Affairs Central Cancer Registry Research Articles

Long term follow up of monoclonal gammopathy of undetermined significance (MGUS) in US Veterans: Racial differences and associations with other malignancies.

7573 Background: Monoclonal gammopathy of undetermined significance (MGUS) is associated with lymphoid malignancies such as lymphoma and myeloma, but the association with other malignancies has not been described in the US veteran population. Methods: Veterans diagnosed with MGUS from 1991-2023 were identified from the US Veteran Affairs Central Cancer Registry (VACCR). Age at the diagnosis of MGUS was divided into four categories of <60, 60-69, 70-79, 80+. Variables collected included demographic factors and the diagnosis of other cancers. Differences were analyzed using the Chi Square test. Results: There were 3975 veterans who met the criteria. Most patients were male (96.7%) with a median age at diagnosis of MGUS of 70.5 (IQR 65.4-76.0). Almost 1/3 of patients were Black and were diagnosed with MGUS at a younger age compared to White veterans (Table, p<0.0001). Over the 32-year period included in this study, 2/3 of patients remained with a diagnosis of MGUS (62.3%) alone whereas 29.4% had 1 additional malignancy diagnosed and 8.3% had 2 or more additional malignancies. Black veterans with MGUS were more likely to have additional malignancies than white patients (41.4% vs 35.9%, p=0.016). MGUS was diagnosed prior to other cancers in 52% of patients and afterward in 48%. The most common cancers diagnosed in patients with MGUS were prostate (31%), lymphomas (13%), GI (12.5%), lung (12.0%), and skin (6.8%). CLL (3.4%), LPL (3.0%). Among lymphomas, CLL (3.4%) and LPL (3.0%) were most common. Of note, multiple myeloma or plasmacytoma was diagnosed in 6.5% of patients. The proportion of patients with MGUS and additional malignancies was comparable in the 4 age cohorts (p=0.072), indicating that younger patients with MGUS were as likely to be diagnosed with additional malignancies as older patients. Conclusions: In US veterans, nearly 1/3 of those diagnosed with MGUS were Black. These patients were younger when diagnosed with MGUS and were more likely to develop additional malignancies compared to White veterans. Over the 32 years of this study, a considerable proportion of veterans with MGUS developed various solid tumors. Further investigation is warranted to understand the racial, genetic, and other factors that may be contributing to the development of cancers in patients with MGUS. [Table: see text]

Lung Cancer Survival Trends in the Veterans Health Administration

IntroductionLung cancer survival is improving in the United States. We investigated whether there was a similar trend within the Veterans Health Administration (VHA), the largest integrated healthcare system in the United States. Materials and MethodsData from the Veterans Affairs Central Cancer Registry were analyzed for temporal survival trends using Kaplan-Meier estimates and linear regression. ResultsA total number of 54,922 Veterans were identified with lung cancer diagnosed from 2010 to 2017. Histologies were classified as non–small-cell lung cancer (NSCLC) (64.2%), small cell lung cancer (SCLC) (12.9%), and ‘other’ (22.9%). The proportion with stage I increased from 18.1% to 30.4%, while stage IV decreased from 38.9% to 34.6% (both P < .001). The 3-year overall survival (OS) improved for stage I (58.6% to 68.4%, P < .001), stage II (35.5% to 48.4%, P < .001), stage III (18.7% to 29.4%, P < .001), and stage IV (3.4% to 7.8%, P < .001). For NSCLC, the median OS increased from 12 to 21 months (P < .001), and the 3-year OS increased from 24.1% to 38.3% (P < .001). For SCLC, the median OS remained unchanged (8 to 9 months, P = .10), while the 3-year OS increased from 9.1% to 12.3% (P = .014). Compared to White Veterans, Black Veterans with NSCLC had similar OS (P = .81), and those with SCLC had higher OS (P = .003). ConclusionLung cancer survival is improving within the VHA. Compared to White Veterans, Black Veterans had similar or higher survival rates. The observed racial equity in outcomes within a geographically and socioeconomically diverse population warrants further investigation to better understand and replicate this achievement in other healthcare systems.

Comparison of Carboplatin With Cisplatin in Small Cell Lung Cancer in US Veterans

The current standard of care for the treatment of small cell lung cancer (SCLC) is concurrent chemoradiation for patients with limited-stage SCLC (LS-SCLC) and chemoimmunotherapy for extensive-stage SCLC (ES-SCLC). The backbone of chemotherapy regimens in both is a platinum-etoposide doublet: cisplatin is traditionally the preferred platinum agent in the curative intent setting, whereas carboplatin is preferred in ES-SCLC because of its favorable toxicity profile. To determine whether cisplatin is associated with better survival outcomes than carboplatin in treating LS-SCLC and ES-SCLC. In this cohort study, data were compiled from the National Veterans Affairs Central Cancer Registry for patients with SCLC who received platinum-based multiagent chemotherapy between 2000 and 2020 for ES-SCLC and 2000 and 2021 for LS-SCLC. Only patients with pathologically confirmed cases of LS-SCLC who received concurrent chemoradiation and ES-SCLC who received chemotherapy were included. The primary end point was overall survival (OS). The secondary end points included OS by Eastern Cooperative Oncology Group performance status, age, and laterality. Interval-censored Weibull and Cox proportional hazard regression models were used to estimate median OS and hazard ratios (HRs), respectively. Survival curves were compared by a Wald test. A total of 4408 SCLC cases were studied. Most patients were White (3589 patients [81.4%]), male (4252 [96.5%]), and non-Hispanic (4142 [94.0%]); 2262 patients (51.3%) were 60 to 69 years old, followed by 1476 patients (33.5%) aged 70 years or older, 631 patients (14.3%) aged 50 to 59 years, and 39 patients (0.9%) aged 30 to 49 years. Among 2652 patients with ES-SCLC, 2032 were treated with carboplatin-based therapy and 660 received cisplatin; the median OS was 8.45 months (95% CI, 7.75-9.20 months) for cisplatin and 8.51 months (95% CI, 8.07-8.97 months) for carboplatin (HR, 1.01; 95% CI, 0.91-1.12; P = .90). Subset analysis showed no survival difference between the 2 agents in different age or performance status groups except for patients aged 70 years and older, for whom the median OS was 6.36 months (95% CI, 5.31-7.56 months) for cisplatin and 8.47 months (95% CI, 7.79-9.19 months) for carboplatin (HR, 0.77; 95% CI, 0.61-0.96; P = .02). Multivariable analysis of performance status and age did not show a significant difference in survival between the 2 groups (HR, 0.96; 95% CI, 0.83-1.10; P = .54). Of 1756 patients with LS-SCLC, 801 received carboplatin, and 1018 received cisplatin. The median OS was 26.92 months (95% CI, 25.03-28.81 months) for cisplatin and 25.58 months (95% CI, 23.64-27.72 months) for carboplatin (HR, 1.04; 95% CI, 0.94-1.16; P = .46). The median OS was not significantly different between 2 agents according to cancer stage (I-III), performance status, and age groups. A multivariable analysis of factors associated with OS accounting for stage (I-III), performance status, and age did not demonstrate a significant difference in survival between carboplatin and cisplatin in patients with LS-SCLC (HR, 0.995; 95% CI, 0.86-1.15; P = .95). Cisplatin is not associated with a survival advantage over carboplatin among patients with either ES-SCLC or LS-SCLC, irrespective of performance status and age. The favorable toxicity profile of carboplatin and comparable OS support its use in both LS-SCLC and ES-SCLC in clinical practice and may allow more room for combination with novel treatment strategies in clinical trials.

34466 Invasive melanoma among Veterans: A comparative analysis with the SEER registry, 2009-2017

Veterans constitute a high-risk population for melanoma, but they are often underrepresented in national registries. We examined differences in melanoma patient and tumor characteristics and melanoma-specific survival between Surveillance, Epidemiology, and End Results (SEER) registry patients and patients in the Veteran Affairs Central Cancer Registry (VACCR). Data were collected from SEER (18 registries) and the VACCR from 2009 to 2017. A total of 15,334 VA enrollees were diagnosed with a primary invasive melanoma vs. 166,265 SEER registry patients. VA enrollees were more frequently greater than 65 years at diagnosis and male compared with their SEER counterparts. VA enrollees were more likely to present with regional or distant disease (17.5% vs. 13.0% in SEER) and more likely to present with tumors greater than 2.00 mm in thickness (20.6% vs. 14.5% in SEER). Comparing melanoma-specific survival, 2-year survival for stage IV melanomas improved from 37.8% in 2011-2014 to 51.5% in 2015-2017. Survival also improved in SEER during these timeframes from 36.4% to 44.8%, respectively. We found that Veterans more commonly present with thicker tumors at more advanced stages than the general population. However, it appears that Veterans with metastatic melanoma are likely benefitting from novel therapies such as PD-1 inhibitors, with a greater increase in survival for stage IV melanomas diagnosed in recent years. Further research is needed to determine if this survival benefit is attributable to novel therapies or if other factors contributed.

The impact of endoscopic submucosal dissection for gastric adenocarcinomas in the United States

Recent studies show promise for endoscopic submucosal dissection (ESD) in the United States, but do not identify the potential impact of ESD among newly diagnosed gastric cancers. We utilize the Veterans Health Administration to identify cancers suitable for ESD, to define the role of ESD in the United States. Retrospective cohort study using the Veterans Affairs Central Cancer Registry to identify patients with gastric cancer who underwent surgical resection from 1995 to 2018. TNM stage was used to categorize those who would meet absolute vs expanded indications for ESD. Primary outcome was lymph node status. Secondary analysis was performed with death as outcome. Of 12,584 primary gastric cancers, 4735 (37.6%) were nonmetastatic gastric adenocarcinomas. Median age at diagnosis was 70.3 years, 4676 (98.8%) male. Total 2306 (48.7%) underwent surgical resection, of which 636 (27.6%) were T1 lesions or cancer in situ. Of these, 44 (6.9%) met absolute indications for resection, 99 (15.6%) met established expanded criteria, and 98 (15.4%) may meet expanded criteria. Half of all tumors in each group were proximal in location. Rate of lymph node positivity was: 4.5%; 95% confidence interval [CI]: 0.5-15.5% in absolute group; 8.1%; 95% CI: 3.6-15.3% in expanded group; 13.3%; 95% CI: 7.3-21.6 in those potentially meeting expanded criteria. Lymph nodes positivity was associated with death (hazard ratio 1.49; 95% CI: 1.36-1.62, P < 0.001). Less than 10% of T1 or in situ cancers meet absolute criteria for ESD. Those that meet expanded criteria had higher risk for lymph node metastases, particularly proximal tumors. Future studies should evaluate the safety of ESD in proximal gastric tumors.

Survival Outcomes in Stage IV Bladder Cancer Patients Treated with Cisplatin/Gemcitabine Versus Carboplatin/Gemcitabine: A Retrospective Analysis in Veteran Patients

Purpose: Gemcitabine/cisplatin (GCi) is the standard regimen used to treat stage IV urothelial bladder cancers. However, most of the bladder cancer patients are older, with poor performance status and renal dysfunction, and are not eligible for cisplatin-containing regimens. There are no randomized studies comparing gemcitabine/carboplatin (GC) and gemcitabine/cisplatin (GCi). Methods: We identified stage IV bladder cancer patients treated within the Veterans Health Administration (VHA), healthcare system between January 2000 and December 2010 from Veterans Affairs Central Cancer Registry (VACCR). Overall survival (OS) was visualized using Kaplan-Meier curves and tested for the significance of the treatment-arm difference using the log-rank test. Results: There were 196 patients with stage IV bladder cancer, out of which 78 patients were treated with GC and 118 patients treated with GCi. The median OS for all patients was 12.5 months a 95% confidence interval (CI) of 10.0-14.6 months. The median OS for patients treated with GC was 13.4 months (95% CI 9.8-17.5 months), and that of the patients treated with GCi was 11.7 months (95% CI 9.3-14.9 months). Cox regression revealed equal group mortality rates, with GC having a (hazard ratio (HR) of 0.96 (CI 0.72-1.27; P= 0.81)) compared to GCi. Conclusion: Our study is the largest comparing GC and GCi in stage IV urothelial bladder cancer patients. It showed that there is no difference in OS in patients treated with GC and GCi.

Association of Mental Health Treatment With Outcomes for US Veterans Diagnosed With Non–Small Cell Lung Cancer

Preexisting mental health disorders (MHDs) are associated with increased mortality in people diagnosed with cancer, yet few data exist on the efficacy of interventions to mitigate this disparity. To evaluate the association of participation in mental health treatment programs (MHTPs), housing support programs, or employment support programs with stage at cancer diagnosis, receipt of stage-appropriate treatment, and mortality among patients with a preexisting MHD. This retrospective, population-based cohort study included 55 315 veterans in the Veterans Affairs Central Cancer Registry (VACCR) who had newly diagnosed non-small cell lung cancer (NSCLC) from September 30, 2000, to December 31, 2011. Data were analyzed from January 15, 2017, to March 17, 2020. Mental health disorders, including schizophrenia, bipolar disorder, depressive disorder, posttraumatic stress disorder, and substance use disorder. Stage at cancer diagnosis, receipt of stage-appropriate cancer treatment, all-cause mortality, and lung cancer-specific mortality. Of 55 315 veterans with a new diagnosis of NSCLC included in the analysis (98.1% men; mean [SD] age, 68.1 [9.8] years), 18 229 had a preexisting MHD, among whom participation in MHTPs was associated with a lower likelihood of being diagnosed in a late stage (odds ratio [OR], 0.62; 95% CI, 0.58-0.66; P < .001), a higher likelihood of receiving stage-appropriate treatment (OR, 1.55; 95% CI, 1.26-1.89; P < .001), lower all-cause mortality (adjusted hazard ratio [AHR], 0.74; 95% CI, 0.72-0.77; P < .001), and lower lung cancer-specific mortality (AHR, 0.77; 95% CI, 0.74-0.80; P < .001). Likewise, participation in housing and employment support programs was associated with similar improvements in all outcomes described above. In veterans with preexisting MHDs diagnosed with NSCLC, participation in MHTPs and housing and employment support programs was associated with improved lung cancer-related outcomes. This study might be the first to demonstrate significant improvement in cancer mortality for patients with MHDs who participate in MHTPs, housing support programs, or employment support programs. This work supports substantial literature that investment in mental health and social needs can improve health outcomes and highlights the importance of further research to identify, evaluate, and implement interventions to improve outcomes for patients with MHDs who are diagnosed with cancer.

Abstract PR11: Racial differences in characteristics of early- vs. late-onset colorectal cancer among veterans

Abstract Introduction: Colorectal cancer (CRC) accounts for approximately 8% of annual cancer cases in the Veterans Health Administration. While CRC incidence is decreasing, evidence suggests that the incidence among the subset of patients diagnosed before the age of 50 is increasing. The purpose of this work is to compare the clinical and demographic characteristics of veterans with early-onset CRC (age at diagnosis &amp;lt;50; EOC) and late-onset CRC (age at diagnosis ≥50; LOC) and assess racial differences within both groups. Methods: We conducted a retrospective analysis of national cohort data in the Veterans Affairs Central Cancer Registry on patients diagnosed with CRC between 2001 and 2011. Descriptive statistics (frequencies, medians) were used to compare characteristics among EOC and LOC patients and evaluate black-white differences within both groups of CRC patients. Results: In this cohort of 31,435 patients, 3% (N=966) had EOC, and this proportion was consistent each year. Statistically significant differences between EOC and LOC were noted for race, stage, and tumor location (all p&amp;lt;0.0001). The black/white race distribution was 33%/64% in EOC and 17%/80% in LOC. For stage, 56% of EOC and 44% of LOC were stage III/IV. Regarding tumor location, 39% of EOC was rectum whereas 30% of LOC was rectum. 5-year overall survival (OS) was 58% in EOC and 50% in LOC (p&amp;lt;0.0001); however, no difference in CRC-specific survival was noted (72% vs 74%, p=.13). We also observed significant differences by race when comparing demographic and clinical characteristics within EOC and LOC. Race-specific results for EOC patients were as follows: Median age was 46 for both blacks and whites; the proportion of blacks diagnosed with Stage III/IV disease was 51% compared to 58% of whites (p=0.001); tumor location was rectum for 31% of blacks and 43% of whites (p=0.0006); and overall and CRC-specific survival rates were similar for blacks and whites. The following was observed among patients with LOC: Blacks were slightly younger than whites (median age 66 vs 69, respectively); stage III/IV disease was noted for 47% of blacks and 43% of whites (p&amp;lt;0.0001); 24% of blacks and 31% of whites had rectum tumor location (p&amp;lt;0.0001); and overall and CRC-specific survival rates were lower among blacks compared to whites. Conclusion: Although we did not find an increasing proportion of EOC over time, EOC was more common in blacks than whites and more common in the distal large bowel. EOC in blacks, however, was more commonly proximal, had less advanced stage at diagnosis but similar survival compared to whites. EOC has distinct clinical characteristics in blacks that may reflect differences in molecular etiology. Our findings emphasize the importance of distinguishing between EOC and LOC to better understand the unique characteristics of early-onset disease and how they might inform prevention and early detection efforts. This abstract is also being presented as Poster C116. Citation Format: Monalesia Chapman, Christina D. Williams, Thomas Ivey Redding, Robin Bartlett, Neeta Chawla, Dawn Provenzale, Michael J. Kelley. Racial differences in characteristics of early- vs. late-onset colorectal cancer among veterans [abstract]. In: Proceedings of the Eleventh AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2018 Nov 2-5; New Orleans, LA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2020;29(6 Suppl):Abstract nr PR11.

Survival Advantage With Adjuvant Chemotherapy for Locoregionally Advanced Rectal Cancer: A Veterans Health Administration Analysis.

Adjuvant chemotherapy (AC) after chemoradiation (CRT) and surgery for locoregionally advanced rectal cancer (LARC) is a standard of care in the United States. This study examined the role, optimal regimen, and duration of AC using data from the largest integrated health system in the United States. Using the Veterans Affairs Central Cancer Registry, patients with stage II-III rectal cancer diagnosed in 2001 through 2011 who received neoadjuvant CRT and surgery with or without AC were identified. Kaplan-Meier analysis, log-rank tests, and propensity score (PS) adjustment analysis were used to assess survival. A total of 866 patients were identified; 417 received AC and 449 did not (observation [OBS] group). Median follow-up was 109 months. Median disease-specific survival (DSS) was not reached. Six-year DSS was 73.7%; 79.5% for the AC group versus 68.0% for the OBS group. PS-matched analysis for DSS favored AC (P=.0002). Median overall survival (OS) was 90.8 months. Six-year OS was 56.7%; 64.3% for AC versus 49.6% for OBS. In PS-matched analysis, median OS was 117.4 months for AC and 74.3 months for OBS (P<.0001). A DSS advantage was seen when comparing ≥4 months with <4 months of AC (P=.023). No difference in DSS or OS was seen with single-agent versus multiagent AC. In this population of patients with LARC treated with neoadjuvant CRT and surgery, OS and DSS were improved among those treated with AC versus OBS. DSS benefits were seen with ≥4 months of AC. No additional benefit was observed with multiagent therapy. In the absence of phase III data, these findings support the use of AC for LARC.

Association Between Inflammatory Bowel Disease and Colorectal Cancer Stage of Disease and Survival

BackgroundInflammatory bowel disease (IBD) is associated with an increased risk of colorectal cancer (CRC). However, there are few data comparing outcomes between IBD and non–IBD-associated CRC. MethodsRetrospective cohort study of patients with CRC identified from the Veteran Affairs (VA) Central Cancer Registry from 1998 to 2012 linked to national VA administrative claims to identify patients with IBD using a previously validated algorithm. The association between IBD status and stage of disease and overall risk of death were evaluated using multivariable logistic and Cox regression, respectively. ResultsAmong 34,570 CRC patients, 217 had IBD. IBD patients were significantly younger for both colon and rectal cancer. IBD patients who developed rectal cancer were significantly more likely to present with locally advanced or metastatic disease (P = 0.007), but there was no difference in stage among patients with colon cancer. This difference persisted after multivariable adjustment (overall—odds ratio [OR] 1.40, 95% confidence interval [1.03-1.90]; colon—OR 1.22 [0.84-1.78]; rectum—OR 2.04 [1.22-3.40]). Total colectomy was more commonly performed among IBD patients. Overall, IBD was associated with a 52% increased risk of death (hazard ratio 1.52 [1.21-1.91]). ConclusionsAlthough IBD is associated with more advanced stage at diagnosis for rectal cancer, it is associated with a worse survival primarily in patients with colon cancer. Further work is needed to better understand the reason for these observed differences between IBD and non-IBD patients and to better delineate the impact of endoscopic surveillance on CRC care and outcomes in IBD patients.

Disparities in lung cancer outcomes for veterans with comorbid mental disorders.

6577 Background: Emerging evidence suggests that cancer patients with comorbid mental disorders have worse outcomes. Lung cancer is the leading cause of cancer-related death in the United States, yet the impact of specific mental disorders on outcomes for patients diagnosed with lung cancer is not well known. Methods: Stage at diagnosis and receipt of stage-appropriate treatment were assessed for 55,315 Veterans with non-small cell lung cancer (NSCLC) in the Veterans Affairs (VA) Central Cancer Registry from 2000 to 2011. Patients were stratified by the presence of specific comorbid mental disorders. Multivariate analysis evaluated the association between mental disorders and survival, as well as the impact of VA treatment programs on survival. Results: Patients with schizophrenia had lower rates of localized disease at diagnosis compared to those without mental disorders. Schizophrenia and dementia were associated with significantly lower rates of stage-appropriate treatment for localized, locoregional, and metastatic disease. Conversely, patients with depression or PTSD were more frequently diagnosed with early-stage disease and significantly more likely to receive stage-appropriate treatment across all stages. After adjusting for baseline differences, stage, and rates of stage-appropriate treatment, hazard of death was higher for patients with schizophrenia (hazard ratio [HR] 1.10; 95% CI, 1.03-1.16; P &lt; .005) and dementia (HR 1.11; 95% CI, 1.06-1.18; P &lt; .0005). Participation in VA-based programs to address mental illness, substance use, and homelessness was associated with a significant reduction in all-cause mortality (HR 0.71; 95% CI, 0.68-0.75; P &lt; .0001) and lung-cancer specific mortality (HR 0.73; 95% CI, 0.69-0.77; P &lt; .0001). Conclusions: Schizophrenia and dementia are strong negative predictors of survival among Veterans diagnosed with NSCLC. VA-based mental health treatment programs are associated with reductions in all-cause and lung cancer-related mortality, highlighting the importance of funding and promoting mental health and supportive programs.

Increasing PET Use in Small Cell Lung Cancer: Survival Improvement and Stage Migration in the VA Central Cancer Registry.

Background: Accurate staging for small cell lung cancer (SCLC) is critical for determining appropriate therapy. The clinical impact of increasing PET adoption and stage migration is well described in non-small cell lung cancer but not in SCLC. The objective of this study was to evaluate temporal trends in PET staging and survival in the Veterans Affairs Central Cancer Registry and the impact of PET on outcomes. Patients and Methods: Patients diagnosed with SCLC from 2001 to 2010 were identified. PET staging, overall survival (OS), and lung cancer-specific survival (LCSS) were assessed over time. The impact of PET staging on OS and LCSS was assessed for limited-stage (LS) and extensive-stage (ES) SCLC. Results: From 2001 to 2010, PET use in a total of 10,135 patients with SCLC increased from 1.1% to 39.2%. Median OS improved for all patients (from 6.2 to 7.9 months), those with LS-SCLC (from 10.9 to 13.2 months), and those with ES-SCLC (from 5.0 to 7.0 months). Among staged patients, the proportion of ES-SCLC increased from 63.9% to 65.7%. Among 1,536 patients with LS-SCLC treated with concurrent chemoradiotherapy, 397 were staged by PET. In these patients, PET was associated with longer OS (median, 19.8 vs 14.3 months; hazard ratio [HR], 0.78; 95% CI, 0.68-0.90; P<.0001) and LCSS (median, 22.9 vs 16.7 months; HR, 0.74; 95% CI, 0.63-0.87; P<.0001) with multivariate adjustment and propensity-matching. In the 6,143 patients with ES-SCLC, PET was also associated with improved OS and LCSS. Conclusions: From 2001 to 2010, PET staging increased in this large cohort, with a corresponding relative increase in ES-SCLC. PET was associated with greater OS and LCSS for LS-SCLC and ES-SCLC, likely reflecting stage migration and stage-appropriate therapy. These findings emphasize the importance of PET in SCLC and support its routine use.

Demographics, Risk Factors, and Incidence of Melanoma in Patients in the New England VA Healthcare system.

A recent study found that the incidence of melanoma and melanoma-related mortality was decreasing in residents of the New England region. However, it is unknown whether this trend is conserved in Veterans of New England who constitute more than 14% of the national Veteran population. Given this, our goal was to analyze the incidence of melanoma in patients of Veteran Integrated Service Network-1 (VISN-1) (geographically consisting of VA health care facilities in Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont) and to calculate an incidence rate ratio (IRR) of melanoma in VISN-1 compared to the general population. Additional goals were to ascertain the risk/susceptibility of this patient population with a view to improve quality of care and outcomes. Data for 523 cases of melanoma [2000-2011] were obtained from the regional branch of the Veterans Affairs Central Cancer Registry (VACCR) within the geographic area comprising VISN-1. A detailed retrospective chart review was conducted on these cases to gather demographic, risk factor, and clinical practice data. Demographic and incidence data from VISN-1 were compared to the general population via data from Surveillance, Epidemiology and End Results Program (SEER) from the same time period. Person-years (PY) were calculated for both populations to measure IRRs which was further standardized for age and gender. VISN-1 patients were predominantly older (94.26% >50 years), Caucasian (99.43%) males (96.75%). Compared to the general population, VISN-1 patients experienced more invasive lesions defined as stage T1 or greater (4.33% vs. 57.12%, p < 0.001), but reduced melanoma-associated mortality (40.96% vs. 19.05%, p < 0.001) although all-cause mortality was approximately doubled (52.20% vs. 26.14%, p < 0.001). Metastatic disease-rates were similar in both [approximately 4% in both]. IRR of melanoma in VISN-1 patients was 0.36 (95% CI: 0.20-0.67; p = 0.0063) which persisted in all age groups/genders. 60.92% of VISN-1 patients had recreational sun-exposure history and 72.41% of tobacco use. 95.02% of melanomas were located in continuously/intermittently sun-exposed areas, 93.28% were surgically-treated with a median treatment delay of 31 days [range 18-48]. Median lost to follow-up was 0 day [range 0-681 days]. Compared to the general population, melanoma incidence was lower in the VISN-1 cohort, possibly due to decreased UV index in the New England region, protective effects of past tobacco use, improved access to care through the VA and regional public health educational efforts. Yet melanomas were more often invasive in the VISN-1 cohort due to advanced age and male sex both of which are associated with more advanced disease at diagnosis. A strength of this study is the calculation of IRR using PY as this method enhances accuracy of incidence calculations. The data were limited by the fact that the population was from one geographic region and consisted mainly of elderly Caucasian males. Descriptive variable data such as sun-protective habits and risk factors from military service are limited by potential recall bias given the retrospective study design. Further study is necessary to replicate these results and to compare our data to Veteran populations from different geographic regions within the USA.

The Research Implications of Prostate Specific Antigen Registry Errors: Data from the Veterans Health Administration

We sought to characterize the effects of prostate specific antigen registry errors on clinical research by comparing cohorts based on cancer registry prostate specific antigen values with those based directly on results in the electronic health record. We defined sample cohorts of men with prostate cancer using data from the Veterans Health Administration, including those with a prostate specific antigen value less than 4.0, 4.0 to 10.0, 10.0 to 20.0 and 20.0 to 98.0 ng/ml, respectively. We compared the composition of each cohort and overall patient survival when using prostate specific antigen values from the Veteran Affairs Central Cancer Registry vs the gold standard electronic health record laboratory file results. There was limited agreement among cohorts when defined by cancer registry prostate specific antigen values vs the laboratory file of the electronic health record. The least agreement of 58% was seen in patients with prostate specific antigen less than 4.0 ng/ml and greatest agreement of 89% was noted among patients with prostate specific antigen between 4.0 and 10.0 ng/ml. In each cohort patients assigned to a cohort based only on the cancer registry prostate specific antigen value had significantly different overall survival when compared with patients assigned based on registry and laboratory file prostate specific antigen values. Cohorts based exclusively on cancer registry prostate specific antigen values may have high rates of misclassification that can introduce concerning differences in key characteristics and result in measurable differences in clinical outcomes.

Cancer Incidence Among Patients of the U.S. Veterans Affairs Health Care System: 2010 Update.

Nearly 50,000 incident cancer cases are reported in Veterans Affairs (VA) Central Cancer Registry (VACCR) annually. This article provides an updated report of cancer incidence recorded in VACCR. Data were obtained from VACCR for incident cancers diagnosed in the VA health care system, focusing on 2010 data. Cancer incidence among VA patients is described by anatomical site, sex, race, stage, and geographic location, and was compared to the general U.S. cancer population. In 2010, among 46,170 invasive cancers, 97% were diagnosed among men. Approximately 80% of newly diagnosed patients were white, 19% black, and less than 2% were other minority races. Median age at diagnosis was 65 years. The three most frequently diagnosed cancers among VA were prostate (29%), lung/bronchus (18%), and colon/rectum (8%). Melanoma and kidney/renal pelvis tied for fourth (4%), and urinary bladder tied for sixth with liver and intrahepatic bile duct (3.4%). Approximately 23% of prostate, 21% of lung/bronchus, and 31% of colon/rectum cancers were diagnosed with Stage I disease. The overall invasive cancer incidence rate among VA users was 505.8 per 100,000 person-years. Although the composition of the VA population is shifting and includes a larger number of women, registry data indicate that incident cancers in VA in 2010 were most similar to those observed among U.S. men. Consistent reporting of VACCR data is important to provide accurate estimates of VA cancer incidence. This information can be used to plan efforts to improve quality of cancer care and access to services.

Abstract 281: Site specific risk factors for colorectal cancer

Abstract Background: Most studies of colorectal cancer (CRC) risk factors pool cases across anatomical sites, though tumor characteristics and embryologic origins differ. Our aim was to conduct a site-stratified (proximal, distal, rectal) case control study of candidate risk factors for CRC. Methods: Our study base was US Veterans with &amp;gt;1 colonoscopy 1999-2011. CRC cases at baseline colonoscopy were identified with the Veterans Affairs Central Cancer Registry. Controls had normal colonoscopy without biopsy, no history of CRC, and no CRC within 3 years of index colonoscopy. Age, sex, race/ethnicity, body mass index (BMI), diabetes, and smoking were considered candidate risk factors. Primary outcome was CRC, stratified by site. Site-specific odds ratios (OR) and 95% confidence intervals (CI) for each risk factor were computed with unadjusted and adjusted multinomial logistic regression models. Results: We identified 21,739 CRC cases and 616,323 normal colonoscopy controls. For cases combined vs. controls, median age was 68 vs. 61 years, 98% vs. 95% were male, median BMI was 27.8 vs. 28.8 kg/m2, 28% vs. 24% had diabetes, and 25% vs. 29% were non-smokers; race/ethnicity was similar. Presence and strength of associations differed by risk factor and CRC site (Table). Smoking was more closely associated with rectal (OR=1.84) than proximal (OR=1.59) or distal cancer (OR=1.50). Diabetes was more closely associated with proximal than distal or rectal cancer (OR=1.28, 1.17 and 1.12, respectively). Blacks had reduced odds for rectal (OR=0.89), but increased odds for distal (OR=1.27) and particularly proximal cancer (OR=1.60) when compared to non-Hispanic whites. For males vs. females, odds of rectal was higher than distal or proximal cancer (OR=2.64, 1.95 and 1.32, respectively). Conclusions: Presence and strength of association of cancer risk factors may differ by CRC site. Site should be a key consideration in future studies of CRC risk. Table 1.Site specific risk factors for 21,739 CRC cases compared to 616,323 normal colonoscopy controlsAnatomic Site of CRC*Proximal (n=7,686)Distal (n=7,036)Rectal (n=7,017)Candidate Risk FactorOR (CI)OR (CI)OR (CI)Age, years†1.100 (1.096-1.103)1.065 (1.062-1.069)‡1.055 (1.051- 1.059)‡§Gender, male vs. female1.318 (1.080-1.608)1.950 (1.538-2.471)‡2.636 (2.006-3.463)‡Race/ethnicityBlack vs. non-Hispanic white1.596 (1.480-1.720)1.270 (1.167-1.381)‡0.886 (0.808-0.971)‡§Hispanic vs. non-Hispanic white1.291 (1.123-1.485)1.531 (1.337-1.753)1.219 (1.053-1.411)§Asian vs. non-Hispanic white0.872 (0.634-1.201)0.917 (0.662-1.272)0.556 (0.371-0.832)BMI, kg/m2†0.994 (0.988-1.000)1.005 (0.999-1.012)‡0.963 (0.957-0.970)‡§Diabetes, yes vs. no1.278 (1.196-1.366)1.170 (1.089-1.257)1.119 (1.038-1.207)‡SmokingCurrent vs. never1.594 (1.476-1.722)1.500 (1.383-1.627)1.837 (1.695-1.992)‡§Former vs. never0.997 (0.926-1.073)1.082 (1.001-1.171)1.085 (0.998-1.119)* Multinomial analyses adjusted for other risk factors, as well as year of colonoscopy, 1999-2011† by one unit increment‡ p&amp;lt;0.05 when compared to proximal cancer§ p&amp;lt;0.05 when compared to distal cancerCRC, colorectal cancer; BMI, body mass index. Citation Format: Samir Gupta, Ranier Bustamante, Ashley Earles, Maria E. Martinez, Karen Messer, Christina D. Williams, Andrew J. Gawron, Tonya Kaltenbach, Lin Liu. Site specific risk factors for colorectal cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 281. doi:10.1158/1538-7445.AM2017-281

Patterns of computed tomography surveillance in survivors of colorectal cancer at Veterans Health Administration facilities.

Annual computed tomography (CT) scans are a component of the current standard of care for the posttreatment surveillance of survivors of colorectal cancer (CRC) after curative-intent resection. The authors conducted a retrospective study with the primary aim of assessing patient, physician, and organizational characteristics associated with the receipt of CT surveillance among veterans. The Department of Veterans Affairs Central Cancer Registry was used to identify patients diagnosed with AJCC collaborative stage I to III CRC between 2001 and 2009. Patient sociodemographic and clinical (ie, CRC stage and comorbidity) characteristics, provider specialty, and organizational characteristics were measured. Hierarchical multivariable logistic regression models were used to assess the association between patient, provider, and organizational characteristics on receipt of 1) consistently guideline-concordant care (at least 1 CT every 12 months for both of the first 2 years of CRC surveillance) versus no CT receipt and 2) potential overuse (>1 CT every 12 months during the first 2 years of CRC surveillance) of CRC surveillance using CT. The authors also analyzed the impact of the 2005 American Society of Clinical Oncology update in CRC surveillance guidelines on care received over time. For 2263 survivors of stage II/III CRC who were diagnosed after 2005, 19.4% of patients received no surveillance CT, whereas potential overuse occurred in both surveillance years for 14.9% of patients. Guideline-concordant care was associated with younger age, higher stage of disease (stage III vs stage II), and geographic region. In adjusted analyses, younger age and higher stage of disease (stage III vs stage II) were found to be associated with overuse. There was no significant difference in the annual rate of CT scanning noted across time periods (year ≤ 2005 vs year > 2005). Among a minority of veteran survivors of CRC, both underuse and potential overuse of CT surveillance were present. Patient factors, but no provider or organizational characteristics, were found to be significantly associated with patterns of care. The 2005 change in American Society of Clinical Oncology guidelines did not appear to have an impact on rates of surveillance CT. Cancer 2017;123:2338-2351. © 2017 American Cancer Society.

Outcomes of Chemotherapy Treatment in Elderly Patients with Hodgkin Lymphoma

Introduction: Hodgkin lymphoma (HL) is a common lymphoid malignancy accounting for approximately 10 percent of all lymphomas. In the United States (US), the incidence of HL has a bimodal distribution curve with peaks at age 20 years and a second peak at approximately age 65 years. Age of diagnosis is an important prognostic marker in HL with younger patients having superior outcomes. Patients diagnosed at greater than age 60 years are considered elderly. Prior analyses of HL treatment in elderly patients have revealed worse outcomes in this population with reported 5-year progression free survival (PFS) and overall survival (OS) from 30-45% and 40-60% ranges, respectively (Evens, Blood 2012). The most common first line treatment for HL is doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD). Elderly patients are thought to have higher risk of bleomycin toxicity and worse outcomes with treatment in comparison to younger patients. Omission of bleomycin or doxorubicin from chemotherapy regimens administered to elderly patients is not uncommon. This study evaluated treatment outcomes of HL in an elderly U.S. Veteran population.Methods: The VHA database was used to identify patients diagnosed with HL using ICD-03 codes C000-C8099, 9651, 9652, 9653-9655, 9663-9667, 9650, 9661-9662, and 9659. Data was available from the Veterans Affairs Central Cancer Registry (VACCR) from October 1st, 2001-December 31st 2013. Data was obtained on patient demographics, weight, height, other clinical characteristics, date of diagnosis and HL directed treatments. Chemotherapeutic agents patients received were collected from the VACCR data and missing data was abstracted using chart review. Patients who received at least one dose of any chemotherapy for HL were considered to have received chemotherapy. Of patients who received chemotherapy, those who received at least one dose of bleomycin or doxorubicin were included in the bleomycin and doxorubicin groups respectively. Patients less than age 60 years were excluded. Patients greater than age 60 years were stratified by age into age groups 61-69 and ≥70 years. Overall survival was measured from date of diagnosis to date of death. Kaplan-Meier method for overall survival was used to evaluate each treatment group. Cox proportional hazard model was used to evaluate risk of death after adjusting for age (61-69 years used as reference) and chemotherapy used (bleomycin or doxorubicin).Results: There were 1,135 unique HL patients [632 (56%) patients ≤ age 60 years, 503 (44%) patients >age 60 years] identified in the VHA database. For patients age years >60, 389 patients (77%) received chemotherapy; with 226 (58%) patients age years 61-69 and 163 (42%) age years ≥70. Bleomycin was administered to 177 (78%) patients age years 61-69 and 106 (65%) patients age years ≥70 (p=0.037). Doxorubicin was administered to 198 (88%) patients age years 61-69 and to 122 (75%) patients age years ≥70 (p=0.0012). Cox proportional hazards analysis demonstrated that patients ≥70 years had a worse overall survival (HR = 1.71; 95% CI 1.276-2.293) in comparison patients age 61-69 years. After adjusting for age and chemotherapy, treatment with doxorubicin (HR 0.67; 95% CI 0.416-1.084) or bleomycin (HR 0.77; 95% CI 0.512-1.192) was associated with an improved survival.Conclusions: This retrospective analysis represents the largest cohort of elderly HL patients with detailed treatment information reported to date. Advanced age (age ≥70 years) was confirmed to be a poor prognostic factor. The chemotherapy agents used in elderly patients also differed by age with less doxorubicin and bleomycin administered to patients age ≥70 years in comparison to those age years 61-69. While not statistically significant, this study demonstrated improved survival in patients receiving bleomycin or doxorubicin regardless of age. Further analyses adjusting for patient comorbidities, evaluating for treatment related toxicity (i.e. pulmonary toxicity) and accounting for cause specific mortality are pending. DisclosuresReagan:Seattle Genetics: Research Funding. Carson:Seattle Genetics: Membership on an entity's Board of Directors or advisory committees.

Metformin, Diabetes, and Survival among U.S. Veterans with Colorectal Cancer.

Metformin has been associated with improved colorectal cancer survival, but investigations are limited by small numbers of patients and confounding by diabetic severity. We examined the association between metformin use and overall survival (OS) in patients with diabetes and colorectal cancer in a large population of U.S. veterans, while adjusting for measures of diabetic severity. Patients diagnosed with colorectal cancer from January 2001 to December 2008 were identified from the Veterans Affairs Central Cancer Registry. Multivariable models were used to examine the adjusted association of OS with diabetes and use of antidiabetic medications. There were 21,352 patients diagnosed with colorectal cancer identified (n = 16,355 nondiabetic patients, n = 2,038 diabetic patients on metformin, n = 2,136 diabetic patients on medications other than metformin, n = 823 diabetic patients not on antidiabetic medication). Diabetic patients had a significantly worse OS than nondiabetic patients, but metformin users had only a 10% increase in death (HRadj 1.10; 95% CI, 1.03-1.17, P = 0.004), as compared with 22% for users of other antidiabetic medications (HRadj 1.22; 95% CI, 1.15-1.29, P < 0.0001). Among colorectal cancer patients with diabetes, metformin users had a 13% improved OS versus patients taking other antidiabetic medications (HRadj 0.87; 95% CI, 0.79-0.95, P = 0.003), while diabetic patients not on any antidiabetic medications did not differ with respect to OS (HRadj 1.02; 95% CI, 0.90-1.15, P = 0.76). Among diabetics with colorectal cancer, metformin use is associated with improved survival, despite adjustments for diabetes severity and other risk factors. These data lend further support to the conduct of randomized studies of possible anticancer effects of metformin among patients with colorectal cancer. Cancer Epidemiol Biomarkers Prev; 25(10); 1418-25. ©2016 AACR.

Impact of Race on Treatment and Survival among U.S. Veterans with Early-Stage Lung Cancer

IntroductionNumerous reports suggest lower rates of surgical procedures and poorer survival for black patients with early-stage (stage I or II) NSCLC than for white patients. This study examined treatment trends among blacks and whites with early-stage NSCLC and determined whether racial disparities exist in survival among patients receiving similar treatment. MethodsA retrospective analysis of 18,466 patients in the Veteran Affairs Central Cancer Registry in whom stage I or II NSCLC was diagnosed in 2001–2010 was conducted. Patients were categorized as receiving an operation, radiation, or other/no treatment. Overall survival (OS) and lung cancer–specific survival (LCSS) were evaluated using Kaplan-Meier and multivariable Cox regression analyses. ResultsThere was a statistically significant disparity between black and white patients receiving an operation that decreased over time to similar rates (p = 0.01). No significant racial differences in receipt of radiation were noted. Race was not associated with OS among all patients (hazard ratio [HR] = 0.97, 95% confidence interval [CI]: 0.93–1.02). Among patients who received an operation, no racial difference in OS was observed (HR = 0.94, 95% CI: 0.87–1.01), but the HR for blacks versus whites was 0.90 (95% CI: 0.82–0.98) for radiation treatment and 0.89 (95% CI: 0.81–0.97) for other/no treatment. Race was not associated with LCSS among all patients combined or within each treatment category. ConclusionsA racial disparity in the rate of operation was no longer apparent at the end of the study period. There was no racial difference in OS or LCSS among all patients in this equal access health care system. Long-documented racial differences in lung cancer treatment and mortality result from disparity of access to health care and delivery of recommended treatment.