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'An Organization in Turmoil': Ken Kizer on the Challenges Facing the VA
'An Organization in Turmoil': Ken Kizer on the Challenges Facing the VA
Kenneth W. Kizer, MD, MPH, knows a thing or two about transition at the US Department of Veterans Affairs (VA). He served as VA Under Secretary of Health from 1994 to 1999, stepping in during an era of crisis with a mandate for transformation.
Kizer, a Distinguished Professor Emeritus at the University of California, Davis School of Medicine, is among the top thinkers about the VA and its future. He recently spoke with Federal Practitioner about community care, the electronic health record transition, and other challenges facing the Veterans Health Administration (VHA).
At stake, Kizer explained, is an invaluable service for veterans—and much more. “VA is the largest provider of training for... multiple types of health professionals that people use every day,” he said. “There’s also the research, the direct care provided to veterans, and the contingency support the VA provides, which was very well demonstrated during the COVID pandemic. These are things that benefit all Americans, not just veterans.”
When you look at the VA, what do you see?
I see an organization in turmoil, a great health care system struggling with multiple major challenges simultaneously. The VHA is becoming a very large health insurance program without the necessary infrastructure, and costs are rising rapidly. And it is trying to roll out a new EHR and implement new third-party administrator contracts while suffering from significant staffing reductions and very depressed morale.
There are a host of other high-visibility and high-impact issues, including a major reorganization. There’s been a paucity of details about exactly what is going to change, who is going to be doing what, and how the changes will affect staffing and workflow.
How will the loss of 35,000 health care positions affect veterans' care?
If you don’t have enough people, then you’re not going to be able to provide the care that is needed. Years ago, I led a project assessing the Roseburg VA Medical Center in Central Oregon. Among other things, there were a lot of problems with cardiology care. The biggest complaint the cardiologists had, and why the hospital couldn’t keep cardiologists on staff, was that there weren’t enough support staff to do the electrocardiograms. The cardiologists had to do the electrocardiograms themselves, which meant they weren’t doing other things they should be doing. You can amplify that example in a hundred different ways in VA today. If physicians don’t have adequate support, they get frustrated and disenfranchised. And they leave.
One of the fallacies I’ve heard mentioned in some congressional hearings is that it’s mainly a matter of lower pay in the VA. Pay may be an issue somewhere on the list of recruiting challenges, but more important issues higher up are things like the support clinicians receive, the work environment, whether they feel valued, and how easy it is for them to do their work. Case in point: If you put in a new EHR that doesn’t work as well as the existing one, then some doctors are going to leave.
Is VA being pushed toward privatization?
At some point it becomes a self-fulfilling prophecy. If you don’t have the staff to provide the services, then you refer more veterans to the community, and you get in a downward spiral. Patients are going to the community, you lose more staff, you continue to be unable to provide services, and more care goes to the community.
A part of this equation that hasn’t been given adequate attention is VA’s teaching mission. If care is increasingly going to the community, those patients won’t be available for the trainees in teaching programs. That in turn impacts the pipeline of clinicians who will be available to serve the population at large. The negative effects will be seen far beyond the VA.
Why have you expressed concern over VA care fragmentation?1
Greater than 80% of VA ICU [intensive care unit] care is now being provided in community hospitals. When patients are discharged from those hospitals, they often continue getting follow-up care in the community because VA doesn’t have good mechanisms to reconnect those patients back to VA care.2
[Other researchers] found that the majority of emergency department care for enrolled veterans in New York State was being paid for by entities other than the VA, most commonly Medicare but also Medicaid and private insurance. Where follow-up care occurred often depended on who paid for the emergency department visit, not necessarily what was best for the patient.3
The core problem is that the VA has very little insight into what’s happening when its enrollees get care that is paid for by another payer. VA doesn’t know when their patients are in a private hospital emergency department, so they can’t reach out in real time, and they can’t reconnect with them afterward.
That is very different than for commercial health plans. They know when one of their enrollees is admitted to an out-of-network hospital, and when they are discharged, and they follow up immediately. VA doesn’t have the infrastructure in place to do that.
Why did the VA spend $44 billion on Medicare Advantage double-payments from 2018 to 2021?4
That number is much larger now—$87 billion from 2019 to 2023. Here’s the problem: When VA enrollees are also enrolled in a Medicare Advantage plan, the Medicare plan gets paid to provide the care for those veterans. But when those enrollees come to the VA, the VA provides and pays for the care but cannot bill Medicare for the costs. So the federal government ends up paying twice for care of the same person.
In a paper I coauthored last December we showed that in 2023 alone VA spent $23 billion for care of veterans enrolled in Medicare Advantage plan. Those duplicative payments accounted for almost 20% of VA's entire medical care budget.5
How can fragmented care be reduced?
Two things really stand out. First, real-time health insurance data sharing across payers is foundational. VA has to know when its patients get care by non-VA providers if it is going to coordinate and provide follow-up care. As a first step, VA and the Centers for Medicare & Medicaid Services need to create a data sharing platform for veterans dually enrolled in VA and Medicare or Medicaid.
This is not a new idea. I tried to do it when I was Under Secretary for Health in the late 1990s, but it never happened for various political reasons. Others have tried since. Maybe now, given how much money is at stake, it will finally get done.
Second, the VA needs to implement rigorous case management for high utilizers. The costs are not evenly distributed across enrollees. Approximately 10% of community care users account for almost 90% of community care expenditures. Common sense says you should intensely manage the care of those high-need patients who account for so much of the costs, try to avoid out-of-network ICU and emergency department care as much as possible, and build relationships with other providers so there are clear mechanisms to reconnect those patients back to VA care after an acute episode is treated outside the VA health system.
Is community care itself the problem?
No. Community care is a good thing for many veterans. It has increased access and made it easier for enrolled veterans to get care in some situations. The problem is that the VA hasn’t built in the mechanisms and processes to share information, manage complex patients, provide follow-up care, or oversee quality in community care.
Historically, VA has been an integrated delivery system that provided the overwhelming majority of care within its own facilities. However, over the last decade it has become a hybrid purchaser-provider system. It has become a very large purchaser of non-VA care, going from about $7 billion to $50 billion in community care spending over the past decade. But the VA hasn’t built the infrastructure—information exchange, case management, utilization review, quality oversight—that a hybrid purchaser-provider system needs to be a prudent purchaser.
What is your perspective on VHA's EHR transition?
The many problems with the rollout of the Oracle/Cerner EHR have been well-documented by the Inspector General, frontline clinicians, and others. The problems have been so bad that implementation has been halted a couple times. They’re now moving forward again, but it remains to be seen whether the problems truly have been fixed.
Still unaddressed is the more fundamental question of whether VistA could have been upgraded and modernized at far less cost and disruption of care. No thorough, deliberative analysis of that was ever done. And some of the ostensible problems with upgrading VistA in years past are no longer an issue.
Given the challenges VA faces, are you optimistic about its future?
While there definitely are problems, they are all solvable. Every challenge the VA is facing can be addressed. The question is when and how, and whether the VA is going to be given a fair chance to work through its challenges.
As for those who look to the private sector and think that’s the solution: They haven’t looked closely enough. The private sector is also struggling with staffing and financing issues, many of the same issues VA is dealing with, just in a somewhat different way. The problems in the private sector will be an increasing challenge for community care going forward.
Overall, my life experience is that dark times are always followed by daylight, so I am confident there are brighter days ahead for VA.
1. Kizer KW. Curbing the growing fragmentation of veterans’ health care. JAMA Health Forum. 2025;6:e254148. doi:10.1001/jamahealthforum.2025.4148
2. Hahn Z, Naiditch H, Talisa V, et al. Intensive care unit admissions purchased or delivered by veterans in the VA health care system. JAMA Health Forum. 2025;6:e255605. doi:10.1001/jamahealthforum.2025.5605
3. Vashi AA, Urech T, Wu S, Asch S. Fragmented financing in emergency department use among US veterans. JAMA Health Forum. 2025;6:e255635. doi:10.1001/jamahealthforum.2025.5635
4. Maremont M, Weaver C, McGinty T. Insurers collected billions from medicare for veterans who cost them almost nothing. The Wall Street Journal. December 2, 2024. Accessed March 17, 2026. https://www.wsj.com/health/healthcare /veterans-medicare-insurers-collect-billions-bfd47d27
5. Trivedi AN, Jiang L, Meyers DJ, et al. Spending by the Veterans Affairs health care system for Medicare Advantage Enrollees. JAMA Health Forum. 2025;6:e255653. doi:10.1001/jamahealthforum.2025.5653
Kenneth W. Kizer, MD, MPH, knows a thing or two about transition at the US Department of Veterans Affairs (VA). He served as VA Under Secretary of Health from 1994 to 1999, stepping in during an era of crisis with a mandate for transformation.
Kizer, a Distinguished Professor Emeritus at the University of California, Davis School of Medicine, is among the top thinkers about the VA and its future. He recently spoke with Federal Practitioner about community care, the electronic health record transition, and other challenges facing the Veterans Health Administration (VHA).
At stake, Kizer explained, is an invaluable service for veterans—and much more. “VA is the largest provider of training for... multiple types of health professionals that people use every day,” he said. “There’s also the research, the direct care provided to veterans, and the contingency support the VA provides, which was very well demonstrated during the COVID pandemic. These are things that benefit all Americans, not just veterans.”
When you look at the VA, what do you see?
I see an organization in turmoil, a great health care system struggling with multiple major challenges simultaneously. The VHA is becoming a very large health insurance program without the necessary infrastructure, and costs are rising rapidly. And it is trying to roll out a new EHR and implement new third-party administrator contracts while suffering from significant staffing reductions and very depressed morale.
There are a host of other high-visibility and high-impact issues, including a major reorganization. There’s been a paucity of details about exactly what is going to change, who is going to be doing what, and how the changes will affect staffing and workflow.
How will the loss of 35,000 health care positions affect veterans' care?
If you don’t have enough people, then you’re not going to be able to provide the care that is needed. Years ago, I led a project assessing the Roseburg VA Medical Center in Central Oregon. Among other things, there were a lot of problems with cardiology care. The biggest complaint the cardiologists had, and why the hospital couldn’t keep cardiologists on staff, was that there weren’t enough support staff to do the electrocardiograms. The cardiologists had to do the electrocardiograms themselves, which meant they weren’t doing other things they should be doing. You can amplify that example in a hundred different ways in VA today. If physicians don’t have adequate support, they get frustrated and disenfranchised. And they leave.
One of the fallacies I’ve heard mentioned in some congressional hearings is that it’s mainly a matter of lower pay in the VA. Pay may be an issue somewhere on the list of recruiting challenges, but more important issues higher up are things like the support clinicians receive, the work environment, whether they feel valued, and how easy it is for them to do their work. Case in point: If you put in a new EHR that doesn’t work as well as the existing one, then some doctors are going to leave.
Is VA being pushed toward privatization?
At some point it becomes a self-fulfilling prophecy. If you don’t have the staff to provide the services, then you refer more veterans to the community, and you get in a downward spiral. Patients are going to the community, you lose more staff, you continue to be unable to provide services, and more care goes to the community.
A part of this equation that hasn’t been given adequate attention is VA’s teaching mission. If care is increasingly going to the community, those patients won’t be available for the trainees in teaching programs. That in turn impacts the pipeline of clinicians who will be available to serve the population at large. The negative effects will be seen far beyond the VA.
Why have you expressed concern over VA care fragmentation?1
Greater than 80% of VA ICU [intensive care unit] care is now being provided in community hospitals. When patients are discharged from those hospitals, they often continue getting follow-up care in the community because VA doesn’t have good mechanisms to reconnect those patients back to VA care.2
[Other researchers] found that the majority of emergency department care for enrolled veterans in New York State was being paid for by entities other than the VA, most commonly Medicare but also Medicaid and private insurance. Where follow-up care occurred often depended on who paid for the emergency department visit, not necessarily what was best for the patient.3
The core problem is that the VA has very little insight into what’s happening when its enrollees get care that is paid for by another payer. VA doesn’t know when their patients are in a private hospital emergency department, so they can’t reach out in real time, and they can’t reconnect with them afterward.
That is very different than for commercial health plans. They know when one of their enrollees is admitted to an out-of-network hospital, and when they are discharged, and they follow up immediately. VA doesn’t have the infrastructure in place to do that.
Why did the VA spend $44 billion on Medicare Advantage double-payments from 2018 to 2021?4
That number is much larger now—$87 billion from 2019 to 2023. Here’s the problem: When VA enrollees are also enrolled in a Medicare Advantage plan, the Medicare plan gets paid to provide the care for those veterans. But when those enrollees come to the VA, the VA provides and pays for the care but cannot bill Medicare for the costs. So the federal government ends up paying twice for care of the same person.
In a paper I coauthored last December we showed that in 2023 alone VA spent $23 billion for care of veterans enrolled in Medicare Advantage plan. Those duplicative payments accounted for almost 20% of VA's entire medical care budget.5
How can fragmented care be reduced?
Two things really stand out. First, real-time health insurance data sharing across payers is foundational. VA has to know when its patients get care by non-VA providers if it is going to coordinate and provide follow-up care. As a first step, VA and the Centers for Medicare & Medicaid Services need to create a data sharing platform for veterans dually enrolled in VA and Medicare or Medicaid.
This is not a new idea. I tried to do it when I was Under Secretary for Health in the late 1990s, but it never happened for various political reasons. Others have tried since. Maybe now, given how much money is at stake, it will finally get done.
Second, the VA needs to implement rigorous case management for high utilizers. The costs are not evenly distributed across enrollees. Approximately 10% of community care users account for almost 90% of community care expenditures. Common sense says you should intensely manage the care of those high-need patients who account for so much of the costs, try to avoid out-of-network ICU and emergency department care as much as possible, and build relationships with other providers so there are clear mechanisms to reconnect those patients back to VA care after an acute episode is treated outside the VA health system.
Is community care itself the problem?
No. Community care is a good thing for many veterans. It has increased access and made it easier for enrolled veterans to get care in some situations. The problem is that the VA hasn’t built in the mechanisms and processes to share information, manage complex patients, provide follow-up care, or oversee quality in community care.
Historically, VA has been an integrated delivery system that provided the overwhelming majority of care within its own facilities. However, over the last decade it has become a hybrid purchaser-provider system. It has become a very large purchaser of non-VA care, going from about $7 billion to $50 billion in community care spending over the past decade. But the VA hasn’t built the infrastructure—information exchange, case management, utilization review, quality oversight—that a hybrid purchaser-provider system needs to be a prudent purchaser.
What is your perspective on VHA's EHR transition?
The many problems with the rollout of the Oracle/Cerner EHR have been well-documented by the Inspector General, frontline clinicians, and others. The problems have been so bad that implementation has been halted a couple times. They’re now moving forward again, but it remains to be seen whether the problems truly have been fixed.
Still unaddressed is the more fundamental question of whether VistA could have been upgraded and modernized at far less cost and disruption of care. No thorough, deliberative analysis of that was ever done. And some of the ostensible problems with upgrading VistA in years past are no longer an issue.
Given the challenges VA faces, are you optimistic about its future?
While there definitely are problems, they are all solvable. Every challenge the VA is facing can be addressed. The question is when and how, and whether the VA is going to be given a fair chance to work through its challenges.
As for those who look to the private sector and think that’s the solution: They haven’t looked closely enough. The private sector is also struggling with staffing and financing issues, many of the same issues VA is dealing with, just in a somewhat different way. The problems in the private sector will be an increasing challenge for community care going forward.
Overall, my life experience is that dark times are always followed by daylight, so I am confident there are brighter days ahead for VA.
Kenneth W. Kizer, MD, MPH, knows a thing or two about transition at the US Department of Veterans Affairs (VA). He served as VA Under Secretary of Health from 1994 to 1999, stepping in during an era of crisis with a mandate for transformation.
Kizer, a Distinguished Professor Emeritus at the University of California, Davis School of Medicine, is among the top thinkers about the VA and its future. He recently spoke with Federal Practitioner about community care, the electronic health record transition, and other challenges facing the Veterans Health Administration (VHA).
At stake, Kizer explained, is an invaluable service for veterans—and much more. “VA is the largest provider of training for... multiple types of health professionals that people use every day,” he said. “There’s also the research, the direct care provided to veterans, and the contingency support the VA provides, which was very well demonstrated during the COVID pandemic. These are things that benefit all Americans, not just veterans.”
When you look at the VA, what do you see?
I see an organization in turmoil, a great health care system struggling with multiple major challenges simultaneously. The VHA is becoming a very large health insurance program without the necessary infrastructure, and costs are rising rapidly. And it is trying to roll out a new EHR and implement new third-party administrator contracts while suffering from significant staffing reductions and very depressed morale.
There are a host of other high-visibility and high-impact issues, including a major reorganization. There’s been a paucity of details about exactly what is going to change, who is going to be doing what, and how the changes will affect staffing and workflow.
How will the loss of 35,000 health care positions affect veterans' care?
If you don’t have enough people, then you’re not going to be able to provide the care that is needed. Years ago, I led a project assessing the Roseburg VA Medical Center in Central Oregon. Among other things, there were a lot of problems with cardiology care. The biggest complaint the cardiologists had, and why the hospital couldn’t keep cardiologists on staff, was that there weren’t enough support staff to do the electrocardiograms. The cardiologists had to do the electrocardiograms themselves, which meant they weren’t doing other things they should be doing. You can amplify that example in a hundred different ways in VA today. If physicians don’t have adequate support, they get frustrated and disenfranchised. And they leave.
One of the fallacies I’ve heard mentioned in some congressional hearings is that it’s mainly a matter of lower pay in the VA. Pay may be an issue somewhere on the list of recruiting challenges, but more important issues higher up are things like the support clinicians receive, the work environment, whether they feel valued, and how easy it is for them to do their work. Case in point: If you put in a new EHR that doesn’t work as well as the existing one, then some doctors are going to leave.
Is VA being pushed toward privatization?
At some point it becomes a self-fulfilling prophecy. If you don’t have the staff to provide the services, then you refer more veterans to the community, and you get in a downward spiral. Patients are going to the community, you lose more staff, you continue to be unable to provide services, and more care goes to the community.
A part of this equation that hasn’t been given adequate attention is VA’s teaching mission. If care is increasingly going to the community, those patients won’t be available for the trainees in teaching programs. That in turn impacts the pipeline of clinicians who will be available to serve the population at large. The negative effects will be seen far beyond the VA.
Why have you expressed concern over VA care fragmentation?1
Greater than 80% of VA ICU [intensive care unit] care is now being provided in community hospitals. When patients are discharged from those hospitals, they often continue getting follow-up care in the community because VA doesn’t have good mechanisms to reconnect those patients back to VA care.2
[Other researchers] found that the majority of emergency department care for enrolled veterans in New York State was being paid for by entities other than the VA, most commonly Medicare but also Medicaid and private insurance. Where follow-up care occurred often depended on who paid for the emergency department visit, not necessarily what was best for the patient.3
The core problem is that the VA has very little insight into what’s happening when its enrollees get care that is paid for by another payer. VA doesn’t know when their patients are in a private hospital emergency department, so they can’t reach out in real time, and they can’t reconnect with them afterward.
That is very different than for commercial health plans. They know when one of their enrollees is admitted to an out-of-network hospital, and when they are discharged, and they follow up immediately. VA doesn’t have the infrastructure in place to do that.
Why did the VA spend $44 billion on Medicare Advantage double-payments from 2018 to 2021?4
That number is much larger now—$87 billion from 2019 to 2023. Here’s the problem: When VA enrollees are also enrolled in a Medicare Advantage plan, the Medicare plan gets paid to provide the care for those veterans. But when those enrollees come to the VA, the VA provides and pays for the care but cannot bill Medicare for the costs. So the federal government ends up paying twice for care of the same person.
In a paper I coauthored last December we showed that in 2023 alone VA spent $23 billion for care of veterans enrolled in Medicare Advantage plan. Those duplicative payments accounted for almost 20% of VA's entire medical care budget.5
How can fragmented care be reduced?
Two things really stand out. First, real-time health insurance data sharing across payers is foundational. VA has to know when its patients get care by non-VA providers if it is going to coordinate and provide follow-up care. As a first step, VA and the Centers for Medicare & Medicaid Services need to create a data sharing platform for veterans dually enrolled in VA and Medicare or Medicaid.
This is not a new idea. I tried to do it when I was Under Secretary for Health in the late 1990s, but it never happened for various political reasons. Others have tried since. Maybe now, given how much money is at stake, it will finally get done.
Second, the VA needs to implement rigorous case management for high utilizers. The costs are not evenly distributed across enrollees. Approximately 10% of community care users account for almost 90% of community care expenditures. Common sense says you should intensely manage the care of those high-need patients who account for so much of the costs, try to avoid out-of-network ICU and emergency department care as much as possible, and build relationships with other providers so there are clear mechanisms to reconnect those patients back to VA care after an acute episode is treated outside the VA health system.
Is community care itself the problem?
No. Community care is a good thing for many veterans. It has increased access and made it easier for enrolled veterans to get care in some situations. The problem is that the VA hasn’t built in the mechanisms and processes to share information, manage complex patients, provide follow-up care, or oversee quality in community care.
Historically, VA has been an integrated delivery system that provided the overwhelming majority of care within its own facilities. However, over the last decade it has become a hybrid purchaser-provider system. It has become a very large purchaser of non-VA care, going from about $7 billion to $50 billion in community care spending over the past decade. But the VA hasn’t built the infrastructure—information exchange, case management, utilization review, quality oversight—that a hybrid purchaser-provider system needs to be a prudent purchaser.
What is your perspective on VHA's EHR transition?
The many problems with the rollout of the Oracle/Cerner EHR have been well-documented by the Inspector General, frontline clinicians, and others. The problems have been so bad that implementation has been halted a couple times. They’re now moving forward again, but it remains to be seen whether the problems truly have been fixed.
Still unaddressed is the more fundamental question of whether VistA could have been upgraded and modernized at far less cost and disruption of care. No thorough, deliberative analysis of that was ever done. And some of the ostensible problems with upgrading VistA in years past are no longer an issue.
Given the challenges VA faces, are you optimistic about its future?
While there definitely are problems, they are all solvable. Every challenge the VA is facing can be addressed. The question is when and how, and whether the VA is going to be given a fair chance to work through its challenges.
As for those who look to the private sector and think that’s the solution: They haven’t looked closely enough. The private sector is also struggling with staffing and financing issues, many of the same issues VA is dealing with, just in a somewhat different way. The problems in the private sector will be an increasing challenge for community care going forward.
Overall, my life experience is that dark times are always followed by daylight, so I am confident there are brighter days ahead for VA.
1. Kizer KW. Curbing the growing fragmentation of veterans’ health care. JAMA Health Forum. 2025;6:e254148. doi:10.1001/jamahealthforum.2025.4148
2. Hahn Z, Naiditch H, Talisa V, et al. Intensive care unit admissions purchased or delivered by veterans in the VA health care system. JAMA Health Forum. 2025;6:e255605. doi:10.1001/jamahealthforum.2025.5605
3. Vashi AA, Urech T, Wu S, Asch S. Fragmented financing in emergency department use among US veterans. JAMA Health Forum. 2025;6:e255635. doi:10.1001/jamahealthforum.2025.5635
4. Maremont M, Weaver C, McGinty T. Insurers collected billions from medicare for veterans who cost them almost nothing. The Wall Street Journal. December 2, 2024. Accessed March 17, 2026. https://www.wsj.com/health/healthcare /veterans-medicare-insurers-collect-billions-bfd47d27
5. Trivedi AN, Jiang L, Meyers DJ, et al. Spending by the Veterans Affairs health care system for Medicare Advantage Enrollees. JAMA Health Forum. 2025;6:e255653. doi:10.1001/jamahealthforum.2025.5653
1. Kizer KW. Curbing the growing fragmentation of veterans’ health care. JAMA Health Forum. 2025;6:e254148. doi:10.1001/jamahealthforum.2025.4148
2. Hahn Z, Naiditch H, Talisa V, et al. Intensive care unit admissions purchased or delivered by veterans in the VA health care system. JAMA Health Forum. 2025;6:e255605. doi:10.1001/jamahealthforum.2025.5605
3. Vashi AA, Urech T, Wu S, Asch S. Fragmented financing in emergency department use among US veterans. JAMA Health Forum. 2025;6:e255635. doi:10.1001/jamahealthforum.2025.5635
4. Maremont M, Weaver C, McGinty T. Insurers collected billions from medicare for veterans who cost them almost nothing. The Wall Street Journal. December 2, 2024. Accessed March 17, 2026. https://www.wsj.com/health/healthcare /veterans-medicare-insurers-collect-billions-bfd47d27
5. Trivedi AN, Jiang L, Meyers DJ, et al. Spending by the Veterans Affairs health care system for Medicare Advantage Enrollees. JAMA Health Forum. 2025;6:e255653. doi:10.1001/jamahealthforum.2025.5653
'An Organization in Turmoil': Ken Kizer on the Challenges Facing the VA
'An Organization in Turmoil': Ken Kizer on the Challenges Facing the VA
Team-Based Care is Crucial for Head-and-Neck Cancer Cases
Team-Based Care is Crucial for Head-and-Neck Cancer Cases
PHOENIX – A 70-year-old Vietnam veteran with oropharyngeal cancer presented challenges beyond his disease.
He couldn’t afford transportation for daily radiation treatments and had lost > 10% of his body weight due to pain and eating difficulties, recalled radiation oncologist Vinita Takiar, MD, PhD, in a presentation at the annual meeting of the Association of VA Hematology/Oncology.
To make matters more difficult, his wife held medical power of attorney despite his apparent competence to make decisions, said Takiar, who formerly worked with the US Department of Veterans Affairs (VA) Cincinnati Healthcare System and is now chair of radiation oncology at Penn State University.
All these factors would likely have derailed his treatment if not for a coordinated team intervention, Takiar said. Fortunately, the clinic launched a multifaceted effort involving representatives from the social work, dentistry, ethics, nutrition, and chaplaincy departments.
When surgery became impossible because the patient couldn’t lie on the operating table for adequate tumor exposure, she said, the existing team framework enabled a seamless and rapid transition to radiation with concurrent chemotherapy.
The patient completed treatment with an excellent response, offering a lesson in the importance of multidisciplinary care in head-and-neck cancers, she said.
In fact, when it comes to these forms of cancer, coordinated care “is probably more impactful than any treatment that we’re going to come up with,” she said. “The data show that when we do multidisciplinary care and we do it well, it actually improves the patient experience and outcomes.”
As Takiar noted, teamwork matters in many ways. It leads to better logistics and can address disparities, reduce financial burden and stigma, and even increase clinical trial involvement.
She pointed to studies linking teamwork to better outcomes, support for patients, and overall survival.
Takiar highlighted different parts of teams headed by radiation oncologists who act as “a node to improve multimodal care delivery.”
Speech and swallowing specialists, for example, are helpful in head-and-neck cancer because “there’s an impact on speech, swallowing, and appearance. Our patients don’t want to go out to dinner with friends because they can’t do it.”
Dentists and prosthodontists are key team members too: “I have dentists who have my cell phone number. They just call me: ‘Can I do this extraction? Was this in your radiation field? What was the dose?’”
Other team members include ear, nose, and throat specialists, palliative and supportive care specialists, medical oncologists, nurses, pathologists, transportation workers, and service connection specialists. She noted that previous military experience can affect radiation therapy. For example, the physical restraints required during treatment present particular challenges for veterans who’ve had wartime trauma. These patients may require therapy adjustments.
What’s next on the horizon? Takiar highlighted precision oncology and molecular profiling, artificial intelligence in care decisions and in radiation planning, telemedicine and virtual tumor boards, and expanded survivorship programs.
As for now, she urged colleagues to not be afraid to chat with radiation oncologists. “Please talk to us. We prioritize open communication and shared decision-making with the entire team,” she said. “If you see something and think your radiation oncologist should know about it, you think it was caused by the radiation, you should reach out to us.”
Takiar reported no disclosures.
PHOENIX – A 70-year-old Vietnam veteran with oropharyngeal cancer presented challenges beyond his disease.
He couldn’t afford transportation for daily radiation treatments and had lost > 10% of his body weight due to pain and eating difficulties, recalled radiation oncologist Vinita Takiar, MD, PhD, in a presentation at the annual meeting of the Association of VA Hematology/Oncology.
To make matters more difficult, his wife held medical power of attorney despite his apparent competence to make decisions, said Takiar, who formerly worked with the US Department of Veterans Affairs (VA) Cincinnati Healthcare System and is now chair of radiation oncology at Penn State University.
All these factors would likely have derailed his treatment if not for a coordinated team intervention, Takiar said. Fortunately, the clinic launched a multifaceted effort involving representatives from the social work, dentistry, ethics, nutrition, and chaplaincy departments.
When surgery became impossible because the patient couldn’t lie on the operating table for adequate tumor exposure, she said, the existing team framework enabled a seamless and rapid transition to radiation with concurrent chemotherapy.
The patient completed treatment with an excellent response, offering a lesson in the importance of multidisciplinary care in head-and-neck cancers, she said.
In fact, when it comes to these forms of cancer, coordinated care “is probably more impactful than any treatment that we’re going to come up with,” she said. “The data show that when we do multidisciplinary care and we do it well, it actually improves the patient experience and outcomes.”
As Takiar noted, teamwork matters in many ways. It leads to better logistics and can address disparities, reduce financial burden and stigma, and even increase clinical trial involvement.
She pointed to studies linking teamwork to better outcomes, support for patients, and overall survival.
Takiar highlighted different parts of teams headed by radiation oncologists who act as “a node to improve multimodal care delivery.”
Speech and swallowing specialists, for example, are helpful in head-and-neck cancer because “there’s an impact on speech, swallowing, and appearance. Our patients don’t want to go out to dinner with friends because they can’t do it.”
Dentists and prosthodontists are key team members too: “I have dentists who have my cell phone number. They just call me: ‘Can I do this extraction? Was this in your radiation field? What was the dose?’”
Other team members include ear, nose, and throat specialists, palliative and supportive care specialists, medical oncologists, nurses, pathologists, transportation workers, and service connection specialists. She noted that previous military experience can affect radiation therapy. For example, the physical restraints required during treatment present particular challenges for veterans who’ve had wartime trauma. These patients may require therapy adjustments.
What’s next on the horizon? Takiar highlighted precision oncology and molecular profiling, artificial intelligence in care decisions and in radiation planning, telemedicine and virtual tumor boards, and expanded survivorship programs.
As for now, she urged colleagues to not be afraid to chat with radiation oncologists. “Please talk to us. We prioritize open communication and shared decision-making with the entire team,” she said. “If you see something and think your radiation oncologist should know about it, you think it was caused by the radiation, you should reach out to us.”
Takiar reported no disclosures.
PHOENIX – A 70-year-old Vietnam veteran with oropharyngeal cancer presented challenges beyond his disease.
He couldn’t afford transportation for daily radiation treatments and had lost > 10% of his body weight due to pain and eating difficulties, recalled radiation oncologist Vinita Takiar, MD, PhD, in a presentation at the annual meeting of the Association of VA Hematology/Oncology.
To make matters more difficult, his wife held medical power of attorney despite his apparent competence to make decisions, said Takiar, who formerly worked with the US Department of Veterans Affairs (VA) Cincinnati Healthcare System and is now chair of radiation oncology at Penn State University.
All these factors would likely have derailed his treatment if not for a coordinated team intervention, Takiar said. Fortunately, the clinic launched a multifaceted effort involving representatives from the social work, dentistry, ethics, nutrition, and chaplaincy departments.
When surgery became impossible because the patient couldn’t lie on the operating table for adequate tumor exposure, she said, the existing team framework enabled a seamless and rapid transition to radiation with concurrent chemotherapy.
The patient completed treatment with an excellent response, offering a lesson in the importance of multidisciplinary care in head-and-neck cancers, she said.
In fact, when it comes to these forms of cancer, coordinated care “is probably more impactful than any treatment that we’re going to come up with,” she said. “The data show that when we do multidisciplinary care and we do it well, it actually improves the patient experience and outcomes.”
As Takiar noted, teamwork matters in many ways. It leads to better logistics and can address disparities, reduce financial burden and stigma, and even increase clinical trial involvement.
She pointed to studies linking teamwork to better outcomes, support for patients, and overall survival.
Takiar highlighted different parts of teams headed by radiation oncologists who act as “a node to improve multimodal care delivery.”
Speech and swallowing specialists, for example, are helpful in head-and-neck cancer because “there’s an impact on speech, swallowing, and appearance. Our patients don’t want to go out to dinner with friends because they can’t do it.”
Dentists and prosthodontists are key team members too: “I have dentists who have my cell phone number. They just call me: ‘Can I do this extraction? Was this in your radiation field? What was the dose?’”
Other team members include ear, nose, and throat specialists, palliative and supportive care specialists, medical oncologists, nurses, pathologists, transportation workers, and service connection specialists. She noted that previous military experience can affect radiation therapy. For example, the physical restraints required during treatment present particular challenges for veterans who’ve had wartime trauma. These patients may require therapy adjustments.
What’s next on the horizon? Takiar highlighted precision oncology and molecular profiling, artificial intelligence in care decisions and in radiation planning, telemedicine and virtual tumor boards, and expanded survivorship programs.
As for now, she urged colleagues to not be afraid to chat with radiation oncologists. “Please talk to us. We prioritize open communication and shared decision-making with the entire team,” she said. “If you see something and think your radiation oncologist should know about it, you think it was caused by the radiation, you should reach out to us.”
Takiar reported no disclosures.
Team-Based Care is Crucial for Head-and-Neck Cancer Cases
Team-Based Care is Crucial for Head-and-Neck Cancer Cases
'Distress is the Norm': How Oncologists Can Open the Door to Patient Mental Health
'Distress is the Norm': How Oncologists Can Open the Door to Patient Mental Health
For patients with cancer, the determining factor in whether they pursue mental health services is often whether their oncologist explicitly says it is a good idea, a psychologist said during the July Association of VA Hematology and Oncology (AVAHO) seminar in Long Beach, California, on treating veterans with renal cell carcinoma (RCC).
Kysa Christie, PhD, of the West Los Angeles Veterans Affairs Medical Center, presented findings from a 2018 study in which researchers asked Swiss patients with cancer whether their oncologist discussed their emotional health with them.
In terms of boosting intake, it did not matter if oncologists acknowledged distress or pointed out that psychosocial services existed. Instead, a direct recommendation made a difference, increasing the likelihood of using the services over a 4-month period after initial assessment (odds ratio, 6.27).
“What it took was, ‘I really recommend this. This is something that I would want you to try,’” Christie said.
Oncologists are crucial links between patients and mental health services, Christie said: “If people don’t ask about [distress], you’re not going to see it, but it’s there. Distress is the norm, right? It is not a weakness. It is something that we expect to see.”
Christie noted that an estimated 20% of cancer patients have major depressive disorder, and 35% to 40% have a diagnosable psychiatric condition. RCC shows disproportionately high rates of mental strain. According to Christie, research suggests that about three-fourths of the population report elevated levels of distress as evidenced by patients who scored ≥ 5 on the NCCN Distress Thermometer. Patients with cancer have an estimated 20% higher risk of suicide, especially during the first 12 months after diagnosis and at end of life, she added.
“Early during a diagnosis phase, where you’re having a lot of tests being done, you know something is happening. But you don’t know what,” Christie said. “It could be very serious. That’s just a lot of stress to hold and not know how to plan for.”
After diagnosis, routine could set in and lower distress, she said. Then terminal illness may spike it back up again. Does mental health treatment work in patients with cancer?
“There’s a really strong body of evidence-based treatments for depression, anxiety, adjustment disorders, and coping with different cancers,” Christie said. But it is a step too far to expect patients to ask for help while they are juggling appointments, tests, infusions, and more. “It’s a big ask, right? It’s setting people up for failure.”
To help, Christie said she is embedded with a medical oncology team and routinely talks with the staff about which patients may need help. “One thing I like to do is try to have brief visits with veterans and introduce myself when they come to clinic. I treat it like an opt-out rather than an opt-in program: I’ll just pop into the exam room. They don’t have to ask to see me.”
Christie focuses on open-ended questions and talks about resources ranging from support groups and brief appointments to extensive individual therapy.
Another approach is a strategy known as the “warm handoff,” when an oncologist directly introduces a patient to a mental health professional. “It’s a transfer of care in front of the veteran: It’s much more time-efficient than putting in a referral.”
Christie explained how this can work. A clinician will ask her to meet with a patient during an appointment, perhaps in a couple minutes.
“Then I pop into the room, and the oncologist says, ‘Thanks for joining us. This is Mr. Jones. He has been experiencing feelings of anxiety and sadness, and we’d appreciate your help in exploring some options that might help.’ I turn to the patient and ask, ‘What more would you add?’ Then I either take Mr. Jones back to my office or stay in clinic, and we’re off to the races.”
Christie reported no disclosures.
For patients with cancer, the determining factor in whether they pursue mental health services is often whether their oncologist explicitly says it is a good idea, a psychologist said during the July Association of VA Hematology and Oncology (AVAHO) seminar in Long Beach, California, on treating veterans with renal cell carcinoma (RCC).
Kysa Christie, PhD, of the West Los Angeles Veterans Affairs Medical Center, presented findings from a 2018 study in which researchers asked Swiss patients with cancer whether their oncologist discussed their emotional health with them.
In terms of boosting intake, it did not matter if oncologists acknowledged distress or pointed out that psychosocial services existed. Instead, a direct recommendation made a difference, increasing the likelihood of using the services over a 4-month period after initial assessment (odds ratio, 6.27).
“What it took was, ‘I really recommend this. This is something that I would want you to try,’” Christie said.
Oncologists are crucial links between patients and mental health services, Christie said: “If people don’t ask about [distress], you’re not going to see it, but it’s there. Distress is the norm, right? It is not a weakness. It is something that we expect to see.”
Christie noted that an estimated 20% of cancer patients have major depressive disorder, and 35% to 40% have a diagnosable psychiatric condition. RCC shows disproportionately high rates of mental strain. According to Christie, research suggests that about three-fourths of the population report elevated levels of distress as evidenced by patients who scored ≥ 5 on the NCCN Distress Thermometer. Patients with cancer have an estimated 20% higher risk of suicide, especially during the first 12 months after diagnosis and at end of life, she added.
“Early during a diagnosis phase, where you’re having a lot of tests being done, you know something is happening. But you don’t know what,” Christie said. “It could be very serious. That’s just a lot of stress to hold and not know how to plan for.”
After diagnosis, routine could set in and lower distress, she said. Then terminal illness may spike it back up again. Does mental health treatment work in patients with cancer?
“There’s a really strong body of evidence-based treatments for depression, anxiety, adjustment disorders, and coping with different cancers,” Christie said. But it is a step too far to expect patients to ask for help while they are juggling appointments, tests, infusions, and more. “It’s a big ask, right? It’s setting people up for failure.”
To help, Christie said she is embedded with a medical oncology team and routinely talks with the staff about which patients may need help. “One thing I like to do is try to have brief visits with veterans and introduce myself when they come to clinic. I treat it like an opt-out rather than an opt-in program: I’ll just pop into the exam room. They don’t have to ask to see me.”
Christie focuses on open-ended questions and talks about resources ranging from support groups and brief appointments to extensive individual therapy.
Another approach is a strategy known as the “warm handoff,” when an oncologist directly introduces a patient to a mental health professional. “It’s a transfer of care in front of the veteran: It’s much more time-efficient than putting in a referral.”
Christie explained how this can work. A clinician will ask her to meet with a patient during an appointment, perhaps in a couple minutes.
“Then I pop into the room, and the oncologist says, ‘Thanks for joining us. This is Mr. Jones. He has been experiencing feelings of anxiety and sadness, and we’d appreciate your help in exploring some options that might help.’ I turn to the patient and ask, ‘What more would you add?’ Then I either take Mr. Jones back to my office or stay in clinic, and we’re off to the races.”
Christie reported no disclosures.
For patients with cancer, the determining factor in whether they pursue mental health services is often whether their oncologist explicitly says it is a good idea, a psychologist said during the July Association of VA Hematology and Oncology (AVAHO) seminar in Long Beach, California, on treating veterans with renal cell carcinoma (RCC).
Kysa Christie, PhD, of the West Los Angeles Veterans Affairs Medical Center, presented findings from a 2018 study in which researchers asked Swiss patients with cancer whether their oncologist discussed their emotional health with them.
In terms of boosting intake, it did not matter if oncologists acknowledged distress or pointed out that psychosocial services existed. Instead, a direct recommendation made a difference, increasing the likelihood of using the services over a 4-month period after initial assessment (odds ratio, 6.27).
“What it took was, ‘I really recommend this. This is something that I would want you to try,’” Christie said.
Oncologists are crucial links between patients and mental health services, Christie said: “If people don’t ask about [distress], you’re not going to see it, but it’s there. Distress is the norm, right? It is not a weakness. It is something that we expect to see.”
Christie noted that an estimated 20% of cancer patients have major depressive disorder, and 35% to 40% have a diagnosable psychiatric condition. RCC shows disproportionately high rates of mental strain. According to Christie, research suggests that about three-fourths of the population report elevated levels of distress as evidenced by patients who scored ≥ 5 on the NCCN Distress Thermometer. Patients with cancer have an estimated 20% higher risk of suicide, especially during the first 12 months after diagnosis and at end of life, she added.
“Early during a diagnosis phase, where you’re having a lot of tests being done, you know something is happening. But you don’t know what,” Christie said. “It could be very serious. That’s just a lot of stress to hold and not know how to plan for.”
After diagnosis, routine could set in and lower distress, she said. Then terminal illness may spike it back up again. Does mental health treatment work in patients with cancer?
“There’s a really strong body of evidence-based treatments for depression, anxiety, adjustment disorders, and coping with different cancers,” Christie said. But it is a step too far to expect patients to ask for help while they are juggling appointments, tests, infusions, and more. “It’s a big ask, right? It’s setting people up for failure.”
To help, Christie said she is embedded with a medical oncology team and routinely talks with the staff about which patients may need help. “One thing I like to do is try to have brief visits with veterans and introduce myself when they come to clinic. I treat it like an opt-out rather than an opt-in program: I’ll just pop into the exam room. They don’t have to ask to see me.”
Christie focuses on open-ended questions and talks about resources ranging from support groups and brief appointments to extensive individual therapy.
Another approach is a strategy known as the “warm handoff,” when an oncologist directly introduces a patient to a mental health professional. “It’s a transfer of care in front of the veteran: It’s much more time-efficient than putting in a referral.”
Christie explained how this can work. A clinician will ask her to meet with a patient during an appointment, perhaps in a couple minutes.
“Then I pop into the room, and the oncologist says, ‘Thanks for joining us. This is Mr. Jones. He has been experiencing feelings of anxiety and sadness, and we’d appreciate your help in exploring some options that might help.’ I turn to the patient and ask, ‘What more would you add?’ Then I either take Mr. Jones back to my office or stay in clinic, and we’re off to the races.”
Christie reported no disclosures.
'Distress is the Norm': How Oncologists Can Open the Door to Patient Mental Health
'Distress is the Norm': How Oncologists Can Open the Door to Patient Mental Health
Contraceptive Care Clinic Focuses on Military Readiness
SAN DIEGO — Not surprisingly, the contraception clinic at Madigan Army Medical Center near Tacoma, Wash., is popular among female soldiers seeking to avoid pregnancy. However, about half of the patients drop by for other reasons, the military pharmacist who runs the program told colleagues here at the Joint Federal Pharmacy Seminar.
“They come to suppress menstruation, to get help with pain, to get help with PCOS [polycystic ovary syndrome] symptoms. They're coming for a wide range of indications that we use contraception to treat,” said Sarah Abel, PharmD, a clinical pharmacist.
Regardless of the reason, Abel emphasized that contraceptives can significantly impact the ability of female soldiers to do their jobs. “If you have heavy periods and can't make it in work, or you have endometriosis and requiring a lot of doctor's appointments, or you're deployed and you get pregnant, these are all situations where contraceptive care matters,” she said. Rates of unintended pregnancy are higher in servicewomen than in the general population.
Abel, who opened the medical center’s contraceptive clinic about 10 years ago, stressed that it’s crucial to military readiness considering that the percentage of women in the American military is approaching 20%.
Thanks to a 2022 edict, military hospitals and clinics are required to offer walk-in contraceptive services with same-day access, no requirements for appointments or referrals. An announcement about the mandate noted that these contraceptive services, such as preventing unplanned pregnancy and decreasing menstrual periods, “support the overall well-being of the force and optimize personal warrior readiness.”
As Abel noted, 29 states and Washington D.C. allow pharmacists to prescribe contraception to outpatients, although the requirements vary. “Can we start practicing at the top of our license and start prescribing in the outpatient setting? Absolutely we should,” she said. “Pharmacists have a very unique opportunity to be a part of this.”
Abel also shared that setting up a contraceptive program requires patience and education. “I cannot tell you how many women have come to me who don't know the different names of their body parts, women who've had two babies that don't understand how their body works. So, I constantly find myself taking extra time to do general sexual education,” she said.
There are many lessons to impart to patients about sexual health. For example, birth control drugs and devices do not prevent transmission of sexually transmitted infections (STIs). “So I have bowls of condoms literally everywhere because condoms are the only thing that protects against STIs,” Abel said.
In terms of devices, “we have diaphragms available and cervical caps,” she said. “The Caya diaphragm is a TRICARE-covered benefit. It’s a small purple diaphragm, one size fits most. We can prescribe it, and it is good for 2 years. Unfortunately, spermicide, which you have to use with these things, is not a TRICARE-covered benefit.”
Hormonal contraceptives are also available, with Abel recommending the continuous monophasic type for most women. “Please don't tell women they have to have their periods. They don't,” she said. “What I'm trying to do is give a woman some stability in her hormones. She can know and expect what she's going to feel like. She's not going to wake up and say, ‘Oh God, today's the day. I'm going to be like this for a week.’”
Patches are another option, and a flurry of patients have been asking about them because of recent TikTok videos promoting their use. “We have the Xulane patch, our bread and butter. They wear it on their shoulder, their hip, their butt, or their back. They leave it in place for a week at a time. And every week, they will change that patch. I usually have to walk patients through a whole month to help them understand how that works.”
Another option, the NuvaRing, is notable because it’s linked to low amounts of breakthrough bleeding Abel noted. An extended form is now available that doesn’t need to be removed during menstrual periods.
Medroxyprogesterone injections, which are linked to bone loss, and subdermal implants, which may be less effective in women over 130% of their ideal weight are also available, she said.
Finally, IUDs are an option, although when they fail, they’re linked to ectopic pregnancies.
Abel has no disclosures.
SAN DIEGO — Not surprisingly, the contraception clinic at Madigan Army Medical Center near Tacoma, Wash., is popular among female soldiers seeking to avoid pregnancy. However, about half of the patients drop by for other reasons, the military pharmacist who runs the program told colleagues here at the Joint Federal Pharmacy Seminar.
“They come to suppress menstruation, to get help with pain, to get help with PCOS [polycystic ovary syndrome] symptoms. They're coming for a wide range of indications that we use contraception to treat,” said Sarah Abel, PharmD, a clinical pharmacist.
Regardless of the reason, Abel emphasized that contraceptives can significantly impact the ability of female soldiers to do their jobs. “If you have heavy periods and can't make it in work, or you have endometriosis and requiring a lot of doctor's appointments, or you're deployed and you get pregnant, these are all situations where contraceptive care matters,” she said. Rates of unintended pregnancy are higher in servicewomen than in the general population.
Abel, who opened the medical center’s contraceptive clinic about 10 years ago, stressed that it’s crucial to military readiness considering that the percentage of women in the American military is approaching 20%.
Thanks to a 2022 edict, military hospitals and clinics are required to offer walk-in contraceptive services with same-day access, no requirements for appointments or referrals. An announcement about the mandate noted that these contraceptive services, such as preventing unplanned pregnancy and decreasing menstrual periods, “support the overall well-being of the force and optimize personal warrior readiness.”
As Abel noted, 29 states and Washington D.C. allow pharmacists to prescribe contraception to outpatients, although the requirements vary. “Can we start practicing at the top of our license and start prescribing in the outpatient setting? Absolutely we should,” she said. “Pharmacists have a very unique opportunity to be a part of this.”
Abel also shared that setting up a contraceptive program requires patience and education. “I cannot tell you how many women have come to me who don't know the different names of their body parts, women who've had two babies that don't understand how their body works. So, I constantly find myself taking extra time to do general sexual education,” she said.
There are many lessons to impart to patients about sexual health. For example, birth control drugs and devices do not prevent transmission of sexually transmitted infections (STIs). “So I have bowls of condoms literally everywhere because condoms are the only thing that protects against STIs,” Abel said.
In terms of devices, “we have diaphragms available and cervical caps,” she said. “The Caya diaphragm is a TRICARE-covered benefit. It’s a small purple diaphragm, one size fits most. We can prescribe it, and it is good for 2 years. Unfortunately, spermicide, which you have to use with these things, is not a TRICARE-covered benefit.”
Hormonal contraceptives are also available, with Abel recommending the continuous monophasic type for most women. “Please don't tell women they have to have their periods. They don't,” she said. “What I'm trying to do is give a woman some stability in her hormones. She can know and expect what she's going to feel like. She's not going to wake up and say, ‘Oh God, today's the day. I'm going to be like this for a week.’”
Patches are another option, and a flurry of patients have been asking about them because of recent TikTok videos promoting their use. “We have the Xulane patch, our bread and butter. They wear it on their shoulder, their hip, their butt, or their back. They leave it in place for a week at a time. And every week, they will change that patch. I usually have to walk patients through a whole month to help them understand how that works.”
Another option, the NuvaRing, is notable because it’s linked to low amounts of breakthrough bleeding Abel noted. An extended form is now available that doesn’t need to be removed during menstrual periods.
Medroxyprogesterone injections, which are linked to bone loss, and subdermal implants, which may be less effective in women over 130% of their ideal weight are also available, she said.
Finally, IUDs are an option, although when they fail, they’re linked to ectopic pregnancies.
Abel has no disclosures.
SAN DIEGO — Not surprisingly, the contraception clinic at Madigan Army Medical Center near Tacoma, Wash., is popular among female soldiers seeking to avoid pregnancy. However, about half of the patients drop by for other reasons, the military pharmacist who runs the program told colleagues here at the Joint Federal Pharmacy Seminar.
“They come to suppress menstruation, to get help with pain, to get help with PCOS [polycystic ovary syndrome] symptoms. They're coming for a wide range of indications that we use contraception to treat,” said Sarah Abel, PharmD, a clinical pharmacist.
Regardless of the reason, Abel emphasized that contraceptives can significantly impact the ability of female soldiers to do their jobs. “If you have heavy periods and can't make it in work, or you have endometriosis and requiring a lot of doctor's appointments, or you're deployed and you get pregnant, these are all situations where contraceptive care matters,” she said. Rates of unintended pregnancy are higher in servicewomen than in the general population.
Abel, who opened the medical center’s contraceptive clinic about 10 years ago, stressed that it’s crucial to military readiness considering that the percentage of women in the American military is approaching 20%.
Thanks to a 2022 edict, military hospitals and clinics are required to offer walk-in contraceptive services with same-day access, no requirements for appointments or referrals. An announcement about the mandate noted that these contraceptive services, such as preventing unplanned pregnancy and decreasing menstrual periods, “support the overall well-being of the force and optimize personal warrior readiness.”
As Abel noted, 29 states and Washington D.C. allow pharmacists to prescribe contraception to outpatients, although the requirements vary. “Can we start practicing at the top of our license and start prescribing in the outpatient setting? Absolutely we should,” she said. “Pharmacists have a very unique opportunity to be a part of this.”
Abel also shared that setting up a contraceptive program requires patience and education. “I cannot tell you how many women have come to me who don't know the different names of their body parts, women who've had two babies that don't understand how their body works. So, I constantly find myself taking extra time to do general sexual education,” she said.
There are many lessons to impart to patients about sexual health. For example, birth control drugs and devices do not prevent transmission of sexually transmitted infections (STIs). “So I have bowls of condoms literally everywhere because condoms are the only thing that protects against STIs,” Abel said.
In terms of devices, “we have diaphragms available and cervical caps,” she said. “The Caya diaphragm is a TRICARE-covered benefit. It’s a small purple diaphragm, one size fits most. We can prescribe it, and it is good for 2 years. Unfortunately, spermicide, which you have to use with these things, is not a TRICARE-covered benefit.”
Hormonal contraceptives are also available, with Abel recommending the continuous monophasic type for most women. “Please don't tell women they have to have their periods. They don't,” she said. “What I'm trying to do is give a woman some stability in her hormones. She can know and expect what she's going to feel like. She's not going to wake up and say, ‘Oh God, today's the day. I'm going to be like this for a week.’”
Patches are another option, and a flurry of patients have been asking about them because of recent TikTok videos promoting their use. “We have the Xulane patch, our bread and butter. They wear it on their shoulder, their hip, their butt, or their back. They leave it in place for a week at a time. And every week, they will change that patch. I usually have to walk patients through a whole month to help them understand how that works.”
Another option, the NuvaRing, is notable because it’s linked to low amounts of breakthrough bleeding Abel noted. An extended form is now available that doesn’t need to be removed during menstrual periods.
Medroxyprogesterone injections, which are linked to bone loss, and subdermal implants, which may be less effective in women over 130% of their ideal weight are also available, she said.
Finally, IUDs are an option, although when they fail, they’re linked to ectopic pregnancies.
Abel has no disclosures.
Rising Cancer Rates Among Young People Spur New Fertility Preservation Options
Rising Cancer Rates Among Young People Spur New Fertility Preservation Options
ATLANTA —Jacqueline Lee, MD, a reproductive endocrinologist at Emory School of Medicine, frequently treats patients with cancer. Recently, she treated 4 women in their 30s with histories of colon cancer, acute lymphoblastic leukemia, lymphoma, and breast cancer. A young man in his 20s sought her care, to discuss his case of lymphoma.
All these patients sought guidance from Lee because they want to protect their ability to have children. At the annual meeting of the Association of VA Hematology/Oncology, Lee explained that plenty of patients are finding themselves in similar straits due in part to recent trends.
Cancer rates in the US have been rising among people aged 15 to 39 years, who now account for 4.2% of all cancer cases. An estimated 84,100 people in this age group are expected to be diagnosed with cancer this year. Meanwhile, women are having children later in life-birth rates are up among those aged 25 to 49 years-making it more likely that they have histories of cancer.
Although it's difficult to predict how cancer will affect fertility, Lee emphasized that many chemotherapy medications, including cisplatin and carboplatin, are cytotoxic. "It's hard to always predict what someone's arc of care is going to be," she said, "so I really have a low threshold for recommending fertility preservation in patients who have a strong desire to have future childbearing."
For women with cancer, egg preservation isn't the only strategy. Clinicians can also try to protect ovarian tissue from pelvic radiation through surgical reposition of the ovaries, Lee noted. In addition goserelin, a hormone-suppressing therapy, may protect the ovaries from chemotherapy, though its effectiveness in boosting pregnancy rates is still unclear.
"When I mentioned this option, it's usually for patients who can't preserve fertility via egg or embryo preservation, or we don't have the luxury of that kind of time," Lee said. "I say that if helps at all, it might help you resume menses after treatment. But infertility is still very common."
For some patients, freezing eggs is an easy decision. "They don't have a reproductive partner they're ready to make embryos with, so we proceed with egg preservation. It's no longer considered experimental and comes with lower upfront costs since the costs of actually making embryos are deferred until the future."
In addition, she said, freezing eggs also avoids the touchy topic of disposing of embryos. Lee cautions patients that retrieving eggs is a 2-week process that requires any initiation of cancer care to be delayed. However, the retrieval process can be adjusted in patients with special needs due to the type of cancer they have.
For prepubertal girls with cancer, ovarian tissue can be removed and frozen as a fertility preservation option. However, this is not considered standard of care. "We don't do it," she said. "We refer out if needed. Hopefully we'll develop a program in the future."
As for the 5 patients that Lee mentioned, with details changed to protect their privacy, their outcomes were as follows:
- The woman with colon cancer, who had undergone a hemicolectomy, chose to defer fertility preservation.
- The woman with acute lymphoblastic leukemia, who was taking depo-Lupron, had undetectable anti-Müllerian hormone (AMH) levels. Lee discussed the possibility of IVF with a donor egg.
- The woman with breast cancer, who was newly diagnosed, deferred fertility preservation.
- The man with lymphoma (Hodgkin's), who was awaiting chemotherapy, had his sperm frozen.
- The woman with lymphoma (new diagnosis) had 27 eggs frozen.
Lee had no disclosures to report.
ATLANTA —Jacqueline Lee, MD, a reproductive endocrinologist at Emory School of Medicine, frequently treats patients with cancer. Recently, she treated 4 women in their 30s with histories of colon cancer, acute lymphoblastic leukemia, lymphoma, and breast cancer. A young man in his 20s sought her care, to discuss his case of lymphoma.
All these patients sought guidance from Lee because they want to protect their ability to have children. At the annual meeting of the Association of VA Hematology/Oncology, Lee explained that plenty of patients are finding themselves in similar straits due in part to recent trends.
Cancer rates in the US have been rising among people aged 15 to 39 years, who now account for 4.2% of all cancer cases. An estimated 84,100 people in this age group are expected to be diagnosed with cancer this year. Meanwhile, women are having children later in life-birth rates are up among those aged 25 to 49 years-making it more likely that they have histories of cancer.
Although it's difficult to predict how cancer will affect fertility, Lee emphasized that many chemotherapy medications, including cisplatin and carboplatin, are cytotoxic. "It's hard to always predict what someone's arc of care is going to be," she said, "so I really have a low threshold for recommending fertility preservation in patients who have a strong desire to have future childbearing."
For women with cancer, egg preservation isn't the only strategy. Clinicians can also try to protect ovarian tissue from pelvic radiation through surgical reposition of the ovaries, Lee noted. In addition goserelin, a hormone-suppressing therapy, may protect the ovaries from chemotherapy, though its effectiveness in boosting pregnancy rates is still unclear.
"When I mentioned this option, it's usually for patients who can't preserve fertility via egg or embryo preservation, or we don't have the luxury of that kind of time," Lee said. "I say that if helps at all, it might help you resume menses after treatment. But infertility is still very common."
For some patients, freezing eggs is an easy decision. "They don't have a reproductive partner they're ready to make embryos with, so we proceed with egg preservation. It's no longer considered experimental and comes with lower upfront costs since the costs of actually making embryos are deferred until the future."
In addition, she said, freezing eggs also avoids the touchy topic of disposing of embryos. Lee cautions patients that retrieving eggs is a 2-week process that requires any initiation of cancer care to be delayed. However, the retrieval process can be adjusted in patients with special needs due to the type of cancer they have.
For prepubertal girls with cancer, ovarian tissue can be removed and frozen as a fertility preservation option. However, this is not considered standard of care. "We don't do it," she said. "We refer out if needed. Hopefully we'll develop a program in the future."
As for the 5 patients that Lee mentioned, with details changed to protect their privacy, their outcomes were as follows:
- The woman with colon cancer, who had undergone a hemicolectomy, chose to defer fertility preservation.
- The woman with acute lymphoblastic leukemia, who was taking depo-Lupron, had undetectable anti-Müllerian hormone (AMH) levels. Lee discussed the possibility of IVF with a donor egg.
- The woman with breast cancer, who was newly diagnosed, deferred fertility preservation.
- The man with lymphoma (Hodgkin's), who was awaiting chemotherapy, had his sperm frozen.
- The woman with lymphoma (new diagnosis) had 27 eggs frozen.
Lee had no disclosures to report.
ATLANTA —Jacqueline Lee, MD, a reproductive endocrinologist at Emory School of Medicine, frequently treats patients with cancer. Recently, she treated 4 women in their 30s with histories of colon cancer, acute lymphoblastic leukemia, lymphoma, and breast cancer. A young man in his 20s sought her care, to discuss his case of lymphoma.
All these patients sought guidance from Lee because they want to protect their ability to have children. At the annual meeting of the Association of VA Hematology/Oncology, Lee explained that plenty of patients are finding themselves in similar straits due in part to recent trends.
Cancer rates in the US have been rising among people aged 15 to 39 years, who now account for 4.2% of all cancer cases. An estimated 84,100 people in this age group are expected to be diagnosed with cancer this year. Meanwhile, women are having children later in life-birth rates are up among those aged 25 to 49 years-making it more likely that they have histories of cancer.
Although it's difficult to predict how cancer will affect fertility, Lee emphasized that many chemotherapy medications, including cisplatin and carboplatin, are cytotoxic. "It's hard to always predict what someone's arc of care is going to be," she said, "so I really have a low threshold for recommending fertility preservation in patients who have a strong desire to have future childbearing."
For women with cancer, egg preservation isn't the only strategy. Clinicians can also try to protect ovarian tissue from pelvic radiation through surgical reposition of the ovaries, Lee noted. In addition goserelin, a hormone-suppressing therapy, may protect the ovaries from chemotherapy, though its effectiveness in boosting pregnancy rates is still unclear.
"When I mentioned this option, it's usually for patients who can't preserve fertility via egg or embryo preservation, or we don't have the luxury of that kind of time," Lee said. "I say that if helps at all, it might help you resume menses after treatment. But infertility is still very common."
For some patients, freezing eggs is an easy decision. "They don't have a reproductive partner they're ready to make embryos with, so we proceed with egg preservation. It's no longer considered experimental and comes with lower upfront costs since the costs of actually making embryos are deferred until the future."
In addition, she said, freezing eggs also avoids the touchy topic of disposing of embryos. Lee cautions patients that retrieving eggs is a 2-week process that requires any initiation of cancer care to be delayed. However, the retrieval process can be adjusted in patients with special needs due to the type of cancer they have.
For prepubertal girls with cancer, ovarian tissue can be removed and frozen as a fertility preservation option. However, this is not considered standard of care. "We don't do it," she said. "We refer out if needed. Hopefully we'll develop a program in the future."
As for the 5 patients that Lee mentioned, with details changed to protect their privacy, their outcomes were as follows:
- The woman with colon cancer, who had undergone a hemicolectomy, chose to defer fertility preservation.
- The woman with acute lymphoblastic leukemia, who was taking depo-Lupron, had undetectable anti-Müllerian hormone (AMH) levels. Lee discussed the possibility of IVF with a donor egg.
- The woman with breast cancer, who was newly diagnosed, deferred fertility preservation.
- The man with lymphoma (Hodgkin's), who was awaiting chemotherapy, had his sperm frozen.
- The woman with lymphoma (new diagnosis) had 27 eggs frozen.
Lee had no disclosures to report.
Rising Cancer Rates Among Young People Spur New Fertility Preservation Options
Rising Cancer Rates Among Young People Spur New Fertility Preservation Options
Thirty-Five Years Later, Gulf War Veterans Remain Sicker Than Counterparts
Thirty-Five Years Later, Gulf War Veterans Remain Sicker Than Counterparts
Gulf War veterans continue to report significantly higher rates of chronic physical and mental health conditions than their counterparts who did not deploy, according to a new analysis of data from an ongoing cohort study.
Veterans had higher rates in 22 of 47 (47%) self-reported medical conditions compared with nondeployed veterans of the same era, reported US Department of Veterans Affairs (VA) Director of Surveillance Military Environment Exposures for Health Outcomes Military Exposures Erin K. Dursa, PhD, MPH, et al in the Journal of Occupational and Environmental Medicine.
The conditions include chronic fatigue syndrome (13.7% vs 6.2%, respectively; adjusted odds ratio [aOR], 2.44), fibromyalgia (7.5% vs 4.2%, respectively; aOR, 2.05), and irritable bowel syndrome (20.8% vs 13.1%, respectively; aOR, 1.73), all of which are considered key components of Gulf War Illness (GWI), or Gulf War Syndrome. The differences were statistically significant.
“This is still happening. They're still sick with the very same things they’ve had for 34 to 35 years,” Robert Haley, MD, professor of medicine at the University of Texas Southwestern Medical Center in Dallas, told Federal Practitioner in an interview. Haley, who has studied GWI for decades, was familiar with the findings but not involved in the new research.
The US deployed nearly 700,000 troops during the Gulf War. Many troops began reporting chronic illness following deployment, during which some were exposed to oil well fires, nerve agents, pesticides, depleted uranium, and other hazards. An estimated 150,000 troops became sick, Haley said.
“Our group and a couple others started very quickly finding evidence that it was a real illness,” he said. “It was physical, not psychological.”
According to the VA, GWI encompasses chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders, and undiagnosed illnesses with symptoms such as abnormal weight loss, fatigue, cardiovascular signs, and muscle and joint pain.
Seeking an Explanation
Research links GWI to exposure to toxic sarin gas, a nerve agent used by Iraq, according to Haley. “It’s analogous to pesticide poisoning,” he said.
Other exposures may play a role, Haley said, but he believes sarin gas is the “major cause.” Sarin gas damages mitochondria within cells, causing them to produce less energy. The actual mechanism, however, remains unknown.
“We're getting real[ly] close to the answer, but we’re not there yet,” Haley said.
A 2000 study reported survey results from 15,000 Gulf War veterans and 15,000 nondeployed counterparts. The deployed veterans had a “higher prevalence of medical conditions, symptoms, functional impairment, and healthcare utilization than Gulf Era veterans.”
The new data, compiled between 2024 and 2025, represent the Gulf War Era cohort study’s fourth follow-up. Researchers surveyed 6888 Gulf War veterans and 5489 nondeployed veterans from the same era (response rate, 46.8%). The Gulf War veterans were 79.9% male; 73.1% White, 20.0% Black, 4.4% Hispanic, and 2.6% identified as another race or ethnicity. Most served in the Army (64.3%), and most were aged 17-25 (37.5%) or 26-32 (29.5%) years at deployment.
The nondeployed veteran group had similar demographics, although the cohort was older. In addition to chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, conditions that were significantly more common in Gulf War veterans than in nondeployed veterans included chronic obstructive pulmonary disease (aOR, 1.62), gastritis (aOR, 1.54), dermatitis (aOR, 1.45), bipolar or manic depression (aOR, 1.45), traumatic brain injury (aOR, 1.43), depression (aOR, 1.38), and alcohol or drug dependence (aOR, 1.36). The differences were statistically significant.
Multiple sclerosis (aOR, 0.42) was significantly less likely to be reported among Gulf War veterans.
The most common conditions reported overall by Gulf War veterans were hypertension (59.9%), sleep apnea (50.8%), arthritis not specified (41.9%), and depression (40.6%).
Affirming Reality
In an interview with Federal Practitioner, Beatrice Golomb, MD, PhD, a professor of medicine at the University of California San Diego and former VA staff physician who studies GWI, noted that researchers adjusted their analyses for body mass index (BMI), although “multiple studies show that weight gain is a metabolic feature of Gulf War Illness.”
This matters, Golomb said, because “if veterans develop increased BMI, and if that increase in BMI then contributes to things like diabetes, heart disease, and other outcomes, then adjusting for BMI will reduce the ability to see the causally-induced problems. For that reason, some problems are likely understated in this article.”
However, Golomb, who was not involved in the study, said the new research “supports findings from earlier studies to a considerable extent.” She added: “It affirms that Gulf War veterans, and those with Gulf War Illness, have elevations in many different health problems. These problems are real and often disabling.”
Lessons for the Clinic
Moving forward, “clinicians should be reminded that these veterans have real health problems, are legitimately affected, often in multiple ways, and deserve to be treated with the honor, respect, compassion, and seriousness they deserve," Golomb said.
In an interview with Federal Practitioner, Kimberly Sullivan, PhD, a research associate professor at Boston University School of Public Health who studies GWI, highlighted a new tool within the VA electronic health record that clinicians can use to screen eligible veterans for it. “This is a big improvement from the past when there was no easy way to track veterans with Gulf War Illness in the medical record, even for care providers trying to identify veterans for treatment studies,” said Sullivan, who was not involved in the new study.
Sullivan added that Gulf War veterans should be screened specifically for chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome.
The VA’s Health Outcomes Military Exposures program funded the study. The study authors have no disclosures. Haley discloses relationships with the Department of Defense and the VA. Golomb and Sullivan have no disclosures.
Gulf War veterans continue to report significantly higher rates of chronic physical and mental health conditions than their counterparts who did not deploy, according to a new analysis of data from an ongoing cohort study.
Veterans had higher rates in 22 of 47 (47%) self-reported medical conditions compared with nondeployed veterans of the same era, reported US Department of Veterans Affairs (VA) Director of Surveillance Military Environment Exposures for Health Outcomes Military Exposures Erin K. Dursa, PhD, MPH, et al in the Journal of Occupational and Environmental Medicine.
The conditions include chronic fatigue syndrome (13.7% vs 6.2%, respectively; adjusted odds ratio [aOR], 2.44), fibromyalgia (7.5% vs 4.2%, respectively; aOR, 2.05), and irritable bowel syndrome (20.8% vs 13.1%, respectively; aOR, 1.73), all of which are considered key components of Gulf War Illness (GWI), or Gulf War Syndrome. The differences were statistically significant.
“This is still happening. They're still sick with the very same things they’ve had for 34 to 35 years,” Robert Haley, MD, professor of medicine at the University of Texas Southwestern Medical Center in Dallas, told Federal Practitioner in an interview. Haley, who has studied GWI for decades, was familiar with the findings but not involved in the new research.
The US deployed nearly 700,000 troops during the Gulf War. Many troops began reporting chronic illness following deployment, during which some were exposed to oil well fires, nerve agents, pesticides, depleted uranium, and other hazards. An estimated 150,000 troops became sick, Haley said.
“Our group and a couple others started very quickly finding evidence that it was a real illness,” he said. “It was physical, not psychological.”
According to the VA, GWI encompasses chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders, and undiagnosed illnesses with symptoms such as abnormal weight loss, fatigue, cardiovascular signs, and muscle and joint pain.
Seeking an Explanation
Research links GWI to exposure to toxic sarin gas, a nerve agent used by Iraq, according to Haley. “It’s analogous to pesticide poisoning,” he said.
Other exposures may play a role, Haley said, but he believes sarin gas is the “major cause.” Sarin gas damages mitochondria within cells, causing them to produce less energy. The actual mechanism, however, remains unknown.
“We're getting real[ly] close to the answer, but we’re not there yet,” Haley said.
A 2000 study reported survey results from 15,000 Gulf War veterans and 15,000 nondeployed counterparts. The deployed veterans had a “higher prevalence of medical conditions, symptoms, functional impairment, and healthcare utilization than Gulf Era veterans.”
The new data, compiled between 2024 and 2025, represent the Gulf War Era cohort study’s fourth follow-up. Researchers surveyed 6888 Gulf War veterans and 5489 nondeployed veterans from the same era (response rate, 46.8%). The Gulf War veterans were 79.9% male; 73.1% White, 20.0% Black, 4.4% Hispanic, and 2.6% identified as another race or ethnicity. Most served in the Army (64.3%), and most were aged 17-25 (37.5%) or 26-32 (29.5%) years at deployment.
The nondeployed veteran group had similar demographics, although the cohort was older. In addition to chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, conditions that were significantly more common in Gulf War veterans than in nondeployed veterans included chronic obstructive pulmonary disease (aOR, 1.62), gastritis (aOR, 1.54), dermatitis (aOR, 1.45), bipolar or manic depression (aOR, 1.45), traumatic brain injury (aOR, 1.43), depression (aOR, 1.38), and alcohol or drug dependence (aOR, 1.36). The differences were statistically significant.
Multiple sclerosis (aOR, 0.42) was significantly less likely to be reported among Gulf War veterans.
The most common conditions reported overall by Gulf War veterans were hypertension (59.9%), sleep apnea (50.8%), arthritis not specified (41.9%), and depression (40.6%).
Affirming Reality
In an interview with Federal Practitioner, Beatrice Golomb, MD, PhD, a professor of medicine at the University of California San Diego and former VA staff physician who studies GWI, noted that researchers adjusted their analyses for body mass index (BMI), although “multiple studies show that weight gain is a metabolic feature of Gulf War Illness.”
This matters, Golomb said, because “if veterans develop increased BMI, and if that increase in BMI then contributes to things like diabetes, heart disease, and other outcomes, then adjusting for BMI will reduce the ability to see the causally-induced problems. For that reason, some problems are likely understated in this article.”
However, Golomb, who was not involved in the study, said the new research “supports findings from earlier studies to a considerable extent.” She added: “It affirms that Gulf War veterans, and those with Gulf War Illness, have elevations in many different health problems. These problems are real and often disabling.”
Lessons for the Clinic
Moving forward, “clinicians should be reminded that these veterans have real health problems, are legitimately affected, often in multiple ways, and deserve to be treated with the honor, respect, compassion, and seriousness they deserve," Golomb said.
In an interview with Federal Practitioner, Kimberly Sullivan, PhD, a research associate professor at Boston University School of Public Health who studies GWI, highlighted a new tool within the VA electronic health record that clinicians can use to screen eligible veterans for it. “This is a big improvement from the past when there was no easy way to track veterans with Gulf War Illness in the medical record, even for care providers trying to identify veterans for treatment studies,” said Sullivan, who was not involved in the new study.
Sullivan added that Gulf War veterans should be screened specifically for chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome.
The VA’s Health Outcomes Military Exposures program funded the study. The study authors have no disclosures. Haley discloses relationships with the Department of Defense and the VA. Golomb and Sullivan have no disclosures.
Gulf War veterans continue to report significantly higher rates of chronic physical and mental health conditions than their counterparts who did not deploy, according to a new analysis of data from an ongoing cohort study.
Veterans had higher rates in 22 of 47 (47%) self-reported medical conditions compared with nondeployed veterans of the same era, reported US Department of Veterans Affairs (VA) Director of Surveillance Military Environment Exposures for Health Outcomes Military Exposures Erin K. Dursa, PhD, MPH, et al in the Journal of Occupational and Environmental Medicine.
The conditions include chronic fatigue syndrome (13.7% vs 6.2%, respectively; adjusted odds ratio [aOR], 2.44), fibromyalgia (7.5% vs 4.2%, respectively; aOR, 2.05), and irritable bowel syndrome (20.8% vs 13.1%, respectively; aOR, 1.73), all of which are considered key components of Gulf War Illness (GWI), or Gulf War Syndrome. The differences were statistically significant.
“This is still happening. They're still sick with the very same things they’ve had for 34 to 35 years,” Robert Haley, MD, professor of medicine at the University of Texas Southwestern Medical Center in Dallas, told Federal Practitioner in an interview. Haley, who has studied GWI for decades, was familiar with the findings but not involved in the new research.
The US deployed nearly 700,000 troops during the Gulf War. Many troops began reporting chronic illness following deployment, during which some were exposed to oil well fires, nerve agents, pesticides, depleted uranium, and other hazards. An estimated 150,000 troops became sick, Haley said.
“Our group and a couple others started very quickly finding evidence that it was a real illness,” he said. “It was physical, not psychological.”
According to the VA, GWI encompasses chronic fatigue syndrome, fibromyalgia, functional gastrointestinal disorders, and undiagnosed illnesses with symptoms such as abnormal weight loss, fatigue, cardiovascular signs, and muscle and joint pain.
Seeking an Explanation
Research links GWI to exposure to toxic sarin gas, a nerve agent used by Iraq, according to Haley. “It’s analogous to pesticide poisoning,” he said.
Other exposures may play a role, Haley said, but he believes sarin gas is the “major cause.” Sarin gas damages mitochondria within cells, causing them to produce less energy. The actual mechanism, however, remains unknown.
“We're getting real[ly] close to the answer, but we’re not there yet,” Haley said.
A 2000 study reported survey results from 15,000 Gulf War veterans and 15,000 nondeployed counterparts. The deployed veterans had a “higher prevalence of medical conditions, symptoms, functional impairment, and healthcare utilization than Gulf Era veterans.”
The new data, compiled between 2024 and 2025, represent the Gulf War Era cohort study’s fourth follow-up. Researchers surveyed 6888 Gulf War veterans and 5489 nondeployed veterans from the same era (response rate, 46.8%). The Gulf War veterans were 79.9% male; 73.1% White, 20.0% Black, 4.4% Hispanic, and 2.6% identified as another race or ethnicity. Most served in the Army (64.3%), and most were aged 17-25 (37.5%) or 26-32 (29.5%) years at deployment.
The nondeployed veteran group had similar demographics, although the cohort was older. In addition to chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome, conditions that were significantly more common in Gulf War veterans than in nondeployed veterans included chronic obstructive pulmonary disease (aOR, 1.62), gastritis (aOR, 1.54), dermatitis (aOR, 1.45), bipolar or manic depression (aOR, 1.45), traumatic brain injury (aOR, 1.43), depression (aOR, 1.38), and alcohol or drug dependence (aOR, 1.36). The differences were statistically significant.
Multiple sclerosis (aOR, 0.42) was significantly less likely to be reported among Gulf War veterans.
The most common conditions reported overall by Gulf War veterans were hypertension (59.9%), sleep apnea (50.8%), arthritis not specified (41.9%), and depression (40.6%).
Affirming Reality
In an interview with Federal Practitioner, Beatrice Golomb, MD, PhD, a professor of medicine at the University of California San Diego and former VA staff physician who studies GWI, noted that researchers adjusted their analyses for body mass index (BMI), although “multiple studies show that weight gain is a metabolic feature of Gulf War Illness.”
This matters, Golomb said, because “if veterans develop increased BMI, and if that increase in BMI then contributes to things like diabetes, heart disease, and other outcomes, then adjusting for BMI will reduce the ability to see the causally-induced problems. For that reason, some problems are likely understated in this article.”
However, Golomb, who was not involved in the study, said the new research “supports findings from earlier studies to a considerable extent.” She added: “It affirms that Gulf War veterans, and those with Gulf War Illness, have elevations in many different health problems. These problems are real and often disabling.”
Lessons for the Clinic
Moving forward, “clinicians should be reminded that these veterans have real health problems, are legitimately affected, often in multiple ways, and deserve to be treated with the honor, respect, compassion, and seriousness they deserve," Golomb said.
In an interview with Federal Practitioner, Kimberly Sullivan, PhD, a research associate professor at Boston University School of Public Health who studies GWI, highlighted a new tool within the VA electronic health record that clinicians can use to screen eligible veterans for it. “This is a big improvement from the past when there was no easy way to track veterans with Gulf War Illness in the medical record, even for care providers trying to identify veterans for treatment studies,” said Sullivan, who was not involved in the new study.
Sullivan added that Gulf War veterans should be screened specifically for chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome.
The VA’s Health Outcomes Military Exposures program funded the study. The study authors have no disclosures. Haley discloses relationships with the Department of Defense and the VA. Golomb and Sullivan have no disclosures.
Thirty-Five Years Later, Gulf War Veterans Remain Sicker Than Counterparts
Thirty-Five Years Later, Gulf War Veterans Remain Sicker Than Counterparts
VA Study: Black Veterans See Similar, Better Cancer Survival Rates as Non-Black Veterans
VA Study: Black Veterans See Similar, Better Cancer Survival Rates as Non-Black Veterans
Unlike Black individuals in the general population who experience disparities in medical care, Black veterans with several types of cancer were just as likely to survive as non-Black veterans, according to a recently published systematic review and meta-analysis. For some cancers, Black veterans reported even better survival outcomes.
The analysis, published by Drew Moghanaki, MD, MPH, Chief of Thoracic Oncology, Department of Radiation Oncology, University of California, Los Angeles, and codirector, Veterans Affairs (VA) Greater Los Angeles Lung Precision Oncology Program, et al, in JAMA Network Open, found that Black veterans had better overall survival (OS) than non-Black veterans (hazard ratio [HR], 0.93) and cancer-specific survival (CSS) (HR, 0.94).
Black veterans had better survival rates for bladder, laryngeal, lung, oropharyngeal, prostate, and plasma cell cancers.
“Once there's equal access to cancer care, we no longer see the purported biological differences that people think are linked to race,” Moghanaki said in an interview with Federal Practitioner.
General Population: Racial Gap
“We've known for decades that there are differences in cancer outcomes for Black people in the US vs non-Black people,” Moghanaki said.
While the gaps in cancer mortality rates between Blacks and Whites have decreased over the last 25 years, colorectal cancer mortality remained 21% higher among Black people than White people in 2024, according to a report from the American Association for Cancer Research.
The association also reported that overall cancer mortality is 13% higher among Black men than White men, despite only 3% higher incidence. Separately, breast cancer mortality in Black women is 35% higher than in White women, even though their incidence is 6% lower.
Research suggests these disparities exist “not so much because of biology, but instead because of the structural and socioeconomic differences that many Black Americans live with in this country,” Moghanaki said.
The VA is different, he said, because “once you’re eligible for VA health care benefits, you’re getting essentially the same health care regardless of skin color.”
For the study, the researchers sought to determine whether the advantages of the VA system were reflected in cancer survival outcomes.
Methodology: Reviewing 34 Years of Data
The authors analyzed 39 studies including 603,256 veterans treated for cancer between 1983 and 2017. Study sizes ranged from 117 to 145,678 subjects. On average, 29.0% (range, 8.9%-55.0%) of participants were Black. Some studies specifically compared Black and White veterans, but the overall meta-analysis compared Black veterans with non-Black veterans.
A total of 29 studies had sufficient data for meta-analyses, including 20 (69%) focused on prostate cancer, 2 (7%) each on non-small cell lung cancer (NSCLC) and pancreatic cancer, and 1 each (3%) on head and neck cancers, esophageal cancer, bladder cancer, breast cancer, and myeloma.
Worse Outcomes for Black Veterans Were Rare
Of the 27 studies that examined OS, most (63%) found similar survival rates between Black and non-Black veterans, with 9 reporting higher survival for Black veterans and only 1 reporting higher survival for non-Black veterans. Among the 17 studies that evaluated CSS, those numbers were 13, 3, and 1, respectively.
Among veterans with prostate cancer, the pooled HRs for Blacks vs non-Blacks were 0.94 for OS and 0.90 for CSS. For NSCLC, they were 0.92 and 0.98, respectively.
The study notes that Black veterans may represent “a positively selected subgroup with respect to health, resilience, or other unmeasured factors, a phenomenon that has been described as a ‘healthy Black veteran effect.”
Other limitations include the high number of prostate cancer studies in the meta-analysis, while several leading causes of cancer death in the US (colorectal, pancreatic, breast), were underrepresented or absent. The analysis also included few women.
The differences in outcomes by race between the VA and general population may be due to the VA’s commitment to providing access to a full range of care and support, Moghanaki said.
“Veterans who are eligible for VA health care benefits also receive housing support, transportation benefits, caregiver support, social services, and mental health services that is often important for anyone with a diagnosis of cancer,” he said, before adding, “The VA’s footprint is large and able to ensure access to care regardless of where veterans live.”
In an interview with Federal Practitioner, Electra D. Paskett, PhD, professor of cancer research and director of the Division of Cancer Prevention and Control at The Ohio State University College of Medicine, who was not involved in the study, said the findings show that “equal access to state-of-the-art care in a timely manner produces good outcomes.”
She offered this message to VA clinicians: “Keep doing what you are doing!”
Moghanaki reported relationships with Bristol Myers Squibb Foundation and Varian Medical Systems, and he was the sole recipient of funding for the study from the Stanley Iezman and Nancy Stark Endowment for Thoracic Radiation Oncology Research at the David Geffen School of Medicine/University of California, Los Angeles. Some other authors reported additional disclosures. Paskett reports no disclosures.
Unlike Black individuals in the general population who experience disparities in medical care, Black veterans with several types of cancer were just as likely to survive as non-Black veterans, according to a recently published systematic review and meta-analysis. For some cancers, Black veterans reported even better survival outcomes.
The analysis, published by Drew Moghanaki, MD, MPH, Chief of Thoracic Oncology, Department of Radiation Oncology, University of California, Los Angeles, and codirector, Veterans Affairs (VA) Greater Los Angeles Lung Precision Oncology Program, et al, in JAMA Network Open, found that Black veterans had better overall survival (OS) than non-Black veterans (hazard ratio [HR], 0.93) and cancer-specific survival (CSS) (HR, 0.94).
Black veterans had better survival rates for bladder, laryngeal, lung, oropharyngeal, prostate, and plasma cell cancers.
“Once there's equal access to cancer care, we no longer see the purported biological differences that people think are linked to race,” Moghanaki said in an interview with Federal Practitioner.
General Population: Racial Gap
“We've known for decades that there are differences in cancer outcomes for Black people in the US vs non-Black people,” Moghanaki said.
While the gaps in cancer mortality rates between Blacks and Whites have decreased over the last 25 years, colorectal cancer mortality remained 21% higher among Black people than White people in 2024, according to a report from the American Association for Cancer Research.
The association also reported that overall cancer mortality is 13% higher among Black men than White men, despite only 3% higher incidence. Separately, breast cancer mortality in Black women is 35% higher than in White women, even though their incidence is 6% lower.
Research suggests these disparities exist “not so much because of biology, but instead because of the structural and socioeconomic differences that many Black Americans live with in this country,” Moghanaki said.
The VA is different, he said, because “once you’re eligible for VA health care benefits, you’re getting essentially the same health care regardless of skin color.”
For the study, the researchers sought to determine whether the advantages of the VA system were reflected in cancer survival outcomes.
Methodology: Reviewing 34 Years of Data
The authors analyzed 39 studies including 603,256 veterans treated for cancer between 1983 and 2017. Study sizes ranged from 117 to 145,678 subjects. On average, 29.0% (range, 8.9%-55.0%) of participants were Black. Some studies specifically compared Black and White veterans, but the overall meta-analysis compared Black veterans with non-Black veterans.
A total of 29 studies had sufficient data for meta-analyses, including 20 (69%) focused on prostate cancer, 2 (7%) each on non-small cell lung cancer (NSCLC) and pancreatic cancer, and 1 each (3%) on head and neck cancers, esophageal cancer, bladder cancer, breast cancer, and myeloma.
Worse Outcomes for Black Veterans Were Rare
Of the 27 studies that examined OS, most (63%) found similar survival rates between Black and non-Black veterans, with 9 reporting higher survival for Black veterans and only 1 reporting higher survival for non-Black veterans. Among the 17 studies that evaluated CSS, those numbers were 13, 3, and 1, respectively.
Among veterans with prostate cancer, the pooled HRs for Blacks vs non-Blacks were 0.94 for OS and 0.90 for CSS. For NSCLC, they were 0.92 and 0.98, respectively.
The study notes that Black veterans may represent “a positively selected subgroup with respect to health, resilience, or other unmeasured factors, a phenomenon that has been described as a ‘healthy Black veteran effect.”
Other limitations include the high number of prostate cancer studies in the meta-analysis, while several leading causes of cancer death in the US (colorectal, pancreatic, breast), were underrepresented or absent. The analysis also included few women.
The differences in outcomes by race between the VA and general population may be due to the VA’s commitment to providing access to a full range of care and support, Moghanaki said.
“Veterans who are eligible for VA health care benefits also receive housing support, transportation benefits, caregiver support, social services, and mental health services that is often important for anyone with a diagnosis of cancer,” he said, before adding, “The VA’s footprint is large and able to ensure access to care regardless of where veterans live.”
In an interview with Federal Practitioner, Electra D. Paskett, PhD, professor of cancer research and director of the Division of Cancer Prevention and Control at The Ohio State University College of Medicine, who was not involved in the study, said the findings show that “equal access to state-of-the-art care in a timely manner produces good outcomes.”
She offered this message to VA clinicians: “Keep doing what you are doing!”
Moghanaki reported relationships with Bristol Myers Squibb Foundation and Varian Medical Systems, and he was the sole recipient of funding for the study from the Stanley Iezman and Nancy Stark Endowment for Thoracic Radiation Oncology Research at the David Geffen School of Medicine/University of California, Los Angeles. Some other authors reported additional disclosures. Paskett reports no disclosures.
Unlike Black individuals in the general population who experience disparities in medical care, Black veterans with several types of cancer were just as likely to survive as non-Black veterans, according to a recently published systematic review and meta-analysis. For some cancers, Black veterans reported even better survival outcomes.
The analysis, published by Drew Moghanaki, MD, MPH, Chief of Thoracic Oncology, Department of Radiation Oncology, University of California, Los Angeles, and codirector, Veterans Affairs (VA) Greater Los Angeles Lung Precision Oncology Program, et al, in JAMA Network Open, found that Black veterans had better overall survival (OS) than non-Black veterans (hazard ratio [HR], 0.93) and cancer-specific survival (CSS) (HR, 0.94).
Black veterans had better survival rates for bladder, laryngeal, lung, oropharyngeal, prostate, and plasma cell cancers.
“Once there's equal access to cancer care, we no longer see the purported biological differences that people think are linked to race,” Moghanaki said in an interview with Federal Practitioner.
General Population: Racial Gap
“We've known for decades that there are differences in cancer outcomes for Black people in the US vs non-Black people,” Moghanaki said.
While the gaps in cancer mortality rates between Blacks and Whites have decreased over the last 25 years, colorectal cancer mortality remained 21% higher among Black people than White people in 2024, according to a report from the American Association for Cancer Research.
The association also reported that overall cancer mortality is 13% higher among Black men than White men, despite only 3% higher incidence. Separately, breast cancer mortality in Black women is 35% higher than in White women, even though their incidence is 6% lower.
Research suggests these disparities exist “not so much because of biology, but instead because of the structural and socioeconomic differences that many Black Americans live with in this country,” Moghanaki said.
The VA is different, he said, because “once you’re eligible for VA health care benefits, you’re getting essentially the same health care regardless of skin color.”
For the study, the researchers sought to determine whether the advantages of the VA system were reflected in cancer survival outcomes.
Methodology: Reviewing 34 Years of Data
The authors analyzed 39 studies including 603,256 veterans treated for cancer between 1983 and 2017. Study sizes ranged from 117 to 145,678 subjects. On average, 29.0% (range, 8.9%-55.0%) of participants were Black. Some studies specifically compared Black and White veterans, but the overall meta-analysis compared Black veterans with non-Black veterans.
A total of 29 studies had sufficient data for meta-analyses, including 20 (69%) focused on prostate cancer, 2 (7%) each on non-small cell lung cancer (NSCLC) and pancreatic cancer, and 1 each (3%) on head and neck cancers, esophageal cancer, bladder cancer, breast cancer, and myeloma.
Worse Outcomes for Black Veterans Were Rare
Of the 27 studies that examined OS, most (63%) found similar survival rates between Black and non-Black veterans, with 9 reporting higher survival for Black veterans and only 1 reporting higher survival for non-Black veterans. Among the 17 studies that evaluated CSS, those numbers were 13, 3, and 1, respectively.
Among veterans with prostate cancer, the pooled HRs for Blacks vs non-Blacks were 0.94 for OS and 0.90 for CSS. For NSCLC, they were 0.92 and 0.98, respectively.
The study notes that Black veterans may represent “a positively selected subgroup with respect to health, resilience, or other unmeasured factors, a phenomenon that has been described as a ‘healthy Black veteran effect.”
Other limitations include the high number of prostate cancer studies in the meta-analysis, while several leading causes of cancer death in the US (colorectal, pancreatic, breast), were underrepresented or absent. The analysis also included few women.
The differences in outcomes by race between the VA and general population may be due to the VA’s commitment to providing access to a full range of care and support, Moghanaki said.
“Veterans who are eligible for VA health care benefits also receive housing support, transportation benefits, caregiver support, social services, and mental health services that is often important for anyone with a diagnosis of cancer,” he said, before adding, “The VA’s footprint is large and able to ensure access to care regardless of where veterans live.”
In an interview with Federal Practitioner, Electra D. Paskett, PhD, professor of cancer research and director of the Division of Cancer Prevention and Control at The Ohio State University College of Medicine, who was not involved in the study, said the findings show that “equal access to state-of-the-art care in a timely manner produces good outcomes.”
She offered this message to VA clinicians: “Keep doing what you are doing!”
Moghanaki reported relationships with Bristol Myers Squibb Foundation and Varian Medical Systems, and he was the sole recipient of funding for the study from the Stanley Iezman and Nancy Stark Endowment for Thoracic Radiation Oncology Research at the David Geffen School of Medicine/University of California, Los Angeles. Some other authors reported additional disclosures. Paskett reports no disclosures.
VA Study: Black Veterans See Similar, Better Cancer Survival Rates as Non-Black Veterans
VA Study: Black Veterans See Similar, Better Cancer Survival Rates as Non-Black Veterans
VA Disability Claims Process Can Worsen Symptoms Associated With Military Sexual Trauma
VA Disability Claims Process Can Worsen Symptoms Associated With Military Sexual Trauma
Interviews with a small sample of veterans seeking disability compensation for military sexual trauma (MST) reveal the US Department of Veterans Affairs (VA) claims process may retraumatize victims by invalidating their experiences and forcing them to relive their assaults, according to a new report.
For some victims, “retraumatization and invalidation contributed to perceptions of VA-enacted institutional betrayal, which impacted their trust in and likelihood of using VA health care,” report Aliya R. Webermann, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in the Journal of Trauma & Dissociation.
One participant recalled that having to write about her trauma “was a big trigger. It was hard. When I was typing it, in the back of my mind, that’s all I could remember. It’s like going through this whole thing all over again.” Another described writing her statement as “brutal.”
Clinical psychologist Anne P. DePrince, PhD, a professor at the University of Denver not involved in the research, said in an interview with Federal Practitioner that the findings “add to a growing number of studies showing that institutional policies can be more than just red tape.
“Policies and procedures, and how those are implemented by staff, can have real consequences for survivors of intimate abuse, adding to the psychological burden they bear.”
The Burden of Military Sexual Trauma
According to a 2016 meta-analysis, 15.7% of US service members and veterans have experienced MST when measured as combined sexual assault and harassment. Viewed separately, assault was reported by 13.9%, including 23.6% of women and 1.9% of men, while harassment was reported by 31.2%, including 52.5% of women and 8.9% of men. The VA defines MST as “sexual assault or threatening sexual harassment experienced during military service.” MST has been linked to posttraumatic stress disorder (PTSD), substance misuse, suicidality, and other adverse outcomes, the new study notes.
Veterans are eligible for service-connected disability compensation for any condition, such as PTSD precipitated by MST, the study authors write, but patients must provide evidence of the trauma and show that the MST caused their disability.
A 2024 analysis found that MST-related PTSD claims for disability were more likely to be denied than combat-related PTSD claims (27.6% vs 18.2%, respectively).
‘I Had to Relive All of That Again’
The researchers recruited 15 victims of MST for interviews in 2024 (73% women, 60% White, 60% Army, mean age 52.6 years). Most served prior to 9/11 and lived in a single state.
In the conversations, which addressed the MST-related claims process, participants described being forced to repeat their stories. “When it was time for me to sit down and write, I had to relive all of that again. It was kind of rough,” one participant said.
Four veterans said being asked to recall their traumas was especially difficult when they were already doing so as part of treatment: “Through therapy, I gotta keep telling the same thing over and over, and it gets old . . . isn’t once enough?” said one veteran, while a male veteran said the experience was “like a knife going into your gut all the time.”
Victims Told They Don’t Fit the Mold
Veterans also described stress during the process.
“It would make me shut down,” said one participant about trying to appeal an initial 10% disability rating. “I used to drink a lot. It took a toll not just on me, but on my relationship.”
Two of the 15 veterans were denied disability, and they described reading their files as traumatic.
“When I read what they put, sometimes I feel as if I’m being assaulted all over again,” one said.
Additionally, some veterans “described being confronted when their lives did not follow a simple pattern of behavior before and after their MST,” the authors write.
One female veteran said: “They were like, ‘But you continued to perform so well and do well in class and still be able to be a military rock star.’ People deal with trauma in different ways. I don’t have to do a 180 and s— the bed to show this is impacting me.”
In other comments, veterans spoke about racial divides—the 2024 analysis found Black veterans were more likely to be denied MST-related disability claims than White veterans—“the living hell” of denied claims, and perceptions of the VA as “an institutional adversary that was distrustful and untrustworthy.”
DePrince said the study highlights the importance of preparing trauma survivors for what they will experience in the claims process.
“My team has learned from survivors across multiple studies just how important clear and accurate information is when trying to navigate legal, health, and social service systems,” she said. “Unfortunately, many survivors find it hard to get clear and accurate information about these processes, which adds to the stress of trying to access much-needed care and resources after trauma.”
Clinical psychologist Sheela Raja, PhD, an associate professor at the University of Illinois Chicago who studies how trauma affects survivors, agreed with DePrince in an interview with Federal Practitioner.
“When survivors know what’s coming, they can prepare, and that alone can make a huge difference,” said Raja, who was familiar with the study findings.
Raja, who has written books about trauma and PTSD, called research such as this “essential.” These reports bring “survivors’ voices forward and help us understand not just their experiences, but the symptoms and stress that can come from navigating systems that weren’t designed with trauma in mind.”
The VA funded the study. The authors have no disclosures. DePrince is associate editor of the Journal of Trauma and Dissociation, where the study appeared, but she was not involved in the review of the paper. Raja has no disclosures.
Interviews with a small sample of veterans seeking disability compensation for military sexual trauma (MST) reveal the US Department of Veterans Affairs (VA) claims process may retraumatize victims by invalidating their experiences and forcing them to relive their assaults, according to a new report.
For some victims, “retraumatization and invalidation contributed to perceptions of VA-enacted institutional betrayal, which impacted their trust in and likelihood of using VA health care,” report Aliya R. Webermann, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in the Journal of Trauma & Dissociation.
One participant recalled that having to write about her trauma “was a big trigger. It was hard. When I was typing it, in the back of my mind, that’s all I could remember. It’s like going through this whole thing all over again.” Another described writing her statement as “brutal.”
Clinical psychologist Anne P. DePrince, PhD, a professor at the University of Denver not involved in the research, said in an interview with Federal Practitioner that the findings “add to a growing number of studies showing that institutional policies can be more than just red tape.
“Policies and procedures, and how those are implemented by staff, can have real consequences for survivors of intimate abuse, adding to the psychological burden they bear.”
The Burden of Military Sexual Trauma
According to a 2016 meta-analysis, 15.7% of US service members and veterans have experienced MST when measured as combined sexual assault and harassment. Viewed separately, assault was reported by 13.9%, including 23.6% of women and 1.9% of men, while harassment was reported by 31.2%, including 52.5% of women and 8.9% of men. The VA defines MST as “sexual assault or threatening sexual harassment experienced during military service.” MST has been linked to posttraumatic stress disorder (PTSD), substance misuse, suicidality, and other adverse outcomes, the new study notes.
Veterans are eligible for service-connected disability compensation for any condition, such as PTSD precipitated by MST, the study authors write, but patients must provide evidence of the trauma and show that the MST caused their disability.
A 2024 analysis found that MST-related PTSD claims for disability were more likely to be denied than combat-related PTSD claims (27.6% vs 18.2%, respectively).
‘I Had to Relive All of That Again’
The researchers recruited 15 victims of MST for interviews in 2024 (73% women, 60% White, 60% Army, mean age 52.6 years). Most served prior to 9/11 and lived in a single state.
In the conversations, which addressed the MST-related claims process, participants described being forced to repeat their stories. “When it was time for me to sit down and write, I had to relive all of that again. It was kind of rough,” one participant said.
Four veterans said being asked to recall their traumas was especially difficult when they were already doing so as part of treatment: “Through therapy, I gotta keep telling the same thing over and over, and it gets old . . . isn’t once enough?” said one veteran, while a male veteran said the experience was “like a knife going into your gut all the time.”
Victims Told They Don’t Fit the Mold
Veterans also described stress during the process.
“It would make me shut down,” said one participant about trying to appeal an initial 10% disability rating. “I used to drink a lot. It took a toll not just on me, but on my relationship.”
Two of the 15 veterans were denied disability, and they described reading their files as traumatic.
“When I read what they put, sometimes I feel as if I’m being assaulted all over again,” one said.
Additionally, some veterans “described being confronted when their lives did not follow a simple pattern of behavior before and after their MST,” the authors write.
One female veteran said: “They were like, ‘But you continued to perform so well and do well in class and still be able to be a military rock star.’ People deal with trauma in different ways. I don’t have to do a 180 and s— the bed to show this is impacting me.”
In other comments, veterans spoke about racial divides—the 2024 analysis found Black veterans were more likely to be denied MST-related disability claims than White veterans—“the living hell” of denied claims, and perceptions of the VA as “an institutional adversary that was distrustful and untrustworthy.”
DePrince said the study highlights the importance of preparing trauma survivors for what they will experience in the claims process.
“My team has learned from survivors across multiple studies just how important clear and accurate information is when trying to navigate legal, health, and social service systems,” she said. “Unfortunately, many survivors find it hard to get clear and accurate information about these processes, which adds to the stress of trying to access much-needed care and resources after trauma.”
Clinical psychologist Sheela Raja, PhD, an associate professor at the University of Illinois Chicago who studies how trauma affects survivors, agreed with DePrince in an interview with Federal Practitioner.
“When survivors know what’s coming, they can prepare, and that alone can make a huge difference,” said Raja, who was familiar with the study findings.
Raja, who has written books about trauma and PTSD, called research such as this “essential.” These reports bring “survivors’ voices forward and help us understand not just their experiences, but the symptoms and stress that can come from navigating systems that weren’t designed with trauma in mind.”
The VA funded the study. The authors have no disclosures. DePrince is associate editor of the Journal of Trauma and Dissociation, where the study appeared, but she was not involved in the review of the paper. Raja has no disclosures.
Interviews with a small sample of veterans seeking disability compensation for military sexual trauma (MST) reveal the US Department of Veterans Affairs (VA) claims process may retraumatize victims by invalidating their experiences and forcing them to relive their assaults, according to a new report.
For some victims, “retraumatization and invalidation contributed to perceptions of VA-enacted institutional betrayal, which impacted their trust in and likelihood of using VA health care,” report Aliya R. Webermann, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in the Journal of Trauma & Dissociation.
One participant recalled that having to write about her trauma “was a big trigger. It was hard. When I was typing it, in the back of my mind, that’s all I could remember. It’s like going through this whole thing all over again.” Another described writing her statement as “brutal.”
Clinical psychologist Anne P. DePrince, PhD, a professor at the University of Denver not involved in the research, said in an interview with Federal Practitioner that the findings “add to a growing number of studies showing that institutional policies can be more than just red tape.
“Policies and procedures, and how those are implemented by staff, can have real consequences for survivors of intimate abuse, adding to the psychological burden they bear.”
The Burden of Military Sexual Trauma
According to a 2016 meta-analysis, 15.7% of US service members and veterans have experienced MST when measured as combined sexual assault and harassment. Viewed separately, assault was reported by 13.9%, including 23.6% of women and 1.9% of men, while harassment was reported by 31.2%, including 52.5% of women and 8.9% of men. The VA defines MST as “sexual assault or threatening sexual harassment experienced during military service.” MST has been linked to posttraumatic stress disorder (PTSD), substance misuse, suicidality, and other adverse outcomes, the new study notes.
Veterans are eligible for service-connected disability compensation for any condition, such as PTSD precipitated by MST, the study authors write, but patients must provide evidence of the trauma and show that the MST caused their disability.
A 2024 analysis found that MST-related PTSD claims for disability were more likely to be denied than combat-related PTSD claims (27.6% vs 18.2%, respectively).
‘I Had to Relive All of That Again’
The researchers recruited 15 victims of MST for interviews in 2024 (73% women, 60% White, 60% Army, mean age 52.6 years). Most served prior to 9/11 and lived in a single state.
In the conversations, which addressed the MST-related claims process, participants described being forced to repeat their stories. “When it was time for me to sit down and write, I had to relive all of that again. It was kind of rough,” one participant said.
Four veterans said being asked to recall their traumas was especially difficult when they were already doing so as part of treatment: “Through therapy, I gotta keep telling the same thing over and over, and it gets old . . . isn’t once enough?” said one veteran, while a male veteran said the experience was “like a knife going into your gut all the time.”
Victims Told They Don’t Fit the Mold
Veterans also described stress during the process.
“It would make me shut down,” said one participant about trying to appeal an initial 10% disability rating. “I used to drink a lot. It took a toll not just on me, but on my relationship.”
Two of the 15 veterans were denied disability, and they described reading their files as traumatic.
“When I read what they put, sometimes I feel as if I’m being assaulted all over again,” one said.
Additionally, some veterans “described being confronted when their lives did not follow a simple pattern of behavior before and after their MST,” the authors write.
One female veteran said: “They were like, ‘But you continued to perform so well and do well in class and still be able to be a military rock star.’ People deal with trauma in different ways. I don’t have to do a 180 and s— the bed to show this is impacting me.”
In other comments, veterans spoke about racial divides—the 2024 analysis found Black veterans were more likely to be denied MST-related disability claims than White veterans—“the living hell” of denied claims, and perceptions of the VA as “an institutional adversary that was distrustful and untrustworthy.”
DePrince said the study highlights the importance of preparing trauma survivors for what they will experience in the claims process.
“My team has learned from survivors across multiple studies just how important clear and accurate information is when trying to navigate legal, health, and social service systems,” she said. “Unfortunately, many survivors find it hard to get clear and accurate information about these processes, which adds to the stress of trying to access much-needed care and resources after trauma.”
Clinical psychologist Sheela Raja, PhD, an associate professor at the University of Illinois Chicago who studies how trauma affects survivors, agreed with DePrince in an interview with Federal Practitioner.
“When survivors know what’s coming, they can prepare, and that alone can make a huge difference,” said Raja, who was familiar with the study findings.
Raja, who has written books about trauma and PTSD, called research such as this “essential.” These reports bring “survivors’ voices forward and help us understand not just their experiences, but the symptoms and stress that can come from navigating systems that weren’t designed with trauma in mind.”
The VA funded the study. The authors have no disclosures. DePrince is associate editor of the Journal of Trauma and Dissociation, where the study appeared, but she was not involved in the review of the paper. Raja has no disclosures.
VA Disability Claims Process Can Worsen Symptoms Associated With Military Sexual Trauma
VA Disability Claims Process Can Worsen Symptoms Associated With Military Sexual Trauma
COVID-19 Pandemic Left Many Veteran Colon Cancers Undetected
Disruptions caused by the COVID-19 pandemic led to an estimated 619 missed cases of colorectal cancer (CRC) diagnoses among US veterans, and those whose cases were caught had larger tumors and more malignant bowel obstructions compared with a prepandemic period, a new longitudinal study finds.
The decline in diagnoses during the pandemic (March 2020-October 2023) represented a 5% decrease in anticipated cases compared with the prepandemic period (January 2017-February 2020) reported Veterans Health Administration (VHA) researchers in the Journal of Gastrointestinal Surgery.
Meanwhile, the percentage of cancers > 4 cm increased from 48.9% to 57.3% from the prepandemic to pandemic periods, and the percentage of patients with malignant bowel obstructions at presentation nearly doubled from 2.7% to 5.3%.
“The COVID-19 pandemic resulted in a significant initial decrease in rates of colon cancer diagnosis, with a slow return to baseline,” Louise Davies, MD, MS, a head-and-neck surgeon at the University of Wisconsin-Madison and senior author of the study told Federal Practitioner. “The length of time it took for things to return to normal surprised us. Patterns of detection did not return to more normal baselines until 2023.”
The Pandemic’s Toll on Colonoscopies
While mortality and diagnosis rates have fallen significantly over the past 3 decades, an estimated 158,850 colorectal cancer cases will be diagnosed in the US in 2026, and 55,230 patients will die. Within the VHA, an estimated 4000 new cases of colorectal cancer are diagnosed annually.
The pandemic disrupted medical care across the board, and colonoscopies were no exceptions. “There are various estimates that there were anywhere from 2 to 3 million missed exams,” said Timothy Pawlik, MD, PhD, MBA, MPH, a surgical oncologist and professor at The Ohio State University Wexner Medical Center, in an interview.
“At the height of the pandemic, all nonurgent procedures were put on hold,” explained Pawlik, who was not involved in the new study. “I suspect that a number of procedures were missed because different institutions and GI practices simply weren't providing that service at that time. In addition, I'm sure there was some reticence among patients to seek care even after the procedures were restarted and reoffered, especially at a hospital.”
Inside the VHA Data
The researchers found that 22,256 VHA patients were diagnosed with CRC during the study period (mean age, 71 years; 95.6% male; 72.1% White, 19.3% Black, and 6.4% Hispanic).
In a subset of 1087 patients, the percentage with an American Society of Anesthesiologists class ≥ 3 rose from 74.4% before the pandemic to 78.9% during it.
In light of the study findings, “clinicians should encourage their eligible patients to get screened for colon cancer, especially if they delayed screening as a result of the pandemic,” Davies said.
Why Colonoscopy Delays Matter
Pawlik, the Ohio State University Wexner Medical Center surgical oncologist, said even small delays in colonoscopies can be important.
“There are data suggesting that even a delay beyond 6 to 12 months can significantly increase the risk of advanced-stage cancer. Longer delays of a year, which were associated with the pandemic, definitely increase the risk of presenting with later stages of disease and potentially have a meaningful impact on your prognosis and survival.”
However, he noted that the study findings are limited because the results don’t clarify when patients were due for colonoscopies.
Still, in the big picture, the research “emphasizes the importance of timely colonoscopy compliance with national guidelines for screening of colon cancer,” he said.
Lessons About At-Home Tests
Pawlik added that the research also highlights that in times of limited access such as pandemics, there can be value to pivoting to home-based screening methods.
Study coauthor Douglas Robertson, MD, MPH, national deputy director of the Colorectal Cancer Screening Program with the US Department of Veterans Affairs National Gastroenterology and Hepatology Program, said the pandemic spurred a shift toward fecal immunochemical testing (FIT) via mail.
The VA is now mailing > 40,000 FIT tests per month to veterans. “This program was an outgrowth of and response to the pandemic and would enhance VA’s readiness to maintain CRC screening efforts should something similar occur in the future,” Robertson said in an interview.
The Department of Veterans Affairs funded the study. Davies, Robertson, and the other study authors have no disclosures. Pawlik is co-editor-in-chief of the Journal of Gastrointestinal Surgery and has no other disclosures.
Disruptions caused by the COVID-19 pandemic led to an estimated 619 missed cases of colorectal cancer (CRC) diagnoses among US veterans, and those whose cases were caught had larger tumors and more malignant bowel obstructions compared with a prepandemic period, a new longitudinal study finds.
The decline in diagnoses during the pandemic (March 2020-October 2023) represented a 5% decrease in anticipated cases compared with the prepandemic period (January 2017-February 2020) reported Veterans Health Administration (VHA) researchers in the Journal of Gastrointestinal Surgery.
Meanwhile, the percentage of cancers > 4 cm increased from 48.9% to 57.3% from the prepandemic to pandemic periods, and the percentage of patients with malignant bowel obstructions at presentation nearly doubled from 2.7% to 5.3%.
“The COVID-19 pandemic resulted in a significant initial decrease in rates of colon cancer diagnosis, with a slow return to baseline,” Louise Davies, MD, MS, a head-and-neck surgeon at the University of Wisconsin-Madison and senior author of the study told Federal Practitioner. “The length of time it took for things to return to normal surprised us. Patterns of detection did not return to more normal baselines until 2023.”
The Pandemic’s Toll on Colonoscopies
While mortality and diagnosis rates have fallen significantly over the past 3 decades, an estimated 158,850 colorectal cancer cases will be diagnosed in the US in 2026, and 55,230 patients will die. Within the VHA, an estimated 4000 new cases of colorectal cancer are diagnosed annually.
The pandemic disrupted medical care across the board, and colonoscopies were no exceptions. “There are various estimates that there were anywhere from 2 to 3 million missed exams,” said Timothy Pawlik, MD, PhD, MBA, MPH, a surgical oncologist and professor at The Ohio State University Wexner Medical Center, in an interview.
“At the height of the pandemic, all nonurgent procedures were put on hold,” explained Pawlik, who was not involved in the new study. “I suspect that a number of procedures were missed because different institutions and GI practices simply weren't providing that service at that time. In addition, I'm sure there was some reticence among patients to seek care even after the procedures were restarted and reoffered, especially at a hospital.”
Inside the VHA Data
The researchers found that 22,256 VHA patients were diagnosed with CRC during the study period (mean age, 71 years; 95.6% male; 72.1% White, 19.3% Black, and 6.4% Hispanic).
In a subset of 1087 patients, the percentage with an American Society of Anesthesiologists class ≥ 3 rose from 74.4% before the pandemic to 78.9% during it.
In light of the study findings, “clinicians should encourage their eligible patients to get screened for colon cancer, especially if they delayed screening as a result of the pandemic,” Davies said.
Why Colonoscopy Delays Matter
Pawlik, the Ohio State University Wexner Medical Center surgical oncologist, said even small delays in colonoscopies can be important.
“There are data suggesting that even a delay beyond 6 to 12 months can significantly increase the risk of advanced-stage cancer. Longer delays of a year, which were associated with the pandemic, definitely increase the risk of presenting with later stages of disease and potentially have a meaningful impact on your prognosis and survival.”
However, he noted that the study findings are limited because the results don’t clarify when patients were due for colonoscopies.
Still, in the big picture, the research “emphasizes the importance of timely colonoscopy compliance with national guidelines for screening of colon cancer,” he said.
Lessons About At-Home Tests
Pawlik added that the research also highlights that in times of limited access such as pandemics, there can be value to pivoting to home-based screening methods.
Study coauthor Douglas Robertson, MD, MPH, national deputy director of the Colorectal Cancer Screening Program with the US Department of Veterans Affairs National Gastroenterology and Hepatology Program, said the pandemic spurred a shift toward fecal immunochemical testing (FIT) via mail.
The VA is now mailing > 40,000 FIT tests per month to veterans. “This program was an outgrowth of and response to the pandemic and would enhance VA’s readiness to maintain CRC screening efforts should something similar occur in the future,” Robertson said in an interview.
The Department of Veterans Affairs funded the study. Davies, Robertson, and the other study authors have no disclosures. Pawlik is co-editor-in-chief of the Journal of Gastrointestinal Surgery and has no other disclosures.
Disruptions caused by the COVID-19 pandemic led to an estimated 619 missed cases of colorectal cancer (CRC) diagnoses among US veterans, and those whose cases were caught had larger tumors and more malignant bowel obstructions compared with a prepandemic period, a new longitudinal study finds.
The decline in diagnoses during the pandemic (March 2020-October 2023) represented a 5% decrease in anticipated cases compared with the prepandemic period (January 2017-February 2020) reported Veterans Health Administration (VHA) researchers in the Journal of Gastrointestinal Surgery.
Meanwhile, the percentage of cancers > 4 cm increased from 48.9% to 57.3% from the prepandemic to pandemic periods, and the percentage of patients with malignant bowel obstructions at presentation nearly doubled from 2.7% to 5.3%.
“The COVID-19 pandemic resulted in a significant initial decrease in rates of colon cancer diagnosis, with a slow return to baseline,” Louise Davies, MD, MS, a head-and-neck surgeon at the University of Wisconsin-Madison and senior author of the study told Federal Practitioner. “The length of time it took for things to return to normal surprised us. Patterns of detection did not return to more normal baselines until 2023.”
The Pandemic’s Toll on Colonoscopies
While mortality and diagnosis rates have fallen significantly over the past 3 decades, an estimated 158,850 colorectal cancer cases will be diagnosed in the US in 2026, and 55,230 patients will die. Within the VHA, an estimated 4000 new cases of colorectal cancer are diagnosed annually.
The pandemic disrupted medical care across the board, and colonoscopies were no exceptions. “There are various estimates that there were anywhere from 2 to 3 million missed exams,” said Timothy Pawlik, MD, PhD, MBA, MPH, a surgical oncologist and professor at The Ohio State University Wexner Medical Center, in an interview.
“At the height of the pandemic, all nonurgent procedures were put on hold,” explained Pawlik, who was not involved in the new study. “I suspect that a number of procedures were missed because different institutions and GI practices simply weren't providing that service at that time. In addition, I'm sure there was some reticence among patients to seek care even after the procedures were restarted and reoffered, especially at a hospital.”
Inside the VHA Data
The researchers found that 22,256 VHA patients were diagnosed with CRC during the study period (mean age, 71 years; 95.6% male; 72.1% White, 19.3% Black, and 6.4% Hispanic).
In a subset of 1087 patients, the percentage with an American Society of Anesthesiologists class ≥ 3 rose from 74.4% before the pandemic to 78.9% during it.
In light of the study findings, “clinicians should encourage their eligible patients to get screened for colon cancer, especially if they delayed screening as a result of the pandemic,” Davies said.
Why Colonoscopy Delays Matter
Pawlik, the Ohio State University Wexner Medical Center surgical oncologist, said even small delays in colonoscopies can be important.
“There are data suggesting that even a delay beyond 6 to 12 months can significantly increase the risk of advanced-stage cancer. Longer delays of a year, which were associated with the pandemic, definitely increase the risk of presenting with later stages of disease and potentially have a meaningful impact on your prognosis and survival.”
However, he noted that the study findings are limited because the results don’t clarify when patients were due for colonoscopies.
Still, in the big picture, the research “emphasizes the importance of timely colonoscopy compliance with national guidelines for screening of colon cancer,” he said.
Lessons About At-Home Tests
Pawlik added that the research also highlights that in times of limited access such as pandemics, there can be value to pivoting to home-based screening methods.
Study coauthor Douglas Robertson, MD, MPH, national deputy director of the Colorectal Cancer Screening Program with the US Department of Veterans Affairs National Gastroenterology and Hepatology Program, said the pandemic spurred a shift toward fecal immunochemical testing (FIT) via mail.
The VA is now mailing > 40,000 FIT tests per month to veterans. “This program was an outgrowth of and response to the pandemic and would enhance VA’s readiness to maintain CRC screening efforts should something similar occur in the future,” Robertson said in an interview.
The Department of Veterans Affairs funded the study. Davies, Robertson, and the other study authors have no disclosures. Pawlik is co-editor-in-chief of the Journal of Gastrointestinal Surgery and has no other disclosures.
Clomiphene Linked to Lower Mortality Than TRT in Vets With Hypogonadism
A retrospective cohort study links clomiphene citrate (CC) to significantly lower mortality rates when compared with testosterone replacement therapy (TRT) in male veterans with hypogonadism or infertility. CC is not approved by the US Food and Drug Administration (FDA) for hypogonadism but is often used off label. Patients taking clomiphene also had significantly lower risk of diseases of the circulatory system, brain, and bones.
The study tracked matched cohorts of 2518 patients taking CC or TRT for a mean 3.5 years. All-cause mortality was lower in the CC group (1.83%) than the TRT group (10.13%, P < .001), reported researchers at the Kansas City Veterans Affairs Medical Center and University of Missouri-Kansas City School of Medicine, et al in Andrology.
The researchers also reported that outcomes were better in the CC group than the TRT group for new-onset hypertension (6.04% vs 10.48%, P < .001), cerebrovascular accident (0.52% vs 1.43%, P < .001), coronary artery disease (1.51% vs 2.26%, P < .048), polycythemia (1.07% vs 2.22%, P < .001), and osteoporosis (1.15% vs 2.07%, P = .009), respectively.
“It seems like clomiphene is a good medication to be used long term, but we still need more investigation into this,” endocrinologist Mariana Garcia-Touza, MD said in an interview with Federal Practitioner.
TRT is a common therapy for male hypogonadism, although the study notes it is linked to thickened blood, breast growth, infertility, fluid retention, obstructive sleep apnea, and cardiovascular and prostate problems. Guidelines recommend against its use in patients with prostate cancer, at high cardiovascular risk, and those trying to have children.
CC is a selective estrogen receptor modulator and used off-label to treat male hypogonadism because it can boost the production of testosterone. The study notes how many Veterans health Administration patients have low testosterone, with previous research reporting the rate among veterans aged ≥ 60 years at 34%.
Garcia-Touza was especially interested in any effect clomiphene has on bones: “We’ve been hearing that it probably affects the bone and can cause osteoporosis, but no one has looked into it.”
The study tracked veterans from December 1990 to September 2024; follow-ups lasted up to 34 years. Patient mean ages were 46.5 and 47.5 years for the HRT and CC groups, respectively. Hypogonadism was the treatment indication for 98.4% and 64.5% and infertility was the indication for 1.6% and 35.5% for the HRT and CC groups, respectively. About 70% of both groups were White.
There were no statistically significant gaps between the groups regarding hip fractures, pulmonary embolism, thrombosis, and vertebral fractures. Garcia-Touza said the all-cause mortality gap the study reported was surprising, although the study did not control for factors that may have differed between the groups.
“This needs to be more carefully examined to see if this is a real finding or if there is some bias in the study that is causing it,” she said.
Moving forward, Garcia-Touza said she hopes to launch a prospective study of TRT vs CC.
Parviz K. Kavoussi, MD, a reproductive urologist at the University of Texas at Austin who was not involved in the study, said in an interview the study’s findings highlight the importance of monitoring patients on TRT for an increase in hematocrit.
“Not all testosterone replacement therapies are created equal from this standpoint,” he said, noting that risk depends on the delivery method. “There are multiple modalities — topical gels, patches, nasal gels, intramuscular injections, subcutaneous pellets, subcutaneous autoinjector pens, and oral testosterone pills. Each of these has a defined percentage risk of secondary erythrocytosis, with some being significantly higher than others.”
As for other potential risks from TRT such as a possible higher mortality rate, Kavoussi noted that a landmark 2023 trial of middle-aged and older men convinced the FDA to no longer require testosterone products to include a black-box warning about cardiovascular disease.
Regarding the question of whether clomiphene works as well as testosterone, Kavoussi noted his group’s research has found clomiphene can normalize testosterone levels biochemically. However, “where clomiphene typically falls short in data and in clinical practice is the level of symptomatic improvement in testosterone deficiency symptoms that patients can achieve in comparison to exogenous testosterone replacement.”
No funding was reported, and the authors – including Garcia-Touza – had no disclosures. Kavoussi discloses relationships with Halozyme and Verity.
A retrospective cohort study links clomiphene citrate (CC) to significantly lower mortality rates when compared with testosterone replacement therapy (TRT) in male veterans with hypogonadism or infertility. CC is not approved by the US Food and Drug Administration (FDA) for hypogonadism but is often used off label. Patients taking clomiphene also had significantly lower risk of diseases of the circulatory system, brain, and bones.
The study tracked matched cohorts of 2518 patients taking CC or TRT for a mean 3.5 years. All-cause mortality was lower in the CC group (1.83%) than the TRT group (10.13%, P < .001), reported researchers at the Kansas City Veterans Affairs Medical Center and University of Missouri-Kansas City School of Medicine, et al in Andrology.
The researchers also reported that outcomes were better in the CC group than the TRT group for new-onset hypertension (6.04% vs 10.48%, P < .001), cerebrovascular accident (0.52% vs 1.43%, P < .001), coronary artery disease (1.51% vs 2.26%, P < .048), polycythemia (1.07% vs 2.22%, P < .001), and osteoporosis (1.15% vs 2.07%, P = .009), respectively.
“It seems like clomiphene is a good medication to be used long term, but we still need more investigation into this,” endocrinologist Mariana Garcia-Touza, MD said in an interview with Federal Practitioner.
TRT is a common therapy for male hypogonadism, although the study notes it is linked to thickened blood, breast growth, infertility, fluid retention, obstructive sleep apnea, and cardiovascular and prostate problems. Guidelines recommend against its use in patients with prostate cancer, at high cardiovascular risk, and those trying to have children.
CC is a selective estrogen receptor modulator and used off-label to treat male hypogonadism because it can boost the production of testosterone. The study notes how many Veterans health Administration patients have low testosterone, with previous research reporting the rate among veterans aged ≥ 60 years at 34%.
Garcia-Touza was especially interested in any effect clomiphene has on bones: “We’ve been hearing that it probably affects the bone and can cause osteoporosis, but no one has looked into it.”
The study tracked veterans from December 1990 to September 2024; follow-ups lasted up to 34 years. Patient mean ages were 46.5 and 47.5 years for the HRT and CC groups, respectively. Hypogonadism was the treatment indication for 98.4% and 64.5% and infertility was the indication for 1.6% and 35.5% for the HRT and CC groups, respectively. About 70% of both groups were White.
There were no statistically significant gaps between the groups regarding hip fractures, pulmonary embolism, thrombosis, and vertebral fractures. Garcia-Touza said the all-cause mortality gap the study reported was surprising, although the study did not control for factors that may have differed between the groups.
“This needs to be more carefully examined to see if this is a real finding or if there is some bias in the study that is causing it,” she said.
Moving forward, Garcia-Touza said she hopes to launch a prospective study of TRT vs CC.
Parviz K. Kavoussi, MD, a reproductive urologist at the University of Texas at Austin who was not involved in the study, said in an interview the study’s findings highlight the importance of monitoring patients on TRT for an increase in hematocrit.
“Not all testosterone replacement therapies are created equal from this standpoint,” he said, noting that risk depends on the delivery method. “There are multiple modalities — topical gels, patches, nasal gels, intramuscular injections, subcutaneous pellets, subcutaneous autoinjector pens, and oral testosterone pills. Each of these has a defined percentage risk of secondary erythrocytosis, with some being significantly higher than others.”
As for other potential risks from TRT such as a possible higher mortality rate, Kavoussi noted that a landmark 2023 trial of middle-aged and older men convinced the FDA to no longer require testosterone products to include a black-box warning about cardiovascular disease.
Regarding the question of whether clomiphene works as well as testosterone, Kavoussi noted his group’s research has found clomiphene can normalize testosterone levels biochemically. However, “where clomiphene typically falls short in data and in clinical practice is the level of symptomatic improvement in testosterone deficiency symptoms that patients can achieve in comparison to exogenous testosterone replacement.”
No funding was reported, and the authors – including Garcia-Touza – had no disclosures. Kavoussi discloses relationships with Halozyme and Verity.
A retrospective cohort study links clomiphene citrate (CC) to significantly lower mortality rates when compared with testosterone replacement therapy (TRT) in male veterans with hypogonadism or infertility. CC is not approved by the US Food and Drug Administration (FDA) for hypogonadism but is often used off label. Patients taking clomiphene also had significantly lower risk of diseases of the circulatory system, brain, and bones.
The study tracked matched cohorts of 2518 patients taking CC or TRT for a mean 3.5 years. All-cause mortality was lower in the CC group (1.83%) than the TRT group (10.13%, P < .001), reported researchers at the Kansas City Veterans Affairs Medical Center and University of Missouri-Kansas City School of Medicine, et al in Andrology.
The researchers also reported that outcomes were better in the CC group than the TRT group for new-onset hypertension (6.04% vs 10.48%, P < .001), cerebrovascular accident (0.52% vs 1.43%, P < .001), coronary artery disease (1.51% vs 2.26%, P < .048), polycythemia (1.07% vs 2.22%, P < .001), and osteoporosis (1.15% vs 2.07%, P = .009), respectively.
“It seems like clomiphene is a good medication to be used long term, but we still need more investigation into this,” endocrinologist Mariana Garcia-Touza, MD said in an interview with Federal Practitioner.
TRT is a common therapy for male hypogonadism, although the study notes it is linked to thickened blood, breast growth, infertility, fluid retention, obstructive sleep apnea, and cardiovascular and prostate problems. Guidelines recommend against its use in patients with prostate cancer, at high cardiovascular risk, and those trying to have children.
CC is a selective estrogen receptor modulator and used off-label to treat male hypogonadism because it can boost the production of testosterone. The study notes how many Veterans health Administration patients have low testosterone, with previous research reporting the rate among veterans aged ≥ 60 years at 34%.
Garcia-Touza was especially interested in any effect clomiphene has on bones: “We’ve been hearing that it probably affects the bone and can cause osteoporosis, but no one has looked into it.”
The study tracked veterans from December 1990 to September 2024; follow-ups lasted up to 34 years. Patient mean ages were 46.5 and 47.5 years for the HRT and CC groups, respectively. Hypogonadism was the treatment indication for 98.4% and 64.5% and infertility was the indication for 1.6% and 35.5% for the HRT and CC groups, respectively. About 70% of both groups were White.
There were no statistically significant gaps between the groups regarding hip fractures, pulmonary embolism, thrombosis, and vertebral fractures. Garcia-Touza said the all-cause mortality gap the study reported was surprising, although the study did not control for factors that may have differed between the groups.
“This needs to be more carefully examined to see if this is a real finding or if there is some bias in the study that is causing it,” she said.
Moving forward, Garcia-Touza said she hopes to launch a prospective study of TRT vs CC.
Parviz K. Kavoussi, MD, a reproductive urologist at the University of Texas at Austin who was not involved in the study, said in an interview the study’s findings highlight the importance of monitoring patients on TRT for an increase in hematocrit.
“Not all testosterone replacement therapies are created equal from this standpoint,” he said, noting that risk depends on the delivery method. “There are multiple modalities — topical gels, patches, nasal gels, intramuscular injections, subcutaneous pellets, subcutaneous autoinjector pens, and oral testosterone pills. Each of these has a defined percentage risk of secondary erythrocytosis, with some being significantly higher than others.”
As for other potential risks from TRT such as a possible higher mortality rate, Kavoussi noted that a landmark 2023 trial of middle-aged and older men convinced the FDA to no longer require testosterone products to include a black-box warning about cardiovascular disease.
Regarding the question of whether clomiphene works as well as testosterone, Kavoussi noted his group’s research has found clomiphene can normalize testosterone levels biochemically. However, “where clomiphene typically falls short in data and in clinical practice is the level of symptomatic improvement in testosterone deficiency symptoms that patients can achieve in comparison to exogenous testosterone replacement.”
No funding was reported, and the authors – including Garcia-Touza – had no disclosures. Kavoussi discloses relationships with Halozyme and Verity.