VA Articles of Interest

December 14, 2018

J Cancer Educ. 2018 Sep 1. doi: 10.1007/s13187-018-1420-y. [Epub ahead of print]
Challenges to Educating Smokers About Lung Cancer Screening: a Qualitative Study of Decision Making Experiences in Primary Care.
Greene PA1, Sayre G2,3, Heffner JL4, Klein DE5, Krebs P6,7, Au DH2,3,8, Zeliadt SB2,3.

Author information
1.    Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, 98108
2.    Health Services Research & Development (HSR&D), Center of Innovation for Veteran-Centered Value-Driven Care, VA Puget Sound Health Care System, Seattle, WA, 98108
3.    Department of Health Services, University of Washington, Seattle, WA,98108
4.    Tobacco and Health Behavior Science Research Group, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
5.    Swedish Medical Group, Swedish Medical Center, Seattle, WA, USA.
6.    New York Harbor VA Health Care System, New York, NY, USA.
7.    School of Medicine, New York University, New York, NY, USA.
8.    Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, WA, USA.

 

Abstract
We sought to qualitatively explore how those at highest risk for lung cancer, current smokers, experienced, understood, and made decisions about participation in lung cancer screening (LCS) after being offered in the target setting for implementation, routine primary care visits. Thirty-seven current smokers were identified within 4 weeks of being offered LCS at seven sites participating in the Veterans Health Administration Clinical Demonstration Project and interviewed via telephone using semi-structured qualitative interviews. Transcripts were coded by two raters and analyzed thematically using iterative inductive content analysis. Five challenges to smokers' decision-making lead to overestimated benefits and minimized risks of LCS: fear of lung cancer fixated focus on inflated screening benefits; shame, regret, and low self-esteem stemming from continued smoking situated screening as less averse and more beneficial; screening was mistakenly believed to provide general evaluation of lungs and reassurance was sought about potential damage caused by smoking; decision-making was deferred to providers; and indifference about numerical educational information that was poorly understood. Biased understanding of risks and benefits was complicated by emotion-driven, uninformed decision-making. Emotional and cognitive biases may interfere with educating and supporting smokers' decision-making and may require interventions tailored for their unique needs.

Front Oncol. 2018 Aug 6;8:296. doi: 10.3389/fonc.2018.00296. eCollection 2018.
Prostate-Specific Antigen Trends Predict the Probability of Prostate Cancer in a Very Large U.S. Veterans Affairs Cohort.
Karnes RJ1, MacKintosh FR2, Morrell CH3, Rawson L2, Sprenkle PC4, Kattan MW5, Colicchia M1,6, Neville TB7.
Author information
1.    Mayo Clinic, Rochester, MN, United States.
2.    VA Sierra Nevada Health Care System, Reno, NV, United States.
3.    Mathematics and Statistics Department, Loyola University Maryland, Baltimore, MD, United States.
4.    VA Connecticut Healthcare System, Yale School of Medicine, New Haven, CT, United States.
5.    Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, United States.
6.    Urology, University of Padua, Padua, Italy.
7.    Soar BioDynamics, Inc., Incline Village, NV, United States.

 

Abstract
If prostate-specific antigen (PSA) trends help identify elevated prostate cancer (PCa) risk, they might provide early warning of progressing cancer for further evaluation and justify annual testing. Our objective was to determine whether PSA trends predict PCa likelihood. A biopsy cohort of 361,657 men was obtained from a Veterans Affairs database (1999-2012). PSA trends were estimated for the 310,458 men with at least 2 PSA tests prior to biopsy. Cancer tumors may grow exponentially with cells doubling periodically. We hypothesized that PSA from prostate cancer grows exponentially above a no cancer baseline. We estimated PSA trends on that basis along with five descriptive variables: last PSA before biopsy, growth rate in PSA from cancer above a baseline, PSA variability around the trend, number of PSA tests, and time span of tests. PSA variability is a new variable that measures percentage deviations of PSA tests from estimated trends with 0% variability for a smoothly increasing trend. Logistic regression models were used to estimate relationships between the probability of PCa at biopsy and the trend variables and age. All five PSA trend variables and age were significant predictors of prostate cancer at biopsy (p < 0.0001). An overall logistic regression model achieved an AUC of 0.67 for men with at least 4 tests over at least 3 years, which was a substantial improvement over a single PSA (AUC 0.58). High probability of PCa was associated with low PSA variability (smooth trends), high PSA, high growth rate, many tests over a long time-span and older age. For example, at 4.0 PSA the probability of cancer is 32% for 1 PSA test and increases to 68% for 8 tests over 7 years with smooth, fast growth (0% variability and 50% exponential growth). Our results show that smooth, fast exponential growth in PSA above a baseline predicts an increased probability of PCa. The probability increases as smooth (low variability) trends are observed for more tests over a longer time span, which makes annual testing worth considering. Worrisome PSA trends might be used to trigger further evaluation and continued monitoring of the trends-even at low PSA levels

J Oncol Pract. 2018 Aug 15:JOP1800159. doi: 10.1200/JOP.18.00159. [Epub ahead of print]
Root Cause Analysis of Oncology Adverse Events in the Veterans Health Administration.
Aboumrad M1, Fuld A1, Soncrant C1, Neily J1, Paull D1, Watts BV1.
Author information
1.    National Center for Patient Safety; White River Junction VA Medical Center, White River Junction, VT; The National Center for Patient Safety, Ann Arbor, MI; and Geisel School of Medicine at Dartmouth, Hanover, NH.

 

Abstract
PURPOSE: 
Oncology providers are leaders in patient safety. Despite their efforts, oncology-related medical errors still occur, sometimes resulting in patient injury or death. The Veterans Health Administration (VHA) National Center of Patient Safety used data obtained from root cause analysis (RCA) to determine how and why these adverse events occurred in the VHA, and how to prevent future reoccurrence. This study details the types of oncology adverse events reported in VHA hospitals and their root causes and suggests actions for prevention and improvement.
METHODS: 
We searched the National Center for Patient Safety adverse event reporting database for RCA related to oncology care from October 1, 2013, to September 8, 2017, to identify event types, root causes, severity of outcomes, care processes, and suggested actions. Two independent reviewers coded these variables, and inter-rater agreement was calculated by κ statistic. Variables were evaluated using descriptive statistics.
RESULTS: 
We identified 48 RCA reports that specifically involved an oncology provider. Event types included care delays (39.5% [n = 19]), issues with chemotherapy (25% [n = 12]) and radiation (12.5% [n = 6]), other (12.5% [n = 6]), and suicide (10.5% [n = 5]). Of the 48 events, 27.1% (n = 13) resulted in death, 4.2% (n = 2) in severe harm, 18.8% (n = 9) in temporary harm, 20.8% (n = 10) in minimal harm, and 2.1% (n = 1) in no harm. The majority of root causes identified a need to improve care processes and policies, interdisciplinary communication, and care coordination.
CONCLUSION: 
This analysis highlights an opportunity to implement system-wide changes to prevent similar events from reoccurring. These actions include comprehensive cancer clinics, usability testing of medical equipment, and standardization of processes and policies. Additional studies are necessary to assess oncologic adverse events across specialties.

J Am Coll Radiol. 2018 Aug 8. pii: S1546-1440(18)30770-1. doi: 10.1016/j.jacr.2018.06.029. 
Quality Improvements of Veterans Health Administration Radiation Oncology Services Through Partnership for Accreditation With the ACR.
Kapoor R1, Moghanaki D2, Rexrode S3, Monzon B3, Ray M3, Hulick PR4, Albuquerque K5, Rosenthal SA6, Palta JR7, Hagan MP7.
Author information
1.    Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia; Radiation Oncology Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia; National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, Virginia. 
2.    Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia; Radiation Oncology Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia.
3.    Radiation Oncology Practice Accreditation Program, American College of Radiology, Reston, Virginia.
4.    Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia; Radiation Oncology Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia; Radiation Oncology Practice Accreditation Program, American College of Radiology, Reston, Virginia.
5.    Radiation Oncology Practice Accreditation Program, American College of Radiology, Reston, Virginia; UT Southwestern Medical Center, Dallas, Texas.
6.    Sutter Medical Group and Sutter Cancer Centers, Sacramento, California.
7.    Department of Radiation Oncology, Virginia Commonwealth University, Richmond, Virginia; Radiation Oncology Service, Hunter Holmes McGuire Veterans Affairs Medical Center, Richmond, Virginia; National Radiation Oncology Program, US Veterans Healthcare Administration, Richmond, Virginia.

 

Abstract
Approximately 20,000 US veterans receive radiation oncology services at a Veterans Healthcare Administration (VHA) medical facility each year. They currently have access to advanced technologies, which include image-guided intensity-modulated radiotherapy, stereotactic radiosurgery, and stereotactic body radiation therapy. Although this provides access to cancer therapies that are modern, safe, and efficient, the technical complexities of these treatments and clinical decision making that goes into the patient selection and prescriptions demand quality assurances at each VHA practice. To meet the challenges of this need, the VHA established a partnership in 2008 with the ACR's Radiation Oncology Practice Accreditation Program (ACR-ROPA). This report summarizes the experience of this ongoing partnership and demonstrates the combined impact of the VHA's mandate for ACR-ROPA accreditation and internal monitoring of all identified corrective actions at each of its radiation oncology practices.

Ann Am Thorac Soc. 2018 Jul 30. doi: 10.1513/AnnalsATS.201805-298RL. [Epub ahead of print]
Outcomes of the First Three Years of a Lung Cancer Screening Program at a Veterans Affairs Medical Center.
Gartman E1,2, Jankowich M3,2, Baptiste J4, Schiff A1,5, Nici L1,6.
Author information
1.    Providence Veterans Affairs Medical Center, Medicine, Providence, Rhode Island, United States.
2.    Brown University Warren Alpert Medical School, 12321, Medicine, Providence, Rhode Island, United States.
3.    Providence VA Medical Center, Medicine, Providence, Rhode Island, United States.
4.    Beth Israel Deaconess Medical Center, 1859, Medicine, Boston, Massachusetts, United States.
5.    Brown University Warren Alpert Medical School, 12321, Providence, Rhode Island, United States.
6.    Brown University Warren Alpert Medical School, 12321, Providence, Rhode Island, United States 

 

Ann Am Thorac Soc. 2018 Jul 26. doi: 10.1513/AnnalsATS.201805-299RL. [Epub ahead of print]
Incidence of Suicide and Association with Palliative Care among Patients with Advanced Lung Cancer.
Sullivan DR1,2,3, Forsberg CW2, Golden SE4, Ganzini L5,6, Dobscha SK2,6, Slatore CG4,7,8,9.
Author information
1.    OHSU, Division of Pulmonary and Critical Care Medicine , Portland, Oregon, United States.
2.    Veterans Affairs Portland Health Care System , Center to Improve Veteran Involvement in Care, Portland, Oregon, United States.
3.    OHSU, Knight Cancer Institute , Portland, Oregon, United States 
4.    Portland VA Medical Center, Center to Improve Veteran Involvement in Care, Portland, Oregon, United States.
5.    Veterans Affairs Portland Health Care System, Center to Improve Veteran Involvement in Care, Portland, Oregon, United States.
6.    OHSU, Department of Psychiatry, Portland, Oregon, United States.
7.    Oregon Health & Sciences University, Division of Pulmonary and Critical Care Medicine, Portland, Oregon, United States.
8.    VA Portland Health Care System, Section of Pulmonary and Critical Care Medicine , Portland, Oregon, United States.9OHSU, Knight Cancer Institute , Portland, Oregon, United States.
9.    Cancer Discov. 2018 Aug;8(8):908. doi: 10.1158/2159-8290.CD-NB2018-097. Epub 2018 Jul 18.

Upping Enrollment of Veterans in Trials.
[No authors listed]

 

Abstract
The NCI and Department of Veterans Affairs (VA) are collaborating on the NCI and VA Interagency Group to Accelerate Trials Enrollment, or NAVIGATE, which will launch at 12 VA facilities across the country. The program aims to increase participation of veterans with cancer in NCI-sponsored clinical trials.

 

Respir Med. 2018 Aug;141:172-179. doi: 10.1016/j.rmed.2018.07.005. Epub 2018 Jul 17.
Time to treatment and survival in veterans with lung cancer eligible for curative intent therapy.
Ha D1, Ries AL2, Montgrain P3, Vaida F4, Sheinkman S5, Fuster MM3.
Author information
1.    Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, United States. 
2.    Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, United States.
3.    Section of Pulmonary and Critical Care Medicine, VA San Diego Healthcare System, San Diego, CA, United States; Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, United States.
4.    Division of Biostatistics and Bioinformatics, Department of Family and Preventative Medicine, University of California San Diego, La Jolla, CA, United States.
5.    Section of Pulmonary and Critical Care Medicine, VA San Diego Healthcare System, San Diego, CA, United States.


Abstract
BACKGROUND: 
The Institute of Medicine emphasizes care timeliness as an important quality metric. We assessed treatment timeliness in stage I-IIIA lung cancer patients deemed eligible for curative intent therapy and analyzed the relationship between time to treatment (TTT) and timely treatment (TT) with survival.
METHODS: 
We retrospectively reviewed consecutive cases of stage I-IIIA lung cancer deemed eligible for curative intent therapy at the VA San Diego Healthcare System between 10/2010-4/2017. We defined TTT as days from chest tumor board to treatment initiation and TT using guideline recommendations. We used multivariable (MVA) Cox proportional hazards regressions for survival analyses.
RESULTS: 
In 177 veterans, the median TTT was 35 days (29 days for chemoradiation, 36 for surgical resection, 42 for definitive radiation). TT occurred in 33% or 77% of patients when the most or least timely guideline recommendation was used, respectively. Patient characteristics associated with longer TTT included other cancer history, high simplified comorbidity score, stage I disease, and definitive radiation treatment. In MVA, TTT and TT [HR 0.53 (95% CI 0.27, 1.01) for least timely definition] were not associated with OS in stage I-IIIA patients, or disease-free survival in subgroup analyses of 122 stage I patients [HR 1.49 (0.62, 3.59) for least timely definition].
CONCLUSION: 
Treatment was timely in 33-77% of veterans with lung cancer deemed eligible for curative intent therapy. TTT and TT were not associated with survival. The time interval between diagnosis and treatment may offer an opportunity to deliver or improve other cancer care.

 

Gastroenterology. 2018 Jul 5. pii: S0016-5085(18)34721-8. doi: 10.1053/j.gastro.2018.06.079. [Epub ahead of print]
No Association Between Screening for Hepatocellular Carcinoma and Reduced Cancer-Related Mortality in Patients With Cirrhosis.
Moon AM1, Weiss NS2, Beste LA3, Su F4, Ho SB5, Jin GY6, Lowy E6, Berry K6, Ioannou GN7.
Author information
1.    Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina.
2.    Department of Epidemiology, University of Washington, Seattle, and Fred Hutchinson Cancer Research Center, Seattle, Washington.
3.    Division of General Internal Medicine, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington.
4.    Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington.
5.    Division of Gastroenterology, Veterans Affairs San Diego Healthcare System and University of California, San Diego, California.
6.    Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington.
7.    Division of Gastroenterology, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington; Research and Development, Veterans Affairs Puget Sound Healthcare System, Seattle, Washington. 

 

Abstract
BACKGROUND & AIMS: 
Screening patients with cirrhosis for hepatocellular carcinoma (HCC) has been recommended. We conducted a matched case-control study within the US Veterans Affairs (VA) health care system to determine whether screening by abdominal ultrasonography (USS) and/or by measuring serum level of α-fetoprotein (AFP) would be associated with decreased cancer-related mortality in patients with cirrhosis.
METHODS: 
We defined cases (n = 238) as patients with cirrhosis who died of HCC from January 1, 2013 through August 31, 2015 and had been in VA care with a diagnosis of cirrhosis for at least 4 years before the diagnosis of HCC. We matched each case to 1 control (n = 238), defined as a patient with cirrhosis who did not die of HCC and had been in VA care for at least 4 years before the date of the matched case's HCC diagnosis. Controls were matched to cases by year of cirrhosis diagnosis, race and ethnicity, age, sex, etiology of cirrhosis, Model for End-Stage Liver Disease score, and VA medical center. We identified all USS and serum AFP tests performed within 4 years before the date of HCC diagnosis in cases or the equivalent index date in controls and determined by chart extraction (blinded to case or control status) whether these tests were performed for screening.
RESULTS: 
There were no significant differences between cases and controls in the proportions of patients who underwent screening USS (52.9% vs 54.2%), screening measurement of serum AFP (74.8% vs 73.5%), screening USS or measurement of serum AFP (81.1% vs 79.4%), or screening USS and measurement of serum AFP (46.6% vs 48.3%) within 4 years before the index date, with or without adjusting for potential confounders. There also was no difference in receipt of these screening tests within 1, 2, or 3 years before the index date.
CONCLUSIONS: 
In a matched case-control study of the VA health care system, we found that screening patients with cirrhosis for HCC by USS, measurement of serum AFP, either test, or both tests was not associated with decreased HCC-related mortality. We encourage additional case-control studies to evaluate the efficacy of screening for HCC in other health care systems, in which available records are sufficiently detailed to enable identification of the indication for USS and AFP tests.
 

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