Melanoma Incidence Rates in Active Duty Military Personnel Compared With a Population-Based Registry in the United States, 2000–2007

Increases in thyroid papillary carcinoma incidence rates have largely been attributed to heightened medical surveillance and improved diagnostics. We examined papillary carcinoma incidence in an equal-access health care system by demographics that are related to incidence. Incidence rates during 1990-2004 among white and black individuals aged 20 to 49 years in the military, and the general U.S. population were compared using data from the Department of Defense's Automated Central Tumor Registry and the National Cancer Institute's Surveillance Epidemiology and End Results (SEER-9) program. Incidence was significantly higher in the military than in the general population among white women [incidence rate ratio (IRR) = 1.42; 95% confidence interval (CI), 1.25-1.61], black women (IRR = 2.31; 95% CI, 1.70-2.99), and black men (IRR = 1.69, 95% CI, 1.10-2.50). Among whites, differences between the two populations were confined to rates of localized tumors (women: IRR = 1.73, 95% CI, 1.47-2.00; men: IRR = 1.51, 95% CI, 1.30-1.75), which may partially be due to variation in staging classification. Among white women, rates were significantly higher in the military regardless of tumor size and rates rose significantly over time both for tumors ≤ 2 cm (military: IRR = 1.64, 95% CI, 1.18-2.28; general population: IRR = 1.55, 95% CI, 1.45-1.66) and > 2 cm (military: IRR = 1.74, 95% CI, 1.07-2.81; general population: IRR = 1.48, 95% CI, 1.27-1.72). Among white men, rates increased significantly only in the general population. Incidence also varied by military service branch. Heightened medical surveillance does not appear to fully explain the differences between the two populations or the temporal increases in either population. These findings suggest the importance of future research into thyroid cancer etiology.

The U.S. Military and general populations may differ in the exposure to sunlight and other risk factors for melanoma and therefore the incidence rates of melanoma may be different in these two populations. However, few studies have compared melanoma incidence rates and trends over time between the military and the general population. Melanoma incidence rates from 1990 to 2004 among white active-duty military personnel and the general U.S. population were compared using data from the Department of Defense Automated Central Tumor Registry and the National Cancer Institute Surveillance, Epidemiology, and End Results program. Age-adjusted melanoma rates overall were significantly lower in the military than in the general population; the incidence rate ratio was 0.75 for men and 0.56 for women. Age-specific rates, however, were significantly lower among individuals younger than 45 years, but significantly higher among those 45 years or older (P < 0.05). Melanoma incidence increased from 1990-1994 to 2000-2004 in both populations, with the most rapid increase (40%) among younger men in the military. Melanoma incidence rates also varied by branch of military service; rates were highest in the air force. These results suggest that melanoma incidence rate patterns differ between the military and the general population. Further studies of risk factors for melanoma in the military are needed to explain these findings.

Melanoma incidence rates may differ between the U.S. active-duty military population and the U.S. general population due to potentially higher exposure to sunlight among military personnel and other risk factors for melanoma. However, few studies have compared melanoma incidence rates and trends over time between the military and the general population. The purpose of this study was to examine melanoma incidence rates from 1990 to 2004 among white active-duty military personnel and the general U.S. population, using data from the military's Automated Central Tumor Registry (ACTUR) and the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program. Age-adjusted melanoma rates overall were significantly lower in the military than in the general population; the incidence rate ratio (IRR) was 0.75 for men and 0.56 for women. Age-specific rates, however, were significantly lower among younger individuals aged &amp;lt;45 years but significantly higher among those aged 45 years or older (p-values&amp;lt;0.05). Melanoma incidence rose from 1990-1994 to 2000-2004 in both populations, with the most rapid increase (40%) among younger men in the military. Melanoma incidence rates also varied by branch of military service with rates highest in the Air Force. These results suggest that melanoma incidence rate patterns differ between the two populations, and further studies of risk factors for melanoma in the military are needed to explain these findings. Citation Information: Cancer Prev Res 2010;3(12 Suppl):B80.

Complementary and Alternative Medicine (CAM) covers a heterogeneous spectrum of ancient to new-age approaches that purport to prevent or treat disease. By definition, CAM practices are not part of conventional western-style medicine because there is a perception of insufficient proof that they are safe and effective or because they are not taught in conventional medical and nursing schools. Complementary interventions are typically used together with conventional western-style treatments, whereas alternative interventions are used instead of conventional approaches. When combined with conventional practices they are often labeled Integrative Medicine (IM). Many people in the United States (US) use CAM and IM modalities1–7 and its use is increasing.2 In 1990, a national survey estimated that 33.8% of US adults used CAM modalities in the previous year,7 which increased to 42.1% in 19973 and 62% in the 2002 National Health Interview Survey (NHIS).1 These surveys included spiritual healing and "folk" medicine (remedies common, ethnically derived remedies used at home), in the CAM modality definition. Recently published results of the 2007 NHIS used a different CAM modality taxonomy and excluded these practices.2,8,9 When prayer specifically for health reasons was excluded, the 2002 and 2007 NHIS found 36% and 38.3%, respectively, of US adults reported using some form of CAM modality in the last 12 months.1,2 These national surveys only include civilian, noninstitutionalized individuals; they do not include our 1.8 million active duty military personnel and families. In the last 10 years, there has been an increase in interest and use of CAM modalities and IM in the military.9 This important segment of the US population receives health care from both military and civilian practitioners; and is subject to similar health risks as civilians plus additional physical, emotional, and cognitive stress of deployment with associated family separations for both the active duty member and families, and the consequences of combat.10,11 It would not be unexpected for military personnel to seek to improve their health through complementary practitioners, potentially at a greater extent due to health and performance expectations,10 and for the same reasons reported by civilians.1,2,11,12 This interest in CAM has been accelerated by the surge of chronic pain, chronic stress, and chronic symptoms associated with trauma and injuries from over a decade of wars in Iraq and Afghanistan.13 However, until recently there were little data to determine which CAM modalities are being used, how often, by whom, and for what purposes. Recently, these informational gaps are being filled in and the current picture is summarized below. USE OF CAM IN THE MILITARY The use of CAM in the military is higher than in the civilian population. Samueli Institute and Research Triangle International conducted the largest and most comprehensive survey of CAM use in over 16,000 active duty service members in all branches stationed both in the United States and overseas.14 Data were drawn from the 2005 Department of Defense (DoD) Survey of Health Related Behaviors among Active Duty Military Personnel, which draws on a worldwide, random sample of over 40,000 service members from all branches, sexes, races, and ranks.15 It asked about overall CAM use and 19 specific CAM therapies using a methodology that closely matched the NHIS used by the National Center for Complementary and Alternative Medicine.16 This military survey showed that approximately 45% of active duty military personnel reported using at least 1 CAM type in the previous 12 months. CAM use when not counting self-prayer was approximately 36%. The 8 most frequently reported CAM approaches included 4 mind body therapies (prayer for your own health: 24.4%; relaxation techniques: 10.8%; art/music therapy: 7.7%; exercise/movement therapy: 6.8%), 2 biologically based therapies (herbal medicine: 8.9%; high-dose megavitamins: 8.4%), and 2 manipulative and body-based methods (massage therapy: 14.1%; chiropractic: 5.2%). Eleven CAM types were used by <5.0% of respondents and 6 types were used by <1% of personnel. When both surveys were adjusted for the 2000 census bureau demographics, CAM use by military personnel was significantly higher than that of the general population (44.5% vs. 36.0% and 38.3% in the 2 NHIS surveys, respectively, P<0.001). Significantly more military personnel reported use of energy healing, guided imagery therapy, massage therapy, hypnosis, and relaxation techniques than civilians in both NHIS surveys (P<0.001) with more reported use of "folk" remedies, high-dose megavitamins, and spiritual healing by others than the 2002 NHIS survey (P<0.001) and more frequent use of biofeedback than the 2002 NHIS and 2007 NHIS surveys (P<0.001 and P<0.01, respectively). There were no statistical differences in reported use of acupuncture and homeopathy. Overall, the prevalence of CAM use in this study was consistent with smaller military surveys where 49.6% CAM use was reported by military veterans in the Southwestern United States,17 and with 37.2% use of 12 CAM modalities (excluding prayer) in US Navy and Marine Corps personnel.18 The vast majority of CAM health care occurs outside the military health system, some of it provided by TRICARE, the military's health insurance program. However, as in the civilian population, most CAM is paid for out of pocket by military personnel as TRICARE covers very few CAM modalities. Massage therapy, used by 14% or an estimated 137,000 personnel, is not a covered benefit, whereas biofeedback (for certain conditions) is covered. Chiropractic is the only CAM modality that is currently included in a systematic manner in the military health system; however, access to chiropractic practitioners is limited. In 2005, 54% of active duty personnel resided in areas served by chiropractic clinics, and the remaining 46% were not served by clinics because of living overseas (14%), in remote areas (5%), or in US installations without chiropractic clinics (28%).19 Herbal medicines and high-dose vitamins also are not covered by military health care. However, many military installations include a General Nutrition Center store on the premises where these products readily are available. Three CAM modalities (yoga, massage, and imagery), which are commonly used for stress management were used by military populations at an estimated 2.5–7 times the rate of civilians. The fact that military members and their families are seeking and personally paying for these therapies outside both direct military care system and the TRICARE System may reflect access problems in Military Treatment Facilities (MTF), a preference for CAM/IM over traditional modalities (ie, not turning away from traditional medicine but rather turning toward and preferring CAM/IM), growing concern about the results of traditional pharmacologically based treatments, and an increasing interest in and need for appropriate access to CAM modalities within the military health system to decrease symptoms and improve function for military members suffering from the "wounds of war." Unmonitored and uninformed use of CAM modalities in the military may have negative consequences on health and military performance. A number of large randomized, placebo controlled trials of herbal treatments20–22 and acupuncture7,23,24 have been negative, making the substitution of these CAM modalities for proven therapies risky. In addition, some CAM therapies, particularly herbal supplements, have been associated with potential harm through toxicity and herb/pharmaceutical interactions.25,26 Herbal medicines and nutrients in doses well above the Dietary Reference Intakes27 are 2 of the CAM modalities most commonly used by military personnel. With 45% of the over 1million active duty personnel reportedly using CAM modalities, and a steady increase globally, it is important to understand why military personnel are using CAM, the role these therapies should play in their health care, and for military health care providers to recognize, monitor, and integrate CAM modalities into their health care practices. OFFERINGS OF CAM IN MTF Two recent surveys have assessed the use of CAM across DoD medical facilities and evaluated their reported effects and attitudes by health care leaders in military MTFs. The first is in a report entitled "Integrative medicine in the military health system report to congress" by the DoD Undersecretary of Personnel and Readiness (P&R).28 In this survey, 29% (120) of 421 MTFs reported offering a total of 275 CAM programs including 213,515 CAM patient visits in calendar year 2012 for active duty members. The most visits were for chiropractic care (73%) and acupuncture therapy (11%). The report states that, of those doing evaluation of CAM they have found: (1) patients reporting a reduction in anxiety levels and improved sleep with meditation; (2) breath-based practices reportedly helped patients to remain sober and reduced overall stress levels; (3) patients using massage therapy noted 75% improvement of symptoms, including pain; and, (4) overall positive outcomes were reported by 50%–90% of patients using massage therapy. The Report also states that patients practicing yoga had declines in psychological symptoms and improvement in overall health. Over 30 research projects have been funded by DoD and have reported improvements in symptoms and sleep, reduction in anxiety and psychological symptoms across a number of CAM practices being used. The Report concluded that: "There is wide-spread use of CAM therapies across the [Military Health System] MHS. Providers and patients were interested in using CAM therapies even though many are not evidence-based. Some providers have added CAM therapies as an adjunct to conventional therapies for a holistic approach to patient management." The second survey, completed by Samueli Institute did a more in-depth survey of CAM availability across a more limited sample of both MTFs and morale, welfare, and recreation (MWRs) centers. The study examined the CAM services offered during the year 2013 in 47 DoD MTFs, and MWRs locations across all military service branches.29 Information was collected on the prevalence of CAM modalities provided; the attitudes and beliefs towards CAM among the leadership in the different facilities; the obstacles and barriers to access in military facilities; the funding sources for CAM offered at military facilities; and, whether CAM is part of the strategic plan for the future of health care delivery. In addition, information was collected on the provision of CAM treatments for highly prevalent conditions in military personnel (pain, combat-related stress, and rehabilitation), how beneficial medical leaders thought CAM was, and how practitioners were accredited to practice CAM modalities. The results of this survey showed that 30 (70%) of the 47 facilities surveyed provided some type of CAM service with most being provided for active duty service members (70%), followed by family members (43%) and retirees (36%). Less than 9% of the participants reported providing CAM services to federal employees, contractors, or members in the community. Overall, acupuncture and chiropractic were among the top 3 most prevalent practices followed by yoga and massage. For pain management the primary CAM modalities were acupuncture (36.2%), chiropractic or osteopathic medicine (27.7%), and breathing exercises (25.5%). For stress and stress-related conditions, the top modalities were acupuncture (25.5%), breathing exercises (21.3%), and biofeedback (17%). For wellness and fitness, offerings included weight management, diet-based therapies, and movement practices. In this Samueli Institute survey, 57% of medical leaders felt that CAM practices were either beneficial (40%) or highly beneficial (17%) with 40% being neutral on the benefit and 3.3% feeling CAM practices were not beneficial. Despite this generally favorable response, over 75% had no provision or guidelines for CAM use in their strategic plans. Still, 46% funded CAM services out of their general budget, with 12% receiving money from the Office of the Army Surgeon General, 8% receiving congressional money, and 4% private money for CAM. Only 10% reported any research or evaluation of CAM going on in their facility. This survey also examined the challenges to improving access to these practices. Although the majority of leadership responses (57%) rated CAM modalities as highly favorable or favorable, the identified obstacles and barriers for access to CAM in military facilities included (in order of frequency): (1) inadequate space to provide services; (2) patients do not know to ask for CAM; (3) CAM costs too much; (4) CAM is too time consuming; and (5) CAM does not contribute to workload coverage. The prevalence of CAM practices provided by MTFs and MWR across DoD shows 75% availability within MTFs, and 33% within MWR facilities and programs. There were no appreciable differences in availability of CAM across military branches. MINDING THE GAP: ALIGNING PATIENTS, PRACTICE, AND POLICY In the report to Congress by DoD P&R, it was recommended to evaluate CAM programs for safety and effectiveness, as well as cost-effectiveness and consider widespread implementation in the military health system if cost-effective. The criteria for how to do this are specified. Part 199 of Title 32, CFR, governs TRICARE benefits and restricts services to those medically necessary drugs, devices, treatments, or procedures for which safety and efficacy have been proven to be comparable or superior to established therapies. Established criteria state that unproven drugs, devices, treatments, or procedures may not be covered: (1) unless reliable evidence shows that any medical treatment or procedure has undergone well-controlled clinical studies that show maximum tolerated dose, toxicity, safety, or efficacy compared with standard treatment or diagnosis; (2) if the available reliable evidence is considered inadequate by experts who recommend further studies or clinical trials are needed. The criteria for making a determination of proven safe and effective to nationally accepted medical standards are evidence that comes from: (1) well-controlled studies of clinically meaningful endpoints published in referred medical literature; (2) published formal technology assessments; (3) published reports of national professional medical associations; and (4) published reports of national expert opinion organizations. However, these guidelines and criteria and not being applied appropriately to CAM modalities. Biofeedback is the only CAM practice currently covered under TRICARE guidelines, and TRICARE only covers biofeedback therapy for nerve injury, not stress management. The 2 most widely used CAM modalities (chiropractic and acupuncture) are excluded in Title 32 CFR section 199.4 (g) even though neither has been evaluated using TRICARE guidelines. In other words, none of the CAM modalities (with the possible exception of biofeedback) have been evaluated by the DoD or TRICARE using their own guidelines for determining which practices should be covered. Despite this, TRICARE declines to pay for acupuncture but will pay for biofeedback. Chiropractic (which also has not been evaluated by TRICARE guidelines) is provided to DoD beneficiates through MTFs but not through TRICARE. Chiropractic is currently being implemented across DoD even though research on the effectiveness of chiropractic in the DoD is only recently underway because of a Congressional mandate and special appropriation.30 Acupuncture is both widely accepted and used in the DoD and currently the Defense and Veteran's Pain Task Force is training medical practitioners in "Battlefield Acupuncture" (BA). BA is a specific auricular acupuncture protocol developed by Col (Ret) Richard Niemtzow, an Air Force physician, seeking to add a simple nonpharmacological pain management technique that could be used by a broad array of first responders and primary care providers to help reduce pain, reduce medication load, and improve function.31 Acupuncture has been shown to be superior to conventional therapy for several chronic conditions prevalent in the military, and has also been shown not to be due only to placebo effects.32 Samueli Institute has performed a comprehensive systematic review of acupuncture for the Trauma Spectrum Response, an important collection of comorbidities often experienced by service members after deployment.33 Recently, a comprehensive review of self-care CAM modalities for pain has been published in a special issue of Pain Medicine in which reasonable evidence for use of yoga, tai chi, and music were found for the treatment of pain.34 These areas are ripe for evaluation by the military and TRICARE Systems for possible inclusion into the array of services provided. CONCLUSIONS Over a decade of war has left hundreds of thousands of our service members and their families suffering from a range of psychological and physical injuries, many leading to or exacerbating chronic pain. They and their health care providers have surged ahead in seeking out drug-free and self-care healing practices to help them recover and return to wholeness in peacetime. The availability of efficacious CAM modalities adds needed access to a cadre of promising services and practices that promote healing and improved function with less medication and fewer unwanted side effects. However, DoD policy and priorities have not kept up with this surge, leaving the majority of active duty service members, veterans, and their families to fend for themselves, to pay for or go without the beneficial effects of CAM and IM practices. As stated in the DoD P&R report to Congress, "At this time, there are insufficient internal evaluations and reported results to determine whether the CAM programs being provided in the MTFs meet these [TRICARE] criteria." It is time for the DoD to step up their efforts to complete these evaluations and ensure that "sufficient evaluation" occurs in a more timely manner. Our long-suffering heroes deserve nothing less!

Background: Post-traumatic stress disorder (PTSD) is a major cause of morbidity amongst active duty and ex-serving military personnel. In recent years increasing efforts have been made to develop more effective treatments. Objective: To determine which psychological therapies are efficacious in treating active duty and ex-serving military personnel with post-traumatic stress disorder (PTSD). Method: A systematic review was undertaken according to Cochrane Collaboration Guidelines. The primary outcome measure was reduction in PTSD symptoms and the secondary outcome dropout. Results: Twenty-four studies with 2386 participants were included. Evidence demonstrated that CBT with a trauma focus (CBT-TF) was associated with the largest evidence of effect when compared to waitlist/usual care in reducing PTSD symptoms post treatment (10 studies; n = 524; SMD −1.22, −1.78 to −0.66). Group CBT-TF was less effective when compared to individual CBT-TF at reducing PTSD symptoms post treatment (1 study; n = 268; SMD −0.35, −0.11 to −0.59). Eye Movement Desensitization and Reprocessing (EMDR) therapy was not effective when compared to waitlist/usual care at reducing PTSD symptoms post treatment (4 studies; n = 92; SMD −0.83, −1.75 to 0.10). There was evidence of greater dropout from CBT-TF therapies compared to waitlist and Present Centred Therapy. Conclusions: The evidence, albeit limited, supports individual CBT-TF as the first-line psychological treatment of PTSD in active duty and ex-serving personnel. There is evidence for Group CBT-TF, but this is not as strong as for individual CBT-TF. EMDR cannot be recommended as a first line therapy at present and urgently requires further evaluation. Lower effect sizes than for other populations with PTSD and high levels of drop-out suggest that CBT-TF in its current formats is not optimally acceptable and further research is required to develop and evaluate more effective treatments for PTSD and complex PTSD in active duty and ex-serving military personnel.

Free AccessVeteransAlpha Delta Sleep in Younger Veterans and Active Duty Military Personnel: An Unrecognized Epidemic? John D. Roehrs, MD, FAASM John D. Roehrs, MD, FAASM Address correspondence to: John D. Roehrs, MD, FAASM, VAMC, Sleep Medicine Service, Tucson, AZ(520) 792-1450 x 5842 E-mail Address: [email protected] VAMC, Tucson, AZ Search for more papers by this author Published Online:March 15, 2015https://doi.org/10.5664/jcsm.4546Cited by:1SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONRecently, we have observed an apparent increased incidence of alpha wave intrusion into N2 and N3 sleep in military and ex-military personnel. Conversations with military physicians in Honolulu, San Antonio, and the sleep center at Walter Reed also suggested that they are seeing an increased number of active duty personnel with this phenomenon.The significance of this finding is not clear and has not been systematically studied. From a 30,000 foot perspective, the US has never before done sleep medicine evaluations on returning active duty personnel and veterans recently discharged from the military. One reason is the compensation which the service member or veteran receives if a diagnosis of sleep apnea is made. None the less, many of the OIF/OEF veterans have sleep problems including complaints of non-restorative sleep along with the other sleep problems including difficulty of initiating and maintaining sleep (DIMS) as well as disorders of excessive somnolence (DOES). These complaints engender sleep medicine consultations many with attended polysomnograms. This apparent increased frequency in returning soldiers and veterans has not been previously reported.Alpha delta sleep was first reported by Hauri et al. in 1973.1 It is most often reported in chronic pain situations. Treatment usually involves treatment of the underlying condition. Patients with fibromyalgia have shown an increased incidence of alpha intrusion.4 A recent report of patients with depression who had PSGs showed a two-fold increase in alpha intrusion.2 A Medline search with keywords of alpha delta sleep in veterans and active duty military returned no articles. However, we have reported one case which has been fairly characteristic.3The patients seem to have in common current or prior military service, usually with one or more deployments to war zones. Many have a sleep disordered breathing diagnosis, especially in veterans (weight gain). Treatment of the OSA with CPAP generally does not reduce the observed alpha intrusion.Several questions are raised by this finding: What is the reason for this increased finding compared to a civilian population group where it is seen very infrequently?Why is it seen in current returned veterans but not apparently in the older Vietnam era veterans?Is there a clinical significance (non-restorative sleep) of sleep deprivation which is associated with depression, self-harm, etc.?Are there medications which could improve the nonrestorative sleep symptoms?What is the natural history of the alpha intrusion—does it spontaneously remit with time and/ or treatment of underlying disorders (depression)?Is this observation merely an epiphenomenon, or is it like hypertension which took many years to elucidate the medical consequences of uncontrolled elevated blood pressure? Is it like OSA, where it was thought to represent a noisy inconvenience, but with study has been shown to be associated with many medical complications? Many of the wounds suffered by our service personnel are not visible, and one wonders if this observation is an EEG manifestation of non-visible wounds. A systematic long term study of those patients with this phenomenon could be helpful in further defining care needed by those patients.Clearly a multicenter registry with a structured long-term follow-up would be needed to begin to answer these questions.DISCLOSURE STATEMENTThe author has indicated no financial conflicts of interest.CITATIONRoehrs JD. Alpha Delta Sleep in Younger Veterans and Active Duty Military Personnel: An Unrecognized Epidemic? J Clin Sleep Med 2015;11(3):277.REFERENCES1 Hauri P, Hawkins DAlpha-delta sleep. Electroencephalogr Clin Neurophysiol; 1973;34:233-7, 4129610. CrossrefGoogle Scholar2 Jaimchariyatam N, Rodriguez CPrevalence and correlates of alpha delta sleep in major depressive disorders. Innov Clinical Neurosci; 2011;8:35-49. Google Scholar3 Nahapetian R, Roehrs JDAlpha intrusion on overnight polysomnogram. Southwest J Pulm Crit Care; 2014;8:3. CrossrefGoogle Scholar4 Moldofsky H, Harris HW, Archambault WT, Kwong T, Lederman SJ Rheumatol; 2011;38:2653-63, 21885490. CrossrefGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited by Daytime Central Thalamic Deep Brain Stimulation Modulates Sleep Dynamics in the Severely Injured Brain: Mechanistic Insights and a Novel Framework for Alpha-Delta Sleep GenerationGottshall J, Adams Z, Forgacs P and Schiff N Frontiers in Neurology, 10.3389/fneur.2019.00020, Vol. 10, Volume 11 • Issue 03 • March 15, 2015ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationDecember 1, 2014Accepted for publicationDecember 1, 2014Published onlineMarch 15, 2015 Information© 2015 American Academy of Sleep MedicinePDF download

Background: Active duty military service members and the general US population differ in several ways related to cancer occurrence. This study aimed to update and expand our previous study which compared incidence of six cancers between the U.S. military and general populations. Methods: Cancers included in this study were pathologically confirmed malignant lung, colorectal, testicular, prostate, cervical and breast tumors diagnosed 1990-2013. The study populations were men and women aged 20-59 in the US active duty military and the population in nine areas covered by the National Cancer Institute’s Surveillance, Epidemiology, and End Results (SEER) cancer registry program. Military data were from the Department of Defense’s Automated Central Tumor Registry (ACTUR) and Defense Manpower Data Center. Age adjusted rates in ACTUR and SEER and incidence rate ratios (IRR) and 95% confidence intervals (95% CI) comparing ACTUR to SEER were calculated. Comparisons were made by sex, race, and cancer stage. Results: Age adjusted incidence rates of colorectal cancer were significantly lower in ACTUR than SEER among White (IRR 0.78; 95% CI 0.72-0.84) and Black men (IRR 0.86; 95% CI 0.74-1.00), respectively. Lung cancer incidence was lower in ACTUR than SEER among White (IRR 0.55; 95% CI 0.49-0.62) and Black men (IRR 0.34; 95% CI 0.26-0.42) and White women (IRR 0.74; 95% CI 0.53-0.98). Whites in ACTUR had significantly lower incidence of testicular cancer (IRR 0.92; 95% CI 0.88-0.96). Lower incidence of cervical cancer in ACTUR was observed among both Whites (IRR 0.82; 95% CI 0.69-0.97) and Blacks (IRR 0.39; 95% CI 0.27-0.54). Incidence of prostate cancer was higher in ACTUR than SEER among both Whites (IRR 2.31; 95% CI 2.18-2.45) and Blacks (IRR 2.35; 95% CI 2.13-2.58). Results by tumor stage showed similar results between the ACTUR and SEER populations for regional and distant tumors, while no differences between the two were observed for localized tumors, except in the case of prostate cancer. Incidence of localized and regional prostate tumors was higher in ACTUR than SEER, while there was no significant difference in distant tumors. Conclusion: Active duty service members had lower age adjusted incidence rates of colorectal, lung, testicular, and cervical cancers, but higher rates of prostate cancer than the general US population. While these findings may result from the combined effects of many factors, the lower incidence in the military may be associated with healthier status of service members. In addition, universal health care for active duty military may lead to earlier diagnosis of some tumors, such as prostate cancer, in the military. Disclaimer: The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, opinions or policies of USUHS, HJF, the DoD or the Departments of the Army, Navy or Air Force. Mention of trade names, commercial products or organizations does not imply endorsement by the US Government. Citation Format: Julie A. Bytnar, Katherine A. McGlynn, Craig D. Shriver, Kangmin Zhu. Cancer incidence in the U.S. military: An updated analysis [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 20.

Every year, millions of people climb in various states of undress into warm, glowing tanning beds, where during a typical 2- to 15-minute session they’ll absorb a controlled dose of ultraviolet (UV) radiation at an intensity up to two to three times stronger than the sunlight striking the equator at noon. The tanning industry has grown rapidly since the 1980s,1 rising to an estimated 28 million users in the United States.2 This rise has been accompanied by an increase in diagnoses of skin cancer. The reasons behind the rising skin cancer diagnoses remain open to debate. Some experts attribute the rise to more frequent skin cancer screening, whereas others blame environmental and behavioral risk factors, particularly changes in UV exposure. In this latter context, UV-emitting tanning beds—classified as carcinogenic to humans by the International Agency for Research on Cancer (IARC)3—have come under growing scrutiny. People tan to look healthy, but looks can be deceiving; UV radiation causes all three types of skin cancer. Melanoma, a tumor of the cells that produce the skin pigment melanin, is the rarest but deadliest type, accounting for 75% of skin cancer deaths worldwide.4 According to the National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) program, melanoma incidence among U.S. whites (who develop the disease more often than other races) rose from 8.7 cases per 100,000 people in 1975 to 28 cases per 100,000 in 2009.5 Most of that increase occurred in older men, who rarely tan indoors. But a closer look at the age-stratified SEER data reveals that melanoma rates among white girls and women aged 15–39 rose by 3.6% per year between 1992 and 2006, compared with a 2% increase per year among boys and men of the same ages.6 Although they’re not tracked by SEER, squamous cell carcinoma (SCC) and basal cell carcinoma (BCC)—the other two types of skin cancer—also appear to be on the rise, according to regional studies from the United States and Europe. A recent study by Anne Marie Skellett, a consulting dermatologist at Norfolk and Norwich University Hospital, reveals that BCC diagnoses among people under age 30 in the United Kingdom jumped 145% between 1981 and 2006.7 Statistics such as these have prompted 33 U.S. states and some municipalities to ban or restrict indoor tanning among children under age 18.8 California’s ban, signed into law in October 2011, was the first,9 followed by Vermont in April 201210 and the city of Chicago the following June.11 Other states have introduced legislation to limit indoor tanning among minors.8 Melanoma in the United States Scanning electron micrograph of a melanoma cell magnified 8,000 times Mary Brady, an associate professor of surgery at Weill Medical College in New York and the author of an editorial on indoor tanning that appeared in the May 2012 issue of the Journal of Clinical Oncology,12 says the bans make sense. “We legislate against smoking in kids less than 18, and that sends a strong message that there’s something wrong with it,” she says. “We need to send the same message on indoor tanning.” But the bans have drawn a backlash from the tanning bed industry, whose representatives say they’ve been unfairly and incorrectly singled out. John Overstreet, executive director at the Indoor Tanning Association in Washington, DC, describes the evidence linking indoor tanning to skin cancer as speculation and advocacy science reported by the media as fact. He points out that UV light triggers skin cells to produce vitamin D, which may have cancer-protective effects. “It’s frustrating,” he says. “There’s no doubt that repeated overexposure to UV or burning can cause skin problems, but you also have to look at the health benefits, and that issue always gets lost.”

This study examined the extent to which high levels of occupational and family stress were associated with mental health problems and productivity loss among active duty military personnel. We analyzed data from the 2002 Department of Defense Survey of Health-Related Behaviors among Military Personnel, which provided extensive population-based information on 12,756 active duty personnel in all branches of the military worldwide. Military personnel reported higher levels of stress at work than in their family life. The personnel reporting the highest levels of occupational stress were those 25 or younger, those who were married with spouses not present, and women. Personnel with high levels of stress had significantly higher rates of mental health problems and productivity loss than those with less stress. We recommend that prevention and intervention efforts geared toward personnel reporting the highest levels of stress be given priority for resources in this population.

Understanding the role of spirituality as a potential coping mechanism for military personnel is important given growing concern about the mental health issues of personnel returning from war. This study seeks to determine the extent to which spirituality is associated with selected mental health problems among active duty military personnel and whether it moderates the relationship between combat exposure/deployment and (a) depression, (b) posttraumatic stress disorder (PTSD), and (c) suicidality in active duty military personnel. Data were drawn from the 2008 Department of Defense Survey of Health Related Behaviors Among Active Duty Military Personnel. Over 24,000 randomly selected active duty personnel worldwide completed an anonymous self-report questionnaire. High spirituality had a significant protective effect only for depression symptoms. Medium, as opposed to high or low, levels of spirituality buffered each of the mental health outcomes to some degree. Medium and low spirituality levels predicted depression symptoms but only among those with moderate combat exposure. Medium spirituality levels also predicted PTSD symptoms among those with moderate levels of combat exposure and predicted self-reported suicidal ideation/attempt among those never deployed. These results point to the complex relationship between spirituality and mental health, particularly among military personnel and the need for further research.

Current military personnel are at risk of developing serious mental health problems, including chronic stress disorders and substance use disorders, as a result of military deployment. The most frequently studied effect of combat exposure is post-traumatic stress disorder (PTSD). High-risk behaviors, including alcohol use and aggression, have been associated with PTSD, but the optimal cutoff score on the PTSD Checklist (PCL) for determining the risk for these behaviors has not been clearly delineated. Using postdeployment active duty (AD) and Reserve component military personnel, the relation between various cutoff scores on the PCL and engaging in high-risk behaviors was examined. AD personnel, for every outcome examined, showed significantly greater odds for each problem behavior when PCL scores were 30 or higher compared to those with PCL scores in the 17 to 29 range. A similar pattern was shown for Reserve component personnel with respect to several problem behaviors, although not for alcohol use behaviors. The differences in problem behaviors for these two populations may be an indication that deployment experiences and combat exposure affect them differently and suggest that despite lower critical PCL scores, AD personnel may be at higher risk for developing problems as a function of the deployment cycle.

: Research in the national population has revealed a link between limited health literacy and disparities in health care utilization and resulting health status. Limited health literacy has also been found at higher rates among individuals who are non-whites, have lower education levels and/or income, and may differ by gender. In the military health system (MHS),gender, race, educational level and income should not impact the availability of health services as all active-duty personnel have universal access to health care. Yet disparities continue to exist in utilization of preventive services and achievement of goals related to improved health status and health outcomes. Limited health literacy may be contributing to these disparities in active duty military personnel with universal access to health care, services, and information. To date, there are no published research studies assessing health literacy in the active-duty military population. Before studies can be conducted to explore the relationship between limited health literacy and health status/outcomes in active duty personnel, research is needed to determine health literacy rates in active duty personnel and the comparability of these rates to rates in the national population. Objective. The purpose of this study was to determine health literacy rates in active duty military personnel receiving health care and services within a culture of universal access, and to compare the health literacy rates of the national population to those of the active duty military.

The prevalence of gambling harm among active duty military personnel is a largely unexplored topic. With different forms of social gambling often found within (or in close proximity to) military bases around the world, understanding the extent of gambling activities and consequent harms occurring within military contexts warrants further attention. This review aims to identify, describe and thematically synthesise published literature on gambling harm and related issues among active duty military personnel. Scoping review methods were applied in order to understand this relatively under-researched population and understand appropriate avenues for future research. A systematic multi-database text word search, incorporating search results from Scopus, Pubmed, Web of Science, PsychInfo, and the Journal Military Medicine, was conducted. A total of 11 sources met inclusion criteria, all originating from the United States of America. The results suggest a distinct gap in the current international literature on this topic. Despite gambling’s long and colourful association with defence downtime, research into gambling harm prevalence rates in relation to what could be considered a high-risk group is limited. Findings reveal that strategies to identify and address gambling harm within this population are severely lacking from the published literature and non-existent outside North America. Implications for understanding and addressing gambling harm among active duty personnel and directions for future research are discussed.

Although the increasing public health impact of excess body weight in the U.S. general population has received national attention, the impact of excess body weight among active duty military personnel is unknown. A study was conducted to determine the direct (increased medical care) and indirect (lost workdays) costs of excess body weight among active duty Air Force (ADAF) personnel in 1997. Based on measured height and weight values, in 1997, 20.4% of ADAF men and 20.5% of ADAF women had body weights that exceeded their official maximum allowable weight for height. Total excess body weight-attributable costs were estimated at $22.8 million per year, with annual direct and indirect costs estimated at $19.3 million (approximately 6% of total annual expenditures for ADAF medical care) and $3.5 million, respectively. Attributable lost workdays were estimated at 28,351 per year. Annual excess body weight-attributable costs among ADAF personnel are high, both in dollars and lost duty days.

Although the increasing public health impact of excess body weight in the U.S. general population has received national attention, the impact of excess body weight among active duty military personnel is unknown. A study was conducted to determine the direct (increased medical care) and indirect (lost workdays) costs of excess body weight among active duty Air Force (ADAF) personnel in 1997. Based on measured height and weight values, in 1997, 20.4% of ADAF men and 20.5% of ADAF women had body weights that exceeded their official maximum allowable weight for height. Total excess body weight-attributable costs were estimated at $22.8 million per year, with annual direct and indirect costs estimated at $19.3 million (approximately 6% of total annual expenditures for ADAF medical care) and $3.5 million, respectively. Attributable lost workdays were estimated at 28,351 per year. Annual excess body weight-attributable costs among ADAF personnel are high, both in dollars and lost duty days.