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VA Articles of Interest (Winter 2023)

Suicide risk following a new cancer diagnosis among Veterans in Veterans Health Administration care

Cancer Med. 2023 Feb; 12(3): 3520–3531.
Published online 2022 Aug 27. doi: 10.1002/cam4.5146
PMID: 36029038

Kallisse R. Dent, 1 Benjamin R. Szymanski, 1 Michael J. Kelley, 2 , 3 , 4 Ira R. Katz, 5 and John F. McCarthy 1

Veterans Affairs (VA) Serious Mental Illness Treatment Resource and Evaluation Center, Office of Mental Health and Suicide Prevention, Ann Arbor Michigan, USA
Veterans Affairs (VA) National Oncology Program, Specialty Care Services, VA, Washington District of Columbia, USA
Duke Cancer Institute, Durham North Carolina, USA
Hematology‐Oncology, Durham VA Health Care System, Durham North Carolina, USA
VA Office of Mental Health and Suicide Prevention, Washington District of Columbia, USA


Background: Cancer diagnoses are associated with an increased risk for suicide. The aim of this study was to evaluate this association among Veterans receiving Veterans Health Administration (VHA) care, a population that has an especially high suicide risk.

Methods: Among 4,926,373 Veterans with VHA use in 2011 and in 2012 or 2013, and without VHA cancer diagnoses in 2011, we assessed suicide risk following incident cancer diagnoses. Risk time was from initial VHA use in 2012–2013 to 12/31/2018 or death, whichever came first. Cox proportional hazards regression models evaluated associations between new cancer diagnoses and suicide risk, adjusting for age, sex, VHA regional network, and mental health comorbidities. Suicide rates were calculated among Veterans with new cancer diagnoses through 84 months following diagnosis.

Results: A new cancer diagnosis corresponded to a 47% higher suicide risk (Adjusted Hazard Ratio [aHR] = 1.47, 95% CI: 1.33–1.63). The cancer subtype associated with the highest suicide risk was esophageal cancer (aHR = 6.01, 95% CI: 3.73–9.68), and other significant subtypes included head and neck (aHR = 3.55, 95% CI: 2.74–4.62) and lung cancer (aHR = 2.35, 95% CI: 1.85–3.00). Cancer stages 3 (aHR = 2.36, 95% CI: 1.80–3.11) and 4 (aHR = 3.53, 95% CI: 2.81–4.43) at diagnosis were positively associated with suicide risk. Suicide rates were highest within 3 months following diagnosis and remained elevated in the 3–6‐ and 6–12‐month periods following diagnosis.

Conclusion: Among Veteran VHA users, suicide risk was elevated following new cancer diagnoses. Risk was particularly high in the first 3 months. Additional screening and suicide prevention efforts may be warranted for VHA Veterans newly diagnosed with cancer.

Keywords: cancer survivors, suicide, veterans

Association of Rurality with Annual Repeat Lung Cancer Screening in the Veterans Health Administration

J Am Coll Radiol. 2022 Jan; 19(1 Pt B): 131–138.
doi: 10.1016/j.jacr.2021.08.027
PMID: 35033300

Lucy B. Spalluto, MD MPH,1,2,3 Jennifer A. Lewis, MD MS MPH,1,3,4 Lauren R. Samuels, PhD,1,5 Carol Callaway-Lane, DNP ACNP-BC,1 Michael E. Matheny, MD MS MPH,1,6,7 Jason Denton,1,6,7,* Jennifer A. Robles, MD MPH,1,8,9 Robert S. Dittus, MD MPH,1,7 David F. Yankelevitz, MD,10 Claudia I. Henschke, PhD MD,10,11 Pierre P. Massion, MD,3,12,13,* Drew Moghanaki, MD MPH,14,15 and Christianne L. Roumie, MD MPH1,7

1.Veterans Health Administration-Tennessee Valley Health Care System Geriatric Research, Education and Clinical Center (GRECC), Nashville, TN
2.Department of Radiology, Vanderbilt University Medical Center, Nashville, TN
3.Vanderbilt-Ingram Cancer Center, Nashville, TN
4.Division of Hematology and Oncology, Vanderbilt University Medical Center, Nashville, TN
5.Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, TN
6.Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
7.Division of General Internal Medicine and Public Health, Vanderbilt University Medical Center, Nashville, TN
8.Veterans Health Administration – Tennessee Valley Healthcare System, Surgery Service, Nashville, TN
9.Department of Urology, Vanderbilt University Medical Center, Nashville, TN
10.Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY
11.Phoenix Veterans Health Care System, Phoenix, AZ
12.Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
13.Veterans Health Administration – Tennessee Valley Healthcare System, Medical Service, Nashville, TN
14.Radiation Oncology, Greater Los Angeles Veterans Affairs Medical Center, Los Angeles, CA
15.Department of Radiation Oncology, University of California at Los Angeles, Los Angeles, CA


Purpose: Lung cancer causes the highest number of cancer-related deaths in the United States. Lung cancer incidence rates, mortality rates, and rates of advanced stage disease are higher among those who live in rural areas. Known disparities in lung cancer outcomes between rural and non-rural populations may, in part, be due to barriers faced by rural populations. We tested the hypothesis that among Veterans who receive initial lung cancer screening, rural Veterans would be less likely to complete annual repeat screening than non-rural Veterans.

Methods: We performed a retrospective cohort study of 10 Veterans Affairs Medical Centers from 2015-2019. We identified rural and non-rural Veterans having lung cancer screening. Rural status was defined by the Rural-Urban Commuting Areas (RUCA). The primary outcome was annual repeat lung cancer screening in the 9-15 month window (primary analysis) and 31 day-18 month window (sensitivity analysis) following the first documented lung cancer screening. To examine rurality as a predictor of annual repeat lung cancer screening, we used multivariable logistic regression models.

Results: In the final analytic sample of 11,402 Veterans, annual repeat lung cancer screening occurred in 27.7% (641/2,316) of rural Veterans versus 31.8% (2,891/9,086) of non-rural Veterans [aOR 0.86, CI 0.73-1.03]. Similar results were seen in the sensitivity analysis with 41.6% (963/2,316) of rural Veterans versus 45.2% (4,110/9,086) of non-rural Veterans, [aOR 0.88, CI 0.73-1.04] having annual repeat screening in the expanded 31 day - 18 month window.

Conclusion: Among a national cohort of Veterans, rural residence was associated with numerically lower odds of annual repeat lung cancer screening than non-rural residence. Continued, intentional outreach efforts to increase annual repeat lung cancer screening amongst rural Veterans may offer an opportunity to decrease deaths from lung cancer.

Improving supportive care for patients with Thoracic Malignancies – A randomized controlled trial

Contemp Clin Trials Commun. 2022 Aug; 28: 100929.
Published online 2022 May 27. doi: 10.1016/j.conctc.2022.100929
PMID: 35669484

Manali I. Patel,a,b, Lakedia Banks,b and Millie Dasb

aDivision of Oncology, Stanford University School of Medicine, Stanford, CA, United States
bMedical Services, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, United States


Veterans have higher lung cancer incidence and mortality rates than civilians. Frequently, Veterans with lung cancer suffer from undertreated symptoms due to complex comorbidities, limited social support, and reluctance in discussing symptoms with their oncologists. Evidence supports proactive symptom screening among civilians with cancer; however, no studies to date have evaluated whether Veteran volunteer-led proactive symptom screening is feasible and effective among Veterans with lung cancer.

The “Improving Supportive Care for Patients with Thoracic Malignancies” study was co-developed by a pre-established Veteran and Family Advisory Board. Veterans with lung cancer are randomized in a 1:1 allocation to either a 9-month intervention combined with usual oncology care (intervention group) or usual oncology care alone (control group). A Veteran volunteer is assigned to all Veterans in the intervention group and conducts weekly symptom assessments using validated symptom surveys and reviews all symptom scores with an oncology nurse practitioner. The primary outcome is to evaluate whether the intervention improves documentation of symptoms at 6 months post-enrollment among Veterans in the intervention group as compared with the control group. Secondary outcomes include changes in patient-reported outcomes (i.e., symptom burden, patient activation, patient satisfaction with decision, health-related quality of life) and differences in acute care use (i.e., emergency department visits, hospitalizations) from baseline (time of enrollment in the study) to 3-, 6-, and 9-months post enrollment.

This study addresses a significant concern expressed by Veterans and their caregivers. Findings can advance our understanding of how to improve symptom-burden among Veterans with lung cancer. Registration #NCT03216109.

Keywords: Veteran health, Cancer care, Symptom management, Supportive cancer care, Lung cancer, Community health worker


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