/2022] Open
Abstract
Neutrophil-lymphocyte ratio is a promising prognostic marker for several cancers. NLR is not useful as a marker of lung cancer survival in localized lung cancer. NLR has potential as a marker of competing mortality risk in localized lung cancer. NLR cutoff of 4.0 is proposed as a clinically useful cutoff point.
Background and purpose Neutrophil-lymphocyte ratio (NLR) has been associated with overall survival (OS) in non-small cell lung cancer (NSCLC). We aimed to assess the utility of NLR as a predictor of lung cancer-specific survival (LCS) and identify an optimal, pretreatment cutoff point in patients with localized NSCLC treated with stereotactic body radiotherapy (SBRT) within the Veterans Affairs’ (VA) national database. Materials and methods In the VA database, we identified patients with biopsy-proven, clinical stage I NSCLC treated with SBRT between 2006 and 2015. Cutoff points for NLR were calculated using Contal/O’Quigley’s and Cox Wald methods. Primary outcomes of OS, LCS, and non-lung cancer survival (NCS) were evaluated in Cox and Fine-Gray models. Results In 389 patients, optimal NLR cutoff was identified as 4.0. In multivariable models, NLR > 4.0 was associated with decreased OS (HR 1.44, p = 0.01) and NCS (HR 1.68, p = 0.01) but not with LCS (HR 1.32, p = 0.09). In a subset analysis of 229 patients with pulmonary function tests, NLR > 4.0 remained associated with worse OS (HR 1.51, p = 0.02) and NCS (HR 2.18, p = 0.01) while the association with LCS decreased further (HR 1.22, p = 0.39). Conclusion NLR was associated with worse OS in patients with localized NSCLC treated with SBRT; however, NLR was only associated with NCS and not with LCS. Pretreatment NLR, with a cutoff of 4.0, offers potential as a marker of competing mortality risk which can aid in risk stratification in this typically frail and comorbid population. Further studies are needed to validate pretreatment NLR as a clinical tool in this setting.
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Affiliation(s)
- Nikhil V Kotha
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA 92037, USA.,Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - Daniel R Cherry
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA 92037, USA.,Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - Alex K Bryant
- Department of Radiation Oncology, University of Michigan, Ann Arbor, MI 48109, USA
| | - Vinit Nalawade
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA 92037, USA.,Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
| | - Tyler F Stewart
- Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA.,Division of Hematology-Oncology, Department of Medicine, University of California San Diego, La Jolla, CA 92093, USA
| | - Brent S Rose
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, La Jolla, CA 92037, USA.,Veterans Affairs San Diego Healthcare System, San Diego, CA 92161, USA
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Optimal treatment strategies for stage I non-small cell lung cancer in veterans with pulmonary and cardiac comorbidities. PLoS One 2021; 16:e0248067. [PMID: 33735217 PMCID: PMC7971489 DOI: 10.1371/journal.pone.0248067] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/19/2021] [Indexed: 12/25/2022] Open
Abstract
Background Veterans are at increased risk of lung cancer and many have comorbidities such as chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). We used simulation modeling to assess projected outcomes associated with different management strategies of Veterans with stage I non-small cell lung cancer (NSCLC) with COPD and/or CAD. Patients and methods Using data from a cohort of 14,029 Veterans (years 2000–2015) with NSCLC we extended a well-validated mathematical model of lung cancer to represent the management and outcomes of Veterans with stage I NSCLC with COPD, with or without comorbid CAD. We simulated multiple randomized trials to compare treatment with lobectomy, limited resection, or stereotactic body radiation therapy (SBRT). Model output estimated expected quality adjusted life years (QALY) of Veterans with stage I NSCLC according to age, tumor size, histologic subtype, COPD severity and CAD diagnosis. Results For Veterans <70 years old lobectomy was associated with greater projected quality-adjusted life expectancy regardless of comorbidity status. For most combinations of tumors and comorbidity profiles there was no dominant treatment for Veterans ≥80 years of age, but less invasive treatments were often superior to lobectomy. Dominant treatment choices differed by CAD status for older patients in a third of scenarios, but not for patients <70 years old. Conclusions The harm/benefit ratio of treatments for stage I NSCLC among Veterans may vary according to COPD severity and the presence of CAD. This information can be used to direct future research study design for Veterans with stage I lung cancer and COPD and/or CAD.
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Murillo J, Artz J, Brahmaroutu A, Gunnell S, Benge J, Lyon K, Fonkem E. An Exploratory Study of the Frequency of Central Nervous System Tumors by Type in the Central Texas Military and Civilian Populations. Cureus 2021; 13:e13885. [PMID: 33868849 PMCID: PMC8043054 DOI: 10.7759/cureus.13885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The types of central nervous system (CNS) tumors in a patient population with a history of military service were compared to the types of CNS tumors in a similar patient population without a military service history to determine if a relationship exists between military service and CNS tumor type. METHODS This study analyzed data for adult patients diagnosed with an intra- or extra-axial CNS tumor from January 2016 to July 2019. One cohort was constructed of patients who had a history of military service (MIL), and the other cohort was made of patients who did not have a history of military service (NMIL). Appropriate parametric and non-parametric analyses were used to compare frequencies of tumor types between cohorts adjusting for potential confounders. RESULTS We identified 2001 patients (MIL, n = 190; NMIL, n = 1811). In the MIL cohort, most patients were males, younger, and more racially diverse. In the primary analysis, the MIL cohort showed higher diagnoses of metastatic tumors compared with the NMIL cohort (X2(1)= 3.71, p=.05). The MIL cohort also showed lower diagnoses of meningioma compared to the NMIL cohort. There was no statically significant difference between cohorts or tumors after adjusting for primary source by gender. CONCLUSIONS MIL experience was associated with lower diagnoses of meningioma but higher diagnoses of metastatic cancer, providing support that there may be potential differences in tumor types between patients with a history of military service and those without military history regarding primary CNS tumor frequency.
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Affiliation(s)
- Jennifer Murillo
- Neurology, Baylor Scott & White Medical Center - Temple, Temple, USA
| | - Jonathan Artz
- Psychiatry, Baylor Scott & White Medical Center - Temple, Temple, USA
| | - Ankita Brahmaroutu
- Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Spencer Gunnell
- Neurology, Baylor Scott & White Medical Center - Temple, Temple, USA
| | - Jared Benge
- Neuropsychology, University of Texas at Austin Dell Medical School, Austin, USA
| | - Kristopher Lyon
- Neurosurgery, Baylor Scott & White Medical Center - Temple, Temple, USA
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