Abstract
Introduction
Lung 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.
Methods
Data from the Veterans Affairs Central Cancer Registry (VACCR) were analyzed for temporal survival trends using Kaplan-Meier (K-M) estimates and linear regression.
Results
54,922 Veterans were identified with lung cancer diagnosed from 2010–2017. 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<0.001). The 3-year overall survival (OS) improved for stage I (58.6% to 68.4%, p<0.001), stage II (35.5% to 48.4%, p<0.001), stage III (18.7% to 29.4%, p<0.001), and stage IV (3.4% to 7.8%, p<0.001). For NSCLC, the median OS increased from 12 to 21 months (p<0.001), and 3-year OS increased from 24.1% to 38.3% (p<0.001). For SCLC, the median OS remained unchanged (8 to 9 months, p=0.10), while the 3-year OS increased from 9.1% to 12.3% (p=0.014). Compared to White Veterans, Black Veterans with NSCLC had similar OS (p=0.81), and those with SCLC had higher OS (p=0.003).
Conclusions
Lung cancer survival is improving within 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.
Keywords: Veterans, Lung Cancer, Race, Survival
Micro-Abstract
A study evaluating >50,000 Veterans diagnosed with lung cancer from 2010–2017 identified improving outcomes for those who received care through the VA. The analysis identified increases in early detection and improved survival for all stages of lung cancer, regardless of non-small cell or small cell lung cancer histology. The study also identified similar survival rates for Black and White Veterans.
1. Introduction
A New England Journal of Medicine (NEJM)1 report in 2020 demonstrated improving survival rates for people diagnosed with lung cancer in the United States (US).1 The study identified increasing 2-year survival rates for men (26% to 35%) and women (35% to 44%) diagnosed between 2001 and 2014. The rates of lung cancer survival increase were found to accelerate between 2013 and 2016. While these increases were observed across different racial and ethnic groups, survival rates remained inferior throughout the study period for non-Hispanic Black men and women demonstrating the persistence of lung cancer racial disparities in the US.
The Veterans Health Administration (VHA) is the largest integrated healthcare system in the US and serves approximately 9 million enrollees.2 It serves a diverse population across multiple racial entities. However, little is known about contemporary survival trends of Veterans with lung cancer who utilize VHA services. We therefore analyzed a national cohort of Veterans with lung cancer who received healthcare within the VHA to evaluate their outcomes and investigate whether survival differences exist by race as observed in the broader population.
2. Methods
We analyzed the survival of Veterans diagnosed with lung cancer between 2010 and 2017 utilizing data managed by the Veterans Affairs Informatics and Computing Infrastructure (VINCI) that was reported through the Veterans Affairs Central Cancer Registry (VACCR). VINCI is an informatics platform that allows access to patient-level electronic health record information and administrative data for all Veterans within the VA healthcare system.3 VINCI incorporates data from the VACCR uploaded by trained registrars at each of the 132 Veterans Affairs (VA) medical centers that provide cancer services.4,5 Data in the VACCR is encoded to meet requirements that have been established by oversight bodies including the North American Association of Central Cancer Registries, the American College of Surgeons’ Commission on Cancer, and the American Joint Commission on Cancer, among others. Data were accessed retrospectively after October 7, 2019 following local institutional review board approval as an exempt project.
Veteran demographics were summarized with descriptive statistics. Trends in annual incidence and mortality rates were evaluated by stage, histology, and race. Overall survival (OS) times were measured from the date of diagnosis with the Kaplan-Meier method for comparisons between groups with the log-rank test. P-values for time-trends in incident cases, proportions, median OS times, and 3-year OS estimates were generated from univariable linear regression of each measure on year of diagnosis.
3. Results
3.1. Study Cohort
The study cohort included a total of 54,922 Veterans with data reported to the VACCR with a diagnosis of lung cancer between 2010–2017. The median age was 70 years, 97% were male, 39.2% lived in rural areas, and among cases with known race, (n=51,768), approximately 16% were Black (Table A). Approximately 15.1% was employed, and the majority were not married (55.7%). Lung cancers were diagnosed at stage I for 22.8%, stage II for 8.4%, stage III for 19.6%, and stage IV for 37.7%; the stage at diagnosis was not reported in 11.6%. The broad histological subtypes were non-small cell lung cancer (NSCLC) in 64.2%, small cell lung cancer (SCLC) in 12.9%, and other or unknown in 22.9%.
Table A –
Characteristics of VHA Enrollees Diagnosed with Lung Cancer Between 2010–17
| Variable | Level | N (%) = 54922 |
|---|---|---|
|
| ||
| Age | ≤ 65 | 16290 (29.7) |
| 66–70 | 12907 (23.5) | |
| 71–75 | 10896 (19.8) | |
| ≥ 76 | 14829 (27.0) | |
| Race | Other | 877 (1.6) |
| Black | 8400 (15.3) | |
| Unknown | 2287 (4.2) | |
| White | 43358 (78.9) | |
| Gender | Female | 1670 (3.0) |
| Male | 53252 (97.0) | |
| Live Rural or Urban | Rural | 21522 (39.2) |
| Urban | 33400 (60.8) | |
| Employment Status | Employed | 8318 (15.1) |
| Not Employed | 23806 (43.3) | |
| Retired | 21527 (39.2) | |
| Unknown | 1271 (2.3) | |
| Marital Status | Unknown | 70 (0.1) |
| Not Married | 30527 (55.6) | |
| Married | 24325 (44.3) | |
| Comorbidity Count | 0 | 16109 (29.3) |
| 1–3 | 15522 (28.3) | |
| 4+ | 23291 (42.4) | |
| Histology | Others | 12602 (22.9) |
| Adenocarcinoma | 19474 (35.5) | |
| Small Cell Carcinoma | 7085 (12.9) | |
| Squamous Cell Carcinoma | 15761 (28.7) | |
| Primary site | Lung NOS | 6418 (11.7) |
| Lung, Lower Lobe | 13508 (24.6) | |
| Lung, Main Bronchus | 1569 (2.9) | |
| Lung, Middle Lobe | 2260 (4.1) | |
| Lung, Overlap | 693 (1.3) | |
| Lung, Upper Lobe | 30474 (55.5) | |
| Stage Group Best | No stage | 6352 (11.6) |
| I | 12536 (22.8) | |
| II | 4602 (8.4) | |
| III | 10741 (19.6) | |
| IV | 20691 (37.7) | |
| Year of Diagnosis | 2010 | 7283 (13.3) |
| 2011 | 7154 (13.0) | |
| 2012 | 7136 (13.0) | |
| 2013 | 6934 (12.6) | |
| 2014 | 6948 (12.7) | |
| 2015 | 6702 (12.2) | |
| 2016 | 6514 (11.9) | |
| 2017 | 6251 (11.4) | |
As shown in Figure A.3, the distribution of incident cases by race did not change over the study period. The proportion of patients reported as White remained constant (77.5% to 77.9%; p=0.82), and there was a non-significant increase in the proportion of Black Veterans diagnosed with lung cancer (15.7% to 17.1%, p=0.17). The proportion reported as other or unknown race declined from 6.7% to 5.0% (p=0.01).
Figure A –
Trends in baseline distributions at diagnosis for (A.1) stage, (A.2) histology, and (A.3) race
3.2. Stage, Histology, and Incidence Trends
Among Veterans diagnosed with lung cancer during the study period, the proportion presenting with stage I lung cancer increased from 18.1% to 30.4% (p<0.001, see Figure A.1). This proportional increase of stage I lung cancers was most notable after 2014 when it was 21.4%. The proportional changes in stage II (7.8% to 7.9%, p=0.64) and stage III (20.9% to 19.9%; p=0.16) did not change significantly. The increase in stage I diagnoses was associated with a statistically significant decrease in the proportion of stage IV lung cancer cases (38.9% to 34.6%; p=0.004). The proportion of lung cancer cases reported with an unknown stage during the study period decreased from 14.3% to 7.3% (p<0.001).
As shown in Figure A.2, among the broad histological lung cancer subgroups, the proportion of patients diagnosed with NSCLC increased from 60.2% to 67.1% (p<0.001). Consequently, the proportion of patients diagnosed with SCLC decreased from 13.5% to 11.8% (p=0.009). The proportion with other histology decreased from 26.3 to 21.0% (p<0.001). Among Veterans with NSCLC, the proportion with adenocarcinoma increased from 54.5% to 57.7% (p=0.003), and the proportion with squamous cell carcinoma decreased from 45.5% to 42.3% (p=0.003).
3.3. Survival Trends
As demonstrated in Figure B.1, the median OS across histological subtypes increased from 11 months to 18 months, and the 3-year OS rate increased from 22.0% to 35.2% (both p<0.001). Improvements in survival were demonstrated across each stage at diagnosis as demonstrated in Figures B.1–B.5. The 3-year OS rates were found to increase for stage I (58.6% to 68.4%, p<0.001), stage II (35.5 to 48.4%, p<0.001) stage III (18.7% to 29.4%, p<0.001), and stage IV (3.4% to 7.8%, p<0.001).
Figure B -.
Overall survival rates for combined NSCLC and SCLC analyzed by Kaplan-Meier method, stratified by year of diagnosis: (B.1) stage I, (B.2) stage II, (B.3) stage III, (B.4) stage IV, (B.5) stage I-IV
Improved survival trends for Veterans with lung cancer were seen within histological subtypes. As shown in Figure C.1, the median OS for Veterans with NSCLC increased from 12 months to 21 months (p<0.001), and the 3-year OS increased from 24.1% to 38.3% (p<0.001). Increased survival rates persisted after stratification by histology (adenocarcinoma vs. squamous cell carcinoma) (see Figures C.2–C.3). Annual survival trends for Veterans with SCLC are shown in Figure C.4 with median survival times remaining relatively unchanged from 8 to 9 months (p=0.10), while 3-year OS rates increased from 9.1% to 12.3% (p=0.014).
Figure C -.
Overall survival for individual lung cancer histologies analyzed by Kaplan-Meier method, stratified by year of diagnosis: (C.1) NSCLC, (C.2) SCLC, (C.3) adenocarcinoma, and (C.4) squamous cell carcinoma
3.4. Association of Race and Survival
As shown in Figure D.1, Black Veterans had higher survival rates than White Veterans with a median OS of 14 vs 13 months and 3-year OS of 27.5% vs 26.8% (both p<0.001). When stratified by broad histological subtypes, the higher OS for Black Veterans was statistically significant for those with SCLC (Figures D.2–D.3).
Figure D -.
Overall survival by race analyzed by Kaplan-Meier method: (D.1) combined NSCLC and SCLC, (D.2) NSCLC, and (D.3) SCLC
4. Discussion
Survival rates for Veterans with lung cancer who received healthcare through the VHA increased significantly during the study period. This observation was made across all stages and histological subtypes and was coincident with the identification of a 68% relative increase in stage I at diagnosis and 11% relative decrease in stage IV diagnoses. Further, compared to White Veterans, we observed Black Veterans with NSCLC and SCLC had better or similar survival rates, respectively.
The increased survival trends for Black and White within VHA resemble findings from the NEJM 2020 report that relied on data from Surveillance, Epidemiology, and End Results (SEER).1 Their analysis had identified a decline in incidence-based lung cancer mortality of 3.2% annually between 2006 and 2013, that increased to 6.3% annually between 2013 and 2016. A more recent report in 2021 from the American Cancer Society made similar observations of accelerated reductions in lung cancer mortality from 2.4% between 2009 and 2013, to 5% between 2014 and 2018.6 Authors of the NEJM report attributed their observations to the recent introduction of recommendations for routine testing of molecular alterations in EGFR and ALK and commercial use of related FDA-approved targeted therapies.1
While it is appropriate to consider molecular testing and select targeted therapies as a dominant driver of improved lung cancer survival, ongoing improvements in each of the following diagnostic and treatment-related factors may have also had an influence: (1) increasing utilization of low-dose chest computed tomography (LDCT) scans for early detection, (2) advances in biopsy techniques to increase the likelihood of obtaining a positive biopsy and correctly staging patients at the time of initial diagnosis (e.g. endobronchial ultrasound and robotic bronchoscopy guided systems),7 (3) incorporation of nurse navigators to improve the timeliness of care,8 (4) technological advances improving the safety of lung cancer surgery and radiation therapy delivery systems (e.g. minimally invasive surgery and image guided radiation therapy),9–11 (5) access to newly FDA-approved targeted therapies and immunotherapies,1 (6) better integration of palliative care for patients with metastatic lung cancer which has been shown to not only prolong survival, but also improve the quality of life for people at the end of their lung cancer journey,12–14 and (7) decreased wait times for healthcare within VHA since passage of the 2014 Veterans Choice Program.15 Given the complex coordination of healthcare required to successfully work up and manage patients with newly diagnosed lung cancer, further research into the relative contributions of each of these diagnostic and therapeutic factors is necessary to replicate the VHA’s success in other healthcare systems.
Regarding the observation of better or similar survival rates in Black versus White Veterans with lung cancer, our findings are consistent with previous reports from the US Department of Defense and VHA.16–19 Collectively, these findings align with the US Military and VHA’s long-standing culture of ensuring healthcare equity which dates back to Executive Order 9881, written by President Harry S. Truman, which declared in 1948: “There shall be equality of treatment and opportunity for all persons in the armed services without regard to race, color, religion or national origin”.
Today, health equity in the VHA is continuously evaluated by numerous individuals and programs, including those associated with the VHA Centers for Health Equity Research and Promotion (established 2001), VHA Health Equity and Rural Outreach Innovation Center (established 2004), and the VHA Office of Health Equity (established 2013). When evaluating health equities in VHA beyond lung cancer, a PubMed query (data not presented) demonstrated over 80% of peer-reviewed publication between 2015–2021 analyzing cancer survival by race (n=50) reported better or similar outcomes for Black versus White Veterans in VHA with bladder,20 prostate,21,22 head & neck,23 pancreatic,24 and lung cancer.25 As smaller healthcare systems in the United States are combining to form large and complex healthcare environments, and racial equities are increasingly becoming a priority, lessons learned in the VHA can serve as an example of how intentional policy implementation can mitigate social determinants of health to reduce healthcare disparities in the broader population.
There are important limitations to consider regarding the study’s findings. The analyses were limited to available cases reported to the VACCR, that are likely underreported due to under-ascertainment, and focused on incident case-based mortality trends. We did not calculate a standardized estimate of cancer incidence rates for Veterans as previously reported by Zullig et. al. in 2017.26 Incident cases and trends reported may therefore not accurately reflect population-based lung cancer incidence rates among the broader Veteran community who utilize their non-VHA healthcare benefits. Further, detailed information about smoking intensity was not evaluated or adjusted for. Regarding a relative increase in the proportion of Veterans diagnosed with stage I lung cancer, it is unlikely that this was achieved by increased utilization of LDCT scans. As reported by Lewis et. al., the number of initial LDCT scans performed within VHA increased from 0 in 2011 to only 27.4 scans per 1000 eligible Veterans in 2017 (Ptrend < 0.001).27 Therefore, the observed stage shift may have been more likely due to a combination of: (1) increased LDCT utilization, (2) improved diagnostic procedures and evaluation of incidental nodules,28 and (3) a decline in the proportion of cases reported with unknown stage during the study period (14.3% to 7.3%). Finally, the impact on treatment trends was not considered in this analysis and deserves further evaluation.
There are also limitations regarding the generalizability of the findings and implications for clinical practice in settings outside the VHA. The reported mitigated differences in lung cancer survival by race was demonstrated in a study population of Veterans who are predominantly white, approximately 90% male, and with lower socioeconomic resources as compared with either non-Veterans or Veterans not engaged in VHA care. Potential interaction between race and socioeconomic status were not explored and may have had a role.
Our study has several strengths. First, it relied on high-quality cancer registry data that was prospectively coded by cancer registrars at local VA medical centers. Second, it identified a large cohort of lung cancer patients with diverse geographic, socioeconomic, and racial backgrounds. Third, it analyzed a population that generally remains within a single healthcare system that captures all their clinical data that are centrally accessible through a national corporate data warehouse. Fourth, the quality of data capture improved over time as evidenced by a 50% decrease in the number of lung cancer cases classified as unknown over the study period.
5. Conclusion
Survival rates for Veterans with lung cancer who utilize VHA for their healthcare steadily increased from 2010 to 2017. Increased survival trends were identified across different histological subtypes and each stage at diagnosis. This observation is likely due to an increase in the percentage of Veterans diagnosed at earlier stages, improved diagnostic technologies, and advancements in medical, surgical, and radiation therapies. The finding of higher or similar survival rates among Black compared to White Veterans demonstrates how an integrated, equal access healthcare system can successfully address lung cancer inequities that continues to be commonly found in the broader US population.
Clinical Practice Points.
Lung cancer survival rates are improving in the US despite persistent racial disparities [Ref: Howlader et al, NEJM 2000]. Yet, publicly reported data are limited to confirm survival rates are improving and racially equitable for Veterans with lung cancer receiving care through the VA. A study evaluating >50,000 Veterans diagnosed with lung cancer from 2010–2017 identified improving outcomes for those who received care through the VA. The analysis identified increases in early detection and improved survival for all stages of lung cancer during the study period, regardless of non-small cell or small cell lung cancer histology. These findings confirm that Veterans are also benefiting from advances in diagnostic and therapeutic treatments for lung cancer. The study also identified that the racial lung cancer disparities documented across the US were not observed within the VA, with similar survival rates demonstrated for Black and White Veterans. Healthcare systems may benefit from a better understanding of VA’s equal access model of healthcare and enterprise-wide programs to address healthcare disparities for all medical conditions that likely contributed to this finding.
Highlights.
Survival rates are increasing for Veterans seeking lung cancer care through the VA
This correlates with increases in stage I and decreases in stage IV diagnoses
Racial equity was observed for Black and White Veterans with lung cancer
Funding:
This study was supported in part by U.S. Department of Veterans Affairs (VA) Office of Rural Health with resources and use of facilities at VA Greater Los Angeles Healthcare System, Los Angeles, CA (DM), Atlanta VA Healthcare System, Decatur, GA (DG) the Center to Improve Veteran Involvement in Care located in VA Portland Healthcare System, Portland, OR (CGS), and VA Tennessee Valley Healthcare System, Nashville, TN (JL & LS). The study was also supported in part by the Bristol Myers Squibb Foundation (DM), the Morningside Center for Innovative and Affordable Medicine (MB), the Emory Woodruff Health Sciences Center (MB), the Winship Data and Technology Applications Shared Resource of Winship Cancer Institute of Emory University (MB), the National Cancer Institute of the National Institutes of Health under Award Numbers P30CA138292 and P50CA217691 (MB), a 2021 Conquer Cancer ASCO Foundation Young Investigator Award (JL), a LUNGevity Foundation VA Research Scholars Award (JL), the Vanderbilt-Ingram Cancer Center Support Grant CA68485 (JL & LS) and the Vanderbilt Scholars in T4 Translational Research (VSTTaR) K12 Program, funded by the National Heart, Lung, and Blood Institute K12HL137943 (JL), and an American Cancer Society Research Scholar Grant, RSG-20-127-01-CPPB (DRS). Funding unrelated to the submitted work includes research funding from RefleXion Medical (LKV), Georgia Research Alliance (WAS), VA and National Cancer Institute (CGS). The content is solely the responsibility of the authors and does not necessarily represent the official views of any funding source listed above.
Glossary
- K-M
Kaplan-Meier
- LDCT
Low-dose chest computed tomography
- NEJM
New England Journal of Medicine
- OS
Overall survival
- SEER
Surveillance, Epidemiology, and End Results
- US
United States
- VA
Veterans Affairs
- VACCR
Veterans Affairs Central Cancer Registry
- VHA
Veterans Health Administration
- VINCI
Veterans Affairs Informatics and Computing Infrastructure
Footnotes
Declarations of Interest: DM is a consultant and/or advisor for AstraZeneca, Delfi Diagnostics, Viewray, and Merck; is a scientific advisor for Lungevity Foundation and GO2 Foundation for Lung Cancer; is co-director of the VA Greater Los Angeles Lung Precision Oncology Program; is on the scientific advisory board and owns stock options in Lung Life AI. DG is a founder of SwitchboardMD, is on the advisory board of Histowiz LLC, and owns stock in PortalBurner LLC, Histowiz LLC, and SwitchboardMD. JL is board member of Rescue Lung Rescue Life and is Co-director of the Tennessee Valley Healthcare System Lung Cancer Screening Program. LS is member of the Tennessee Valley Healthcare System Lung Cancer Screening Steering Committee and Vice Chair of Health Equity at Vanderbilt University Medical Center Radiology. CS is Medical Director of the VAPORHCS lung nodule surveillance system, Director for the VISN 20 Centralized Lung Cancer Screening Program, and Chief Consultant for the VA National Center for Lung Cancer Screening. He does not receive additional renumeration for this role. He has a grant from the Oregon Health & Science University Knight Cancer Institute (KCI) to develop a nodule/lung cancer risk prediction model that includes working with a for-profit company, Optellum, Ltd. Neither he nor the KCI receive renumeration for this collaboration. All other authors declare no conflicts of interest.
CRediT Author Statement
Drew Moghanaki – Conceptualization, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Supervision, Visualization, Writing – original draft, Writing – review & editing
James Taylor – Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing
Alex K. Bryant – Methodology, Visualization, Writing – review & editing
Lucas Vitzthum - Writing – review & editing
Nikhil Sebastian – Conceptualization, Formal analysis, Investigation, Methodology, Visualization, Writing – review & editing
David Gutman – Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – review & editing
Abigail Burns – Project administration, Writing – review & editing
Zhonglu Huang – Data curation, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing
Jennifer Lewis - Writing – review & editing
Lucy Spalluto - Writing – review & editing
Christina D. Williams – Writing – review & editing
Donald R. Sullivan – Writing – review & editing
Christopher G. Slatore – Writing – review & editing
Madhusmita Behera – Project administration, Supervision, Writing – review & editing
William A. Stokes – Conceptualization, Formal analysis, Investigation, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing
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References
- 1.Howlader N, Forjaz G, Mooradian MJ, et al. The Effect of Advances in Lung-Cancer Treatment on Population Mortality. N Engl J Med. Aug 13 2020;383(7):640–649. doi: 10.1056/NEJMoa1916623 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Administration VH. Veterans Health Administration Home Page. Updated August 2, 2022. https://www.va.gov/health/
- 3.(VINCI) ViaCI. VA HSR RES 13–457. Accessed Retrieved after January 21, 2020, from https://vincicentral.vinci.med.va.gov.
- 4.Zullig LL, Jazowski SA, Chawla N, et al. Summary of Veterans Health Administration Cancer Data Sources. J Registry Manag. Fall 2019;46(3):76–83. [PubMed] [Google Scholar]
- 5.Data VOO. Data from: Veterans Affairs Central Cancer Registry. 2020.
- 6.Siegel RL, Miller KD, Fuchs HE, Jemal A. Cancer Statistics, 2021. CA Cancer J Clin Jan 2021;71(1):7–33. doi: 10.3322/caac.21654 [DOI] [PubMed] [Google Scholar]
- 7.Ekeke CN, Vercauteren M, Istvaniczdravkovic S, Semaan R, Dhupar R. Lung Nodule Evaluation Using Robotic-Assisted Bronchoscopy at a Veteran’s Affairs Hospital. J Clin Med. Aug 19 2021;10(16)doi: 10.3390/jcm10163671 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Hunnibell LS, Rose MG, Connery DM, et al. Using nurse navigation to improve timeliness of lung cancer care at a veterans hospital. Clin J Oncol Nurs. Feb 2012;16(1):29–36. doi: 10.1188/12.CJON.29-36 [DOI] [PubMed] [Google Scholar]
- 9.Heiden BT, Eaton DB Jr., Chang SH, et al. Comparison between Veteran and Non-Veteran Populations with Clinical Stage I Non-Small Cell Lung Cancer Undergoing Surgery. Ann Surg. May 11 2021;doi: 10.1097/SLA.0000000000004928 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Dawson GA, Cheuk AV, Lutz S, et al. The Availability of Advanced Radiation Oncology Technology within the Veterans Health Administration Radiation Oncology Centers. Fed Pract. May 2016;33(Suppl 4):18S–22S. [PMC free article] [PubMed] [Google Scholar]
- 11.Syed YA, Stokes W, Rupji M, et al. Surgical Outcomes for Early Stage Non-small Cell Lung Cancer at Facilities With Stereotactic Body Radiation Therapy Programs. Chest. Nov 14 2021;doi: 10.1016/j.chest.2021.11.004 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Sullivan DR, Chan B, Lapidus JA, et al. Association of Early Palliative Care Use With Survival and Place of Death Among Patients With Advanced Lung Cancer Receiving Care in the Veterans Health Administration. JAMA Oncol. Dec 1 2019;5(12):1702–1709. doi: 10.1001/jamaoncol.2019.3105 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Sullivan DR, Teno JM, Reinke LF. Evolution of Palliative Care in the Department of Veterans Affairs: Lessons from an Integrated Health Care Model. J Palliat Med. Jan 2022;25(1):15–20. doi: 10.1089/jpm.2021.0246 [DOI] [PubMed] [Google Scholar]
- 14.Gutt R, Malhotra S, Moghanaki D, et al. Radiotherapeutic Care of Patients With Stage IV Lung Cancer with Thoracic Symptoms in the Veterans Health Administration. Fed Pract. May 2020;37(Suppl 2):S38–S42. [PMC free article] [PubMed] [Google Scholar]
- 15.Penn M, Bhatnagar S, Kuy S, et al. Comparison of Wait Times for New Patients Between the Private Sector and United States Department of Veterans Affairs Medical Centers. JAMA Netw Open. Jan 4 2019;2(1):e187096. doi: 10.1001/jamanetworkopen.2018.7096 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Williams CD, Salama JK, Moghanaki D, Karas TZ, Kelley MJ. Impact of Race on Treatment and Survival among U.S. Veterans with Early-Stage Lung Cancer. J Thorac Oncol. Oct 2016;11(10):1672–81. doi: 10.1016/j.jtho.2016.05.030 [DOI] [PubMed] [Google Scholar]
- 17.Ganti AK, Subbiah SP, Kessinger A, Gonsalves WI, Silberstein PT, Loberiza FR Jr. Association between race and survival of patients with non--small-cell lung cancer in the United States veterans affairs population. Clin Lung Cancer. Mar 2014;15(2):152–8. doi: 10.1016/j.cllc.2013.11.004 [DOI] [PubMed] [Google Scholar]
- 18.Zullig LL, Carpenter WR, Provenzale DT, et al. The association of race with timeliness of care and survival among Veterans Affairs health care system patients with late-stage non-small cell lung cancer. Cancer Manag Res. 2013;5:157–63. doi: 10.2147/CMAR.S46688 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Brzezniak C, Satram-Hoang S, Goertz HP, et al. Survival and Racial Differences of Non-Small Cell Lung Cancer in the United States Military. J Gen Intern Med. Oct 2015;30(10):1406–12. doi: 10.1007/s11606-015-3280-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Kotha NV, Kumar A, Qiao EM, et al. Association of Health-Care System and Survival in African American and Non-Hispanic White Patients With Bladder Cancer. J Natl Cancer Inst. Apr 11 2022;114(4):600–608. doi: 10.1093/jnci/djab219 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Deka R, Courtney PT, Parsons JK, et al. Association Between African American Race and Clinical Outcomes in Men Treated for Low-Risk Prostate Cancer With Active Surveillance. JAMA. Nov 3 2020;324(17):1747–1754. doi: 10.1001/jama.2020.17020 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Klebaner D, Courtney PT, Garraway IP, et al. Association of Health-Care System With Prostate Cancer-Specific Mortality in African American and Non-Hispanic White Men. J Natl Cancer Inst. Oct 1 2021;113(10):1343–1351. doi: 10.1093/jnci/djab062 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23.Voora RS, Kotha NV, Kumar A, et al. Association of race and health care system with disease stage and survival in veterans with larynx cancer. Cancer. Aug 1 2021;127(15):2705–2713. doi: 10.1002/cncr.33557 [DOI] [PubMed] [Google Scholar]
- 24.Del Valle JP, Fillmore NR, Molina G, et al. Socioeconomic Disparities in Pancreas Cancer Resection and Survival in the Veterans Health Administration. Ann Surg Oncol. May 2022;29(5):3194–3202. doi: 10.1245/s10434-021-11250-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Heiden BT, Eaton DB Jr., Chang SH, et al. Racial Disparities in the Surgical Treatment of Clinical Stage I Non-Small Cell Lung Cancer Among Veterans. Chest. Apr 8 2022;doi: 10.1016/j.chest.2022.03.045 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26.Zullig LL, Sims KJ, McNeil R, et al. Cancer Incidence Among Patients of the U.S. Veterans Affairs Health Care System: 2010 Update. Mil Med. Jul 2017;182(7):e1883–e1891. doi: 10.7205/MILMED-D-16-00371 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Lewis JA, Samuels LR, Denton J, et al. National Lung Cancer Screening Utilization Trends in the Veterans Health Administration. JNCI Cancer Spectr. Oct 2020;4(5):pkaa053. doi: 10.1093/jncics/pkaa053 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Ganti AK, Klein AB, Cotarla I, Seal B, Chou E. Update of Incidence, Prevalence, Survival, and Initial Treatment in Patients With Non-Small Cell Lung Cancer in the US. JAMA Oncol. Dec 1 2021;7(12):1824–1832. doi: 10.1001/jamaoncol.2021.4932 [DOI] [PMC free article] [PubMed] [Google Scholar]