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Bihn JR, Cioffi G, Waite KA, Kruchko C, Neff C, Price M, Ostrom QT, Swinnerton KN, Elbers DC, Mooney MA, Rachlin J, Stein TD, Brophy MT, Do NV, Ferguson RE, Priemer DS, Perl DP, Hickman RA, Nabors B, Rusiecki J, Barnholtz-Sloan JS, Fillmore NR. Brain tumors in United States military veterans. Neuro Oncol 2024; 26:387-396. [PMID: 37738677 PMCID: PMC10836768 DOI: 10.1093/neuonc/noad182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Comprehensive analysis of brain tumor incidence and survival in the Veteran population has been lacking. METHODS Veteran data were obtained from the Veterans Health Administration (VHA) Medical Centers via VHA Corporate Data Warehouse. Brain tumor statistics on the overall US population were generated from the Central Brain Tumor Registry of the US data. Cases were individuals (≥18 years) with a primary brain tumor, diagnosed between 2004 and 2018. The average annual age-adjusted incidence rates (AAIR) and 95% confidence intervals were estimated per 100 000 population and Kaplan-Meier survival curves evaluated overall survival outcomes among Veterans. RESULTS The Veteran population was primarily white (78%), male (93%), and between 60 and 64 years old (18%). Individuals with a primary brain tumor in the general US population were mainly female (59%) and between 18 and 49 years old (28%). The overall AAIR of primary brain tumors from 2004 to 2018 within the Veterans Affairs cancer registry was 11.6. Nonmalignant tumors were more common than malignant tumors (AAIR:7.19 vs 4.42). The most diagnosed tumors in Veterans were nonmalignant pituitary tumors (AAIR:2.96), nonmalignant meningioma (AAIR:2.62), and glioblastoma (AAIR:1.96). In the Veteran population, survival outcomes became worse with age and were lowest among individuals diagnosed with glioblastoma. CONCLUSIONS Differences between Veteran and US populations can be broadly attributed to demographic composition differences of these groups. Prior to this, there have been no reports on national-level incidence rates and survival outcomes for Veterans. These data provide vital information that can drive efforts to understand disease burden and improve outcomes for individuals with primary brain tumors.
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Affiliation(s)
- John R Bihn
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Gino Cioffi
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
| | - Kristin A Waite
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
| | - Carol Kruchko
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
| | - Corey Neff
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mackenzie Price
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
| | - Quinn T Ostrom
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina, USA
- The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Danne C Elbers
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Michael A Mooney
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jacob Rachlin
- VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Thor D Stein
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University, Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Mary T Brophy
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University, Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Nhan V Do
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University, Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Ryan E Ferguson
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Boston University, Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - David S Priemer
- Department of Pathology, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
- Henry M. Jackson Foundation for The Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Daniel P Perl
- Department of Pathology, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | - Richard A Hickman
- Henry M. Jackson Foundation for The Advancement of Military Medicine, Bethesda, Maryland, USA
- Human Oncology and Pathogenesis Program, Sloan Kettering Institute, New York, New York, USA
- Murtha Cancer Center Research Program, Department of Surgery, Uniformed Services University of Health Sciences, Bethesda, Maryland, USA
| | - Burt Nabors
- Department of Neurology, Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jennifer Rusiecki
- Department of Preventive Medicine and Biostatistics, Uniformed Services University School of Medicine, Bethesda, Maryland, USA
| | - Jill S Barnholtz-Sloan
- Trans Divisional Research Program, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Bethesda, Maryland, USA
- Central Brain Tumor Registry of the United States, Hinsdale, Illinois, USA
- Center for Biomedical Informatics and Information Technology, National Cancer Institute, Bethesda, Maryland, USA
| | - Nathanael R Fillmore
- VA Boston Healthcare System, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
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DuMontier C, La J, Bihn J, Corrigan J, Yildirim C, Dharne M, Hassan H, Yellapragada S, Abel GA, Gaziano JM, Do NV, Brophy M, Kim DH, Munshi NC, Fillmore NR, Driver JA. More intensive therapy as more effective treatment for frail patients with multiple myeloma [corrected]. Blood Adv 2023; 7:6275-6284. [PMID: 37582048 PMCID: PMC10589796 DOI: 10.1182/bloodadvances.2023011019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/07/2023] [Accepted: 08/07/2023] [Indexed: 08/17/2023] Open
Abstract
Although randomized controlled trial data suggest that the more intensive triplet bortezomib-lenalidomide-dexamethasone (VRd) is superior to the less intensive doublet lenalidomide-dexamethasone (Rd) in patients newly diagnosed with multiple myeloma (MM), guidelines have historically recommended Rd over VRd for patients who are frail and may not tolerate a triplet. We identified 2573 patients (median age, 69.7 years) newly diagnosed with MM who were initiated on VRd (990) or Rd (1583) in the national US Veterans Affairs health care System from 2004 to 2020. We measured frailty using the Veterans Affairs Frailty Index. To reduce imbalance in confounding, we matched patients for MM stage and 1:1 based on a propensity score. Patients who were moderate-severely frail had a higher prevalence of stage III MM and myeloma-related frailty deficits than patients who were not frail. VRd vs Rd was associated with lower mortality (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.70-0.94) in the overall matched population. Patients who were moderate-severely frail demonstrated the strongest association (HR 0.74; 95% CI, 0.56-0.97), whereas the association weakened in those who were mildly frail (HR, 0.80; 95% CI, 0.61-1.05) and nonfrail (HR, 0.86; 95% CI, 0.67-1.10). VRd vs Rd was associated with a modestly higher incidence of hospitalizations in the overall population, but this association weakened in patients who were moderate-severely frail. Our findings confirm the benefit of VRd over Rd in US veterans and further suggest that this benefit is strongest in patients with the highest levels of frailty, arguing that more intensive treatment of myeloma may be more effective treatment of frailty itself.
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Affiliation(s)
- Clark DuMontier
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - Jennifer La
- Harvard Medical School, Boston, MA
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
| | - John Bihn
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
| | - June Corrigan
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
| | - Cenk Yildirim
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
| | - Mayuri Dharne
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
| | - Hamza Hassan
- Chobanian and Avedisian School of Medicine, Boston University, Boston, MA
- Boston Medical Center, Boston, MA
| | - Sarvari Yellapragada
- Debakey VA Medical Center and Dan L. Duncan Cancer Center, Baylor College of Medicine, Houston, TX
| | - Gregory A. Abel
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
| | - J Michael Gaziano
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
| | - Nhan V. Do
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Chobanian and Avedisian School of Medicine, Boston University, Boston, MA
| | - Mary Brophy
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Chobanian and Avedisian School of Medicine, Boston University, Boston, MA
| | - Dae H. Kim
- Harvard Medical School, Boston, MA
- Hebrew SeniorLife and Marcus Institute for Aging Research, Boston, MA
| | - Nikhil C. Munshi
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Veterans Affairs, Boston Healthcare System, Boston, MA
| | - Nathanael R. Fillmore
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
- Dana-Farber Cancer Institute, Boston, MA
- Harvard Medical School, Boston, MA
- Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, MA
- Chobanian and Avedisian School of Medicine, Boston University, Boston, MA
| | - Jane A. Driver
- New England Geriatrics Research, Education and Clinical Center, VA Boston Healthcare System, Boston, MA
- Division of Aging, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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Sun L, Brody R, Candelieri D, Lynch JA, Cohen RB, Li Y, Getz KD, Ky B. Risk of Cardiovascular Events Among Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2023; 149:717-725. [PMID: 37347472 PMCID: PMC10288380 DOI: 10.1001/jamaoto.2023.1342] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/27/2023] [Indexed: 06/23/2023]
Abstract
Importance Cardiovascular (CV) disease is a substantial cause of morbidity and mortality in cancer due to shared risk factors and exposure to potentially cardiotoxic cancer therapy. However, our understanding of CV risk in patients with head and neck squamous cell carcinoma (HNSCC) is limited. Objective To define CV risk profiles, incident stroke, myocardial infarction (MI), and mortality in patients with HNSCC. Design, Setting, and Participants This retrospective, population-based cohort study included 35 897 US veterans with newly diagnosed HNSCC from January 1, 2000, to December 31, 2020. Data were analyzed from May 2022 to January 2023. Exposures Demographic, cancer-specific, and treatment characteristics. Main Outcomes Prevalence of CV risk factors, medication use, and control at HNSCC diagnosis; cumulative incidence of stroke and MI; and all-cause death. Results Of 35 857 US veterans with HNSCC (median [IQR] age, 63 [58-69] years; 176 [0.5%] American Indian or Alaska Native, 57 [0.2%] Asian, 5321 [16.6%] Black, 207 [0.6%] Native Hawaiian or Other Pacific Islander, and 26 277 [82.0%] White individuals), there were high rates of former or current smoking (16 341 [83%]), hypertension (24 023 [67%]), diabetes (7988 [22%]), and hyperlipidemia (18 421 [51%]). Although most patients were taking risk-lowering medications, 15 941 (47%) had at least 1 uncontrolled CV risk factor. Black race was associated with increased risk of having uncontrolled CV risk factor(s) (relative risk, 1.06; 95% CI, 1.03-1.09), and patients with larynx cancer had higher rates of prevalent and uncontrolled risk factors compared with other cancer subsites. Considering death as a competing risk, the 10-year cumulative incidence of stroke and MI was 12.5% and 8.3%, respectively. In cause-specific hazards models, hypertension, diabetes, carotid artery stenosis, coronary artery disease, and presence of uncontrolled CV risk factor(s) were significantly associated with stroke and MI. In extended Cox models, incident stroke and MI were associated with a 47% (95% CI, 41%-54%) and 71% (95% CI, 63%-81%) increased risk of all-cause death, respectively. Conclusion The results of this cohort study suggest that in HNSCC, the burden of suboptimally controlled CV risk factors and incident risk of stroke and MI are substantial. Modifiable CV risk factors are associated with risk of adverse CV events, and these events are associated with a higher risk of death. These findings identify populations at risk and potentially underscore the importance of modifiable CV risk factor control and motivate strategies to reduce CV risk in HNSCC survivorship care.
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Affiliation(s)
- Lova Sun
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Robert Brody
- Division of Otorhinolaryngology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
- Corporal Michael Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | | | - Julie A. Lynch
- VA Salt Lake City Health Care System, University of Utah, Salt Lake City
| | - Roger B. Cohen
- Division of Hematology Oncology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Yimei Li
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Kelly D. Getz
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Bonnie Ky
- Division of Cardiology, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
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Cheng D, Dumontier C, Sheikh AR, La J, Brophy MT, Do NV, Driver JA, Tuck DP, Fillmore NR. Prognostic value of the veterans affairs frailty index in older patients with non-small cell lung cancer. Cancer Med 2022; 11:3009-3022. [PMID: 35338613 PMCID: PMC9359868 DOI: 10.1002/cam4.4658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Older patients with non-small cell lung cancer (NSCLC) are a heterogeneous population with varying degrees of frailty. An electronic frailty index such as the Veterans Affairs Frailty Index (VA-FI) can potentially help identify vulnerable patients at high risk of poor outcomes. METHODS NSCLC patients ≥65 years old and diagnosed in 2002-2017 were identified using the VA Central Cancer Registry. The VA-FI was calculated using administrative codes from VA electronic health records data linked with Medicare and Medicaid data. We assessed associations between the VA-FI and times to mortality, hospitalization, and emergency room (ER) visit following diagnosis by Kaplan-Meier analysis and multivariable stratified Cox models. We also evaluated the change in discrimination and calibration of reference prognostic models after adding VA-FI. RESULTS We identified a cohort of 42,204 older NSCLC VA patients, in which 55.5% were classified as frail (VA-FI >0.2). After adjustment, there was a strong association between VA-FI and the risk of mortality (HR = 1.23 for an increase of four deficits or, equivalently, an increase of 0.129 on VA-FI, p < 0.001), hospitalization (HR = 1.16 for four deficits, p < 0.001), and ER visit (HR = 1.18 for four deficits, p < 0.001). Adding VA-FI to baseline prognostic models led to statistically significant improvements in time-dependent area under curves and did not have a strong impact on calibration. CONCLUSION Older NSCLC patients with higher VA-FI have significantly elevated risks of mortality, hospitalizations, and ER visits following diagnosis. An electronic frailty index can serve as an accessible tool to identify patients with vulnerabilities to inform clinical care and research.
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Affiliation(s)
- David Cheng
- Massachusetts General HospitalBostonMAUnited States
- Department of MedicineHarvard Medical SchoolBostonMAUnited States
| | - Clark Dumontier
- Department of MedicineHarvard Medical SchoolBostonMAUnited States
- VA Boston Healthcare SystemBostonMAUnited States
- Brigham and Women's HospitalBostonMAUnited States
| | | | - Jennifer La
- VA Boston Healthcare SystemBostonMAUnited States
| | - Mary T. Brophy
- VA Boston Healthcare SystemBostonMAUnited States
- Boston UniversityBostonMAUnited States
| | - Nhan V. Do
- VA Boston Healthcare SystemBostonMAUnited States
- Boston UniversityBostonMAUnited States
| | - Jane A. Driver
- Department of MedicineHarvard Medical SchoolBostonMAUnited States
- VA Boston Healthcare SystemBostonMAUnited States
- Boston UniversityBostonMAUnited States
- Dana‐Farber Cancer InstituteBostonMAUnited States
| | - David P. Tuck
- VA Boston Healthcare SystemBostonMAUnited States
- Boston UniversityBostonMAUnited States
| | - Nathanael R. Fillmore
- Department of MedicineHarvard Medical SchoolBostonMAUnited States
- VA Boston Healthcare SystemBostonMAUnited States
- Dana‐Farber Cancer InstituteBostonMAUnited States
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