VA Articles of Interest (Spring 2022)

Urol Oncol 2020 Jan;38(1):1.e1-1.e10. doi: 10.1016/j.urolonc.2019.09.027. Epub 2019 Nov 5.

Real-world practice patterns in veterans with metastatic castration-resistant prostate cancer

Ahmad S Halwani¹, Kelli M Rasmussen², Vikas Patil³, Catherine C Li³, Christina M Yong³, Zachary Burningham³, Sumati Gupta¹, Sujata Narayanan⁴, Shih-Wen Lin⁴, Susheela Carroll⁴, Shivani K Mhatre⁴, Julie N Graff⁵, Robert Dreicer⁶, Brian C Sauer³

Affiliations

¹George E. Wahlen Veterans Health Administration, Salt Lake City, UT; University of Utah, Salt Lake City, UT; Huntsman Cancer Institute, Salt Lake City, UT.
²George E. Wahlen Veterans Health Administration, Salt Lake City, UT; University of Utah, Salt Lake City, UT. Electronic address: kelli.rasmussen@hsc.utah.edu.
³George E. Wahlen Veterans Health Administration, Salt Lake City, UT; University of Utah, Salt Lake City, UT.
⁴Genentech, Inc, South San Francisco, California, FL.
⁵Oregon Health & Science University, Knight Cancer Center, Portland, OR.
⁶University of Virginia Cancer Center, Charlottesville, VA

Abstract

Background: Metastatic castration-resistant prostate cancer (mCRPC) is incurable, with most patients surviving less than 3 years. However, many treatments that extend survival have been approved in the past decade.

Objective: To describe the patient demographics, disease characteristics, treatment patterns, and outcomes in a cohort of Veterans diagnosed with mCRPC in the Veterans Health Administration.

Design: We identified 3,637 Veterans diagnosed with prostate cancer between January 2006 and August 2015 with evidence of mCRPC through December 2016. We described the most commonly used systemic mCRPC treatments according to mCRPC diagnosis era: Epoch 1 (2006-2010) or Epoch 2 (2011-2016). Patient demographics, disease characteristics, and treatment patterns were examined using descriptive statistics. An unadjusted Kaplan-Meier method was used to estimate the median time to biochemical progression and overall survival (OS) with 95% confidence intervals.

Results: The median age at initial prostate cancer diagnosis was 68 years. Approximately 67% of patients were non-Hispanic white, 29% were black, and 4% were other/unknown. A high-risk Gleason score (8-10) was reported in 748 (67%) of patients in Epoch 1 and 1578 (63%) of patients in Epoch 2, and the median prostate-specific antigen level at initial prostate cancer diagnosis was higher in Epoch 1 patients than in Epoch 2 patients (68 vs. 35 ng/ml). Following mCRPC diagnosis, the most common first-line therapies in Epoch 1 patients were docetaxel (83%) and abiraterone (9%), whereas Epoch 2 patients mainly received abiraterone (47%), docetaxel (36%), and enzalutamide (15%). In Epoch 1 and Epoch 2 patients, the median time to biochemical progression (unadjusted) was 9 and 13 months, respectively, and the median OS (unadjusted) was 15 and 23 months, respectively.

Conclusions: The introduction of new therapies has resulted in increased use of the noncytotoxic agents abiraterone and enzalutamide as first-line treatment in lieu of docetaxel. Our results suggest that more recently diagnosed patients (Epoch 2) have a delayed time to biochemical progression and longer OS (unadjusted) compared with patients diagnosed earlier (Epoch 1).

Keywords: Castration resistant; Metastatic; Practice patterns; Prostate cancer; Real world.

Chest 2021 Jul;160(1):358-367. doi: 10.1016/j.chest.2021.02.016. Epub 2021 Feb 19.

Access to Lung Cancer Screening in the Veterans Health Administration: Does Geographic Distribution Match Need in the Population?

Jacqueline H Boudreau¹, Donald R Miller², Shirley Qian¹, Eduardo R Nunez³, Tanner J Caverly⁴, Renda Soylemez Wiener⁵

Affiliations

¹Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA.
²Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA; Center for Population Health, Department of Biomedical and Nutritional Sciences, University of Massachusetts, Lowell, MA.
³Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA; The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA.
⁴Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI; Department of Learning Health Sciences and Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI.
⁵Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford MA; VA Boston Healthcare System, Boston, MA; The Pulmonary Center, Department of Medicine, Boston University School of Medicine, Boston, MA. Electronic address: rwiener@bu.edu.

Abstract

Background: Studies show uneven access to Medicare-approved lung cancer screening (LCS) programs across the United States. The Veterans Health Administration (VA), the largest national US integrated health system, is potentially well positioned to coordinate LCS services across regional units to ensure that access matches distribution of need nationally.

Research question: To what extent does LCS access (considering both VA and partner sites) and use match the distribution of eligible Veterans at state and regional levels?

Methods: In this retrospective analysis, we identified LCS examinations in VA facilities between 2013 and 2019 from the VA Corporate Data Warehouse and plotted VA facilities with LCS geographically. We compared estimated LCS rates (unique Veterans screened per LCS-eligible population) across states and VA regional units. Finally, we assessed whether the VA's new partnership with the GO₂ Foundation for Lung Cancer (which includes more than 750 LCS centers) closes geographic gaps in LCS access.

Results: We identified 71,898 LCS examinations in 96 of 139 (69.1%) VA facilities in 44 states between 2013 and 2019, with substantial variation across states (0-8 VA LCS facilities per state). Screening rates among eligible Veterans in the population varied more than 30-fold across regional networks (rate ratio, 33.6; 95% CI, 30.8-36.7 for VA New England vs Veterans Integrated Service Network 4), with weak correlation between eligible populations and LCS rates (coefficient, -0.30). Partnering with the GO₂ Foundation for Lung Cancer expands capacity and access (eg, all states now have ≥ 1 VA or partner LCS site), but 9 of the 12 states with the highest proportions of rural Veterans still have ≤ 3 total LCS facilities.

Interpretation: Disparities in LCS access exist based on where Veterans live, particularly for rural Veterans, even after partnering with the GO₂ Foundation for Lung Cancer. The nationally integrated VA system has an opportunity to leverage regional resources to distribute and coordinate LCS services better to ensure equitable access.

Keywords: access; lung cancer; lung cancer screening; preventive medicine; rural; veteran.

J Palliat Med 2020 Aug;23(8):1038-1044. doi: 10.1089/jpm.2019.0485. Epub 2020 Mar 2.

Concurrent Hospice Care and Cancer-Directed Treatment for Advanced Lung Cancer and Receipt of Aggressive Care at the End of Life in the Veteran's Health Administration

Carolyn J Presley¹, Ling Han², John R O'Leary², Weiwei Zhu², Emily Corneau³, Herta Chao²⁴, Tracy Shamas⁴, Michal Rose²⁴, Karl Lorenz⁵, Cari R Levy⁶, Vincent Mor³⁷, Cary P Gross⁸

Affiliations

¹Department of Internal Medicine, Medical Oncology, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA.
²Yale University School of Medicine, New Haven, Connecticut, USA.
³Providence Veterans Health Administration Medical Center, Center of Innovation, Providence, Rhode Island, USA.
⁴Connecticut Veterans Health Administration Medical Center, West Haven, Connecticut, USA.
⁵Department of Medicine, Primary Care and Population Health, Stanford University, Palo Alto, California, USA.
⁶Eastern Colorado VA Healthcare System, Aurora, Colorado, USA.
⁷Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, Rhode Island, USA.
⁸National Clinician Scholars Program, Yale School of Medicine, New Haven, Connecticut, USA.

Abstract

Background: Aggressive care at the end of life (EOL) is a persistent issue for patients with stage IV nonsmall cell lung cancer (NSCLC). We evaluated the use of concurrent care (CC) with hospice care and cancer-directed treatment simultaneously within the Veteran's Health Administration (VHA) and aggressive care at the EOL. Objective: To determine whether VHA facility-level CC is associated with changes in aggressive care at the EOL. Design/Setting: Veterans with stage IV NSCLC who died between 2006 and 2012 and received lung cancer care within the VHA. Measurements: The primary outcome was aggressive care at EOL (i.e., hospital admissions, chemotherapy, and intensive care unit) within the last month of life. To compare aggressive care across VHA facilities, we used a random intercept multilevel logistic regression model to examine the association between facility-level CC within each study year (<10%, 10% to 19%, and ≥20%) and aggressive care at the EOL among the decedents as a binary outcome. Results: In total, 18,371 veterans with NSCLC at 154 VHA facilities were identified. Facilities delivering CC for ≥20% of veterans (high CC) increased from 20.0% in 2006 to 43.2% in 2012 (p < 0.001). Overall, hospice care significantly increased and aggressive care at EOL decreased over the study period. However, facility-level CC adoption was not associated with any difference in aggressive care at EOL (adjusted odds ratio high CC vs. low CC: 0.91 [95% CI, 0.79 to 1.05], p = 0.21). Conclusions: Although the VHA adoption of CC increased hospice use among patients with NSCLC, additional measures may be needed to decrease aggressive care at the EOL.

Keywords: concurrent care; end-of-life; hospice; lung cancer; quality of life.

Future Oncol 2021 Feb;17(4):411-422. doi: 10.2217/fon-2020-0522. Epub 2020 Oct 29.

Real-world practice patterns and outcomes in Veterans with relapsed/refractory diffuse large B-cell lymphoma

Hsu-Chih Chien¹², Deborah Morreall¹², Vikas Patil¹², Kelli M Rasmussen¹², Chunyang Li¹², Christina M Yong¹², Zachary Burningham¹², Anthony Masaquel³, Mary Halloran³, Elisha De Long-Sieg³, Mathias Schulz³, Brian C Sauer¹², Ahmad S Halwani¹²⁴

Affiliations

¹George E Wahlen Veterans Health Administration, Salt Lake City, UT 84148, USA.
²VERITAS, Division of Epidemiology, University of Utah, Salt Lake City, UT 84112, USA.
³Genentech, Inc, South San Francisco, CA 94080, USA.
⁴Hematology & Hematologic Malignancies, Huntsman Cancer Institute, Salt Lake City, UT 84112, USA.

Abstract

Aim: To describe practices and outcomes in veterans with relapsed/refractory diffuse large B-cell lymphoma. Patients & methods: Using Veteran Affairs Cancer Registry System and electronic health record data, we identified relapsed/refractory diffuse large B-cell lymphoma patients completing second-line treatment (2L) in 2000-2016. Treatments were classified as aggressive/nonaggressive. Analyses included descriptive statistics and the Kaplan-Meier estimation of progression-free survival and overall survival. Results: Two hundred and seventy patients received 2L. During median 9.7-month follow-up starting from 2L, 470 regimens were observed, averaging 2.7 regimens/patient: 219 aggressive, 251 nonaggressive. One hundred and twenty-one patients proceeded to third-line, 50 to fourth-line and 18 to fifth-line treatment. Median progression-free survival in 2L was 5.2 months. Median overall survival was 9.5 months. Forty-four patients (16.3%) proceeded to bone marrow transplant. Conclusion: More effective, less toxic treatments are needed and should be initiated earlier in treatment trajectory.

Keywords: outcomes; practice patterns; real-world evidence; relapsed/refractory diffuse large B-cell lymphoma.

JAMA Oncol 2019 Jun 1;5(6):810-816. doi: 10.1001/jamaoncol.2019.0081.

Association of Expanded VA Hospice Care With Aggressive Care and Cost for Veterans With Advanced Lung Cancer

Vincent Mor¹², Todd H Wagner³⁴⁵, Cari Levy⁶⁷, Mary Ersek⁸⁹, Susan C Miller², Risha Gidwani-Marszowski³⁴¹⁰, Nina Joyce², Katherine Faricy-Anderson¹¹¹, Emily A Corneau¹, Karl Lorenz⁴⁵, Bruce Kinosian¹², Scott Shreve¹³¹⁴

Affiliations

¹Center of Innovation in Long-term Services and Supports (LTSS COIN), Providence VA Medical Center, Providence, Rhode Island.
²Department of Health Services, Policy & Practice, Brown University School of Public Health, Providence, Rhode Island.
³Health Economics Resource Center, VA Palo Alto Healthcare System, Palo Alto, California.
⁴Center of Innovation to Implementation, VA Palo Alto Healthcare System, Palo Alto, California.
⁵Stanford University School of Medicine, Palo Alto, California.
⁶Eastern Colorado VA Healthcare System, Denver.
⁷University of Colorado, Division of Health Care Policy and Research, Aurora.
⁸Veteran Experience Center (formerly, the PROMISE Center), Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.
⁹University of Pennsylvania School of Nursing, Philadelphia.
¹⁰Division of Primary Care and Population Health, Stanford University, Stanford, California.
¹¹Alpert Medical School of Brown University, Providence, Rhode Island.
¹²Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania.
¹³Hospice and Palliative Care Program, U.S. Department of Veterans Affairs.
¹⁴Penn State College of Medicine, Hershey, Pennsylvania.

Abstract

Importance: Medicare hospice beneficiaries discontinue disease-modifying treatments because the hospice benefit limits access. While veterans have concurrent access to hospice care and Veterans Affairs (VA) Medical Center (VAMC)-provided treatments, the association of this with changes in treatment and costs of veterans' end-of-life care is unknown.

Objective: To determine whether increasing availability of hospice care, without restrictions on disease-modifying treatments, is associated with reduced aggressive treatments and medical care costs at the end of life.

Design, setting, and participants: A modified difference-in-differences study design, using facility fixed effects, compared patient outcomes during years with relatively high vs lower hospice use. This study evaluated 13 085 veterans newly diagnosed with stage IV non-small cell lung cancer (NSCLC) from 113 VAMCs with a minimum of 5 veterans diagnosed with stage IV NSCLC per year, between 2006 and 2012. Data analyses were conducted between January 2017 and July 2018.

Exposures: Using VA inpatient, outpatient, pharmacy claims, and similar Medicare data, we created VAMC-level annual aggregates of all patients who died of cancer for hospice use, cancer treatment, and/or concurrent receipt of both in the last month of life, dividing all VAMC years into quintiles of exposure to hospice availability.

Main outcomes and measures: Receipt of aggressive treatments (2 or more hospital admissions within 30 days, tube feeding, mechanical ventilation, intensive care unit [ICU] admission) and total costs in the first 6 months after diagnosis.

Results: Of the 13 085 veterans included in the study, 12 858 (98%) were men; 10 531 (81%) were white, and 5949 (46%) were older than 65 years. Veterans with NSCLC treated in a VAMC in the top hospice quintile (79% hospice users), relative to the bottom quintile (55% hospice users), were more than twice as likely to have concurrent cancer treatment after initiating hospice care (adjusted odds ratio [AOR], 2.28; 95% CI, 1.67-3.31). Nonetheless, for veterans with NSCLC seen in VAMCs in the top hospice quintile, the AOR of receiving aggressive treatment in the 6 months after diagnosis was 0.66 (95% CI, 0.53-0.81), and the AOR of ICU use was 0.78 (95% CI, 0.62-0.99) relative to patients seen in VAMCs in the bottom hospice quintile. The 6-month costs were lower by an estimated $266 (95% CI, -$358 to -$164) per day for the high-quintile group vs the low-quintile group. There was no survival difference.

Conclusions and relevance: Increasing the availability of hospice care without restricting treatment access for veterans with advanced lung cancer was associated with less aggressive medical treatment and significantly lower costs while still providing cancer treatment.

Clin Genitourin Cancer 2021 Aug;19(4):369-369.e7. doi: 10.1016/j.clgc.2021.01.010. Epub 2021 Feb 18.

The Stage at Presentation and Oncologic Outcomes for Agent Orange Exposed and Non-Exposed United States Veterans Diagnosed With Prostate Cancer

Alexander E Tward¹, Jonathan D Tward²

Affiliations

¹College of Arts & Sciences, Washington University in St. Louis, St. Louis, Missouri.
²Department of Radiation Oncology, Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah. Electronic address: Jonathan.Tward@hci.utah.edu.

Abstract

Introduction: It is unknown if Agent Orange (AO)-exposed veterans have worse outcomes than unexposed Veterans after prostate cancer treatment. We evaluated oncologic outcomes based on AO exposure history, accounting for known prognostic covariates not previously studied.

Methods: US military Veterans diagnosed with prostate adenocarcinoma born between 1930 and 1956 were identified from our prospectively gathered institutional database. Evaluable patients had to have known AO exposure status, age, National Comprehensive Cancer Network risk group, Charlson comorbidity score, smoking status, and type of initial therapy. The risk of death, metastasis, and progression stratified by initial therapy was analyzed using Cox regression.

Results: Seventy AO-exposed and 561 non-exposed Veterans were identified (median follow-up, 10.0 years). AO-exposed veterans (AOeV) were slightly younger (64.0 vs 65.7 years; P = .013) at diagnosis and presented at more advanced stages (stage 4: 14.3% vs 2.5%) than non-AOeV. There was no difference for overall survival (hazard ratio [HR], 0.86; P = .576; metastasis-free survival (HR, 1.5; P = .212), or progression-free survival (HR, 0.67; P = .060) between AOeV vs non-AOeV in analyses stratified by treatment received accounting for other prognostic covariates. Cigarette smoking was associated with a 2- to 3-fold increased risk of death over those who quit or never smoked.

Conclusion: Although AOeV do present at a younger age and higher clinical stages than non-AOeV, the oncologic outcomes after accounting for treatments received and other prognostic covariates are similar.

Keywords: Tetrachlorodibenzo-p-dioxin; Vietnam veterans.

Head Neck 2021 Jan;43(1):108-115. doi: 10.1002/hed.26465. Epub 2020 Sep 12.

National trends in oropharyngeal cancer incidence and survival within the Veterans Affairs Health Care System

Jose P Zevallos¹², Jennifer R Kramer³⁴, Vlad C Sandulache⁵⁶⁷, Sean T Massa¹², Christine M Hartman³, Angela L Mazul¹², Benjamin M Wahle¹, Sophie P Gerndt¹, Erich M Sturgis⁵⁶, Elizabeth Y Chiao³⁴

Affiliations

¹Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
²John Cochran Veterans Affairs Medical Center, St. Louis, Missouri, USA.
³VA Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
⁴Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.
⁵ENT Section, Operative Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.
⁶Bobby R. Alford Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA.
⁷Center for Translational Research on Inflammatory Disease (CTRID), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.

Background: Oropharyngeal squamous cell carcinoma (OPSCC) epidemiology has not been examined previously in the nationwide Veterans Affairs (VA) population.

Methods: Joinpoint regression analysis was applied to OPSCC cases identified from VA administrative data from 2000 to 2012.

Results: We identified 12 125 OPSCC cases (incidence: 12.2 of 100 000 persons). OPSCC incidence declined between 2000 and 2006 (annual percent change [APC] = -4.27, P < .05), then increased between 2006 and 2012 (APC = 7.02, P < .05). Significant incidence increases occurred among white (APC = 7.19, P < .05) and African American (APC = 4.87, P < .05) Veterans and across all age cohorts. The percentage of never-smokers increased from 8% in 2000 to 15.7% in 2012 (P < .001), and 2-year overall survival improved from 31.2% (95% confidence interval (CI) [30-33.4]) to 55.7% (95% CI [54.4-57.1]).

Conclusions: OPSCC incidence is increasing across all racial and age cohorts in the VA population. Smoking rates remain high among Veterans with OPSCC and gains in survival lag those reported in the general population.

Keywords: Veterans Affairs; human papilloma virus; joinpoint; oropharyngeal cancer; survival.

Psychooncology 2021 Apr;30(4):581-590. doi: 10.1002/pon.5605. Epub 2020 Dec 13.

Posttraumatic stress disorder and suicide among veterans with prostate cancer

Maya Aboumrad¹, Brian Shiner¹², Lorelei Mucci³, Nabin Neupane¹, Florian R Schroeck¹², Zachary Klaassen⁴, Stephen J Freedland⁵⁶, Yinong Young-Xu¹²

Affiliations

¹White River Junction Veterans Affairs Medical Center, White River Junction, Vermont, USA.
²Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA.
³Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA.
⁴Medical College of Georgia at Augusta University, Augusta, Georgia, USA.
⁵Cedars-Sinai Medical Center, Los Angeles, California, USA.
⁶Durham Veterans Affairs Medical Center, Durham, North Carolina, USA.

Abstract

Objective: To evaluate the effect of a preexisting posttraumatic stress disorder (PTSD) diagnosis on suicide and non-suicide mortalities among men with newly diagnosed prostate cancer, and examine potential mediating factors for the relationship between PTSD and suicide.

Methods: We used patient-level data from Veterans Health Administration electronic medical records to identify men (age ≥40 years) diagnosed with prostate cancer between 2004 and 2014. We used Fine and Gray regression model to estimate the risk for competing mortality outcomes (suicide, non-suicide, and alive). We used structural equation models to evaluate the mediating factors.

Results: Our cohort comprised 214,649 men with prostate cancer, of whom 12,208 (5.7%) had a preexisting PTSD diagnosis. Patients with PTSD compared to those without utilized more healthcare services and had lower risk cancer at diagnosis. Additionally, they experienced more suicide deaths (N = 26, 0.21% vs. N = 269, 0.13%) and fewer non-suicide deaths (N = 1399, 11.5% vs. N = 45,625, 22.5%). On multivariable analysis, PTSD was an independent suicide risk factor (HR = 2.35; 95% CI: 1.16, 4.78). Depression, substance use disorder, and any definitive prostate cancer treatment were partial mediators. However, PTSD was associated with lower non-suicide mortality risk (HR = 0.86; 95% CI: 0.77, 0.96).

Conclusion: Patients with PTSD experienced greater suicide risk even after adjusting for important mediators. They may have experienced lower non-suicide mortality risk due to favorable physical health resulting from greater healthcare service use and early diagnosis of lower risk cancer. Our findings highlight the importance of considering psychiatric illnesses when treating patients with prostate cancer and the need for interventions to ameliorate suicide risk.

Keywords: cancer; depression; mental health; oncology; posttraumatic stress disorder; prostate cancer; psychooncology; substance use disorder; suicide; treatment.