AVAHO

TOPLINE: A large-scale case-control study using the Million Veteran Program (MVP) found The study found independent associations of both genetic predisposition and Agent Orange (AO) exposure for several lymphoid malignant neoplasm subtypes.

METHODOLOGY:

• A case-control study included 255,155 US veterans enrolled in the MVP with available genotype, Agent Orange exposure information, and lymphoid malignant neoplasm diagnosis from January 1, 1965, through June T1, 2024.

• Analysis focused on non-Hispanic White veterans (median age 67 years; 92.5% male) due to ancestry distribution requirements for genome-wide association studies data availability.

• Researchers excluded 628 samples across all lymphoid malignant neoplasm groups and 61,343 control samples due to unavailability of AO exposure information.

• Investigators analyzed risk for chronic lymphocytic leukemia, diffuse large B-cell lymphoma, follicular lymphoma, marginal zone lymphoma, and multiple myeloma as primary outcomes.

TAKEAWAY:

• Agent Orange exposure was associated with increased risk for chronic lymphocytic leukemia (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), diffuse large B-cell lymphoma (OR, 1.26; 95% CI, 1.03-1.53), follicular lymphoma (OR, 1.71; 95% CI, 1.39-2.11), and multiple myeloma (OR, 1.58; 95% CI, 1.35-1.86).

• Polygenic risk scores showed significant associations with all subtypes: chronic lymphocytic leukemia (OR, 1.81; 95% CI, 1.70-1.93), diffuse large B-cell lymphoma (OR, 1.12; 95% CI, 1.02-1.21), follicular lymphoma (OR, 1.33; 95% CI, 1.21-1.47), marginal zone lymphoma (OR, 1.17; 95% CI, 1.04-1.32), and multiple myeloma (OR, 1.41; 95% CI, 1.31-1.52).

• No significant polygenic risk score and AO exposure interactions were observed in the development of any lymphoid malignant neoplasm subtypes.

• The researchers found independent associations of both genetic predisposition and Agent Orange exposure on several lymphoid malignant neoplasm subtypes.

IN PRACTICE:

"Our study addressed the public health concerns surrounding AO exposure and lymphoid malignant neoplasms, finding that both AO exposure and polygenic risk are independently associated with disease, suggesting potentially distinct and additive pathways that merit further investigation,” the authors wrote.

SOURCE: The study was led by Xueyi Teng, PhD, Department of Biological Chemistry, School of Medicine, University of California in Irvine, and Helen Ma, MD, Tibor Rubin Veterans Affairs Medical Center in Long Beach. It was published online in JAMA Network Open.

LIMITATIONS: According to the authors, while this represents the largest study of Agent Orange exposure and genetic risk in lymphoid malignant neoplasm development, the power to find interaction associations in specific subtypes might be limited. Self-reported AO exposure may have introduced survival bias, especially in aggressive subtypes, as patients with aggressive tumors might have died before joining the MVP. Additionally, approximately half of the patients were diagnosed with lymphoid malignant neoplasm before self-reporting AO exposure in the survey, potentially introducing recall bias.

DISCLOSURES: Xueyi Teng, PhD, reported receiving grants from the George E. Hewitt Foundation for Medical Research Postdoc Fellowship during the conduct of the study. The research was supported by grant MVPOOO and Veterans Affairs Career Development Award 1IK2CX002437-O1A1. No other disclosures were reported.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: A large-scale case-control study using the Million Veteran Program (MVP) found The study found independent associations of both genetic predisposition and Agent Orange (AO) exposure for several lymphoid malignant neoplasm subtypes.

METHODOLOGY:

• A case-control study included 255,155 US veterans enrolled in the MVP with available genotype, Agent Orange exposure information, and lymphoid malignant neoplasm diagnosis from January 1, 1965, through June T1, 2024.

• Analysis focused on non-Hispanic White veterans (median age 67 years; 92.5% male) due to ancestry distribution requirements for genome-wide association studies data availability.

• Researchers excluded 628 samples across all lymphoid malignant neoplasm groups and 61,343 control samples due to unavailability of AO exposure information.

• Investigators analyzed risk for chronic lymphocytic leukemia, diffuse large B-cell lymphoma, follicular lymphoma, marginal zone lymphoma, and multiple myeloma as primary outcomes.

TAKEAWAY:

• Agent Orange exposure was associated with increased risk for chronic lymphocytic leukemia (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), diffuse large B-cell lymphoma (OR, 1.26; 95% CI, 1.03-1.53), follicular lymphoma (OR, 1.71; 95% CI, 1.39-2.11), and multiple myeloma (OR, 1.58; 95% CI, 1.35-1.86).

• Polygenic risk scores showed significant associations with all subtypes: chronic lymphocytic leukemia (OR, 1.81; 95% CI, 1.70-1.93), diffuse large B-cell lymphoma (OR, 1.12; 95% CI, 1.02-1.21), follicular lymphoma (OR, 1.33; 95% CI, 1.21-1.47), marginal zone lymphoma (OR, 1.17; 95% CI, 1.04-1.32), and multiple myeloma (OR, 1.41; 95% CI, 1.31-1.52).

• No significant polygenic risk score and AO exposure interactions were observed in the development of any lymphoid malignant neoplasm subtypes.

• The researchers found independent associations of both genetic predisposition and Agent Orange exposure on several lymphoid malignant neoplasm subtypes.

IN PRACTICE:

"Our study addressed the public health concerns surrounding AO exposure and lymphoid malignant neoplasms, finding that both AO exposure and polygenic risk are independently associated with disease, suggesting potentially distinct and additive pathways that merit further investigation,” the authors wrote.

SOURCE: The study was led by Xueyi Teng, PhD, Department of Biological Chemistry, School of Medicine, University of California in Irvine, and Helen Ma, MD, Tibor Rubin Veterans Affairs Medical Center in Long Beach. It was published online in JAMA Network Open.

LIMITATIONS: According to the authors, while this represents the largest study of Agent Orange exposure and genetic risk in lymphoid malignant neoplasm development, the power to find interaction associations in specific subtypes might be limited. Self-reported AO exposure may have introduced survival bias, especially in aggressive subtypes, as patients with aggressive tumors might have died before joining the MVP. Additionally, approximately half of the patients were diagnosed with lymphoid malignant neoplasm before self-reporting AO exposure in the survey, potentially introducing recall bias.

DISCLOSURES: Xueyi Teng, PhD, reported receiving grants from the George E. Hewitt Foundation for Medical Research Postdoc Fellowship during the conduct of the study. The research was supported by grant MVPOOO and Veterans Affairs Career Development Award 1IK2CX002437-O1A1. No other disclosures were reported.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE: A large-scale case-control study using the Million Veteran Program (MVP) found The study found independent associations of both genetic predisposition and Agent Orange (AO) exposure for several lymphoid malignant neoplasm subtypes.

METHODOLOGY:

• A case-control study included 255,155 US veterans enrolled in the MVP with available genotype, Agent Orange exposure information, and lymphoid malignant neoplasm diagnosis from January 1, 1965, through June T1, 2024.

• Analysis focused on non-Hispanic White veterans (median age 67 years; 92.5% male) due to ancestry distribution requirements for genome-wide association studies data availability.

• Researchers excluded 628 samples across all lymphoid malignant neoplasm groups and 61,343 control samples due to unavailability of AO exposure information.

• Investigators analyzed risk for chronic lymphocytic leukemia, diffuse large B-cell lymphoma, follicular lymphoma, marginal zone lymphoma, and multiple myeloma as primary outcomes.

TAKEAWAY:

• Agent Orange exposure was associated with increased risk for chronic lymphocytic leukemia (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.40-1.84), diffuse large B-cell lymphoma (OR, 1.26; 95% CI, 1.03-1.53), follicular lymphoma (OR, 1.71; 95% CI, 1.39-2.11), and multiple myeloma (OR, 1.58; 95% CI, 1.35-1.86).

• Polygenic risk scores showed significant associations with all subtypes: chronic lymphocytic leukemia (OR, 1.81; 95% CI, 1.70-1.93), diffuse large B-cell lymphoma (OR, 1.12; 95% CI, 1.02-1.21), follicular lymphoma (OR, 1.33; 95% CI, 1.21-1.47), marginal zone lymphoma (OR, 1.17; 95% CI, 1.04-1.32), and multiple myeloma (OR, 1.41; 95% CI, 1.31-1.52).

• No significant polygenic risk score and AO exposure interactions were observed in the development of any lymphoid malignant neoplasm subtypes.

• The researchers found independent associations of both genetic predisposition and Agent Orange exposure on several lymphoid malignant neoplasm subtypes.

IN PRACTICE:

"Our study addressed the public health concerns surrounding AO exposure and lymphoid malignant neoplasms, finding that both AO exposure and polygenic risk are independently associated with disease, suggesting potentially distinct and additive pathways that merit further investigation,” the authors wrote.

SOURCE: The study was led by Xueyi Teng, PhD, Department of Biological Chemistry, School of Medicine, University of California in Irvine, and Helen Ma, MD, Tibor Rubin Veterans Affairs Medical Center in Long Beach. It was published online in JAMA Network Open.

LIMITATIONS: According to the authors, while this represents the largest study of Agent Orange exposure and genetic risk in lymphoid malignant neoplasm development, the power to find interaction associations in specific subtypes might be limited. Self-reported AO exposure may have introduced survival bias, especially in aggressive subtypes, as patients with aggressive tumors might have died before joining the MVP. Additionally, approximately half of the patients were diagnosed with lymphoid malignant neoplasm before self-reporting AO exposure in the survey, potentially introducing recall bias.

DISCLOSURES: Xueyi Teng, PhD, reported receiving grants from the George E. Hewitt Foundation for Medical Research Postdoc Fellowship during the conduct of the study. The research was supported by grant MVPOOO and Veterans Affairs Career Development Award 1IK2CX002437-O1A1. No other disclosures were reported.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

TOPLINE:

A higher consumption of cruciferous vegetables such as broccoli and cauliflower was associated with a notably reduced risk for colon cancer (CC), with an optimal intake of 40-60 g/d providing a risk reduction of 20% to 26%.

METHODOLOGY:

• Previous meta-analyses have studied the association between the intake of cruciferous vegetables and the risk for CC; however, the quantitative dose-response relationship remained uncharacterized, limiting insights for dietary guidance.
• Researchers performed a systematic review and meta-analysis of 17 studies (seven cohort and 10 case-control studies) to analyze the dose-response association between the consumption of cruciferous vegetables and CC risk.
• Studies were included if they enrolled adults without CC at baseline (cohort studies) or adults with diagnosed cases who were matched with control individuals (case-control studies), quantified the dietary intake of cruciferous vegetables through standardized questionnaires, and included comparator groups with lower or no intake of such vegetables.
• The studies included 639,539 participants, of whom 97,595 had CC. Incident cases of CC were confirmed via medical records, pathology, registries, or validated self-report.

TAKEAWAY:

• A pooled analysis revealed that people who consumed the largest amounts of cruciferous vegetables had a 20% lower risk for CC than those who consumed the lowest amounts.
• A dose-response analysis showed that risk reduction was near maximal at an intake of 40-60 g/d (odds ratio, 0.74-0.8), with benefits plateauing beyond this range.
• The peak protective effect per gram occurred at an intake of 20-40 g/d of cruciferous vegetables and fell after 60 g/d.

IN PRACTICE:

“The pathophysiology of CC has been linked to dietary factors, specifically inadequate intake of vegetables and dietary fiber, as well as excessive alcohol and caffeine use. These empirical findings lend credence to our results, suggesting a potential chemopreventive role of CV [cruciferous vegetables] against CC development,” the authors wrote.

SOURCE:

This study, led by Bo Lai, Department of Interventional Radiology, The Second Clinical Medical School of Inner Mongolia University for the Nationalities, Yakeshi, China, was published online in BMC Gastroenterology.

LIMITATIONS:

The inclusion of both case-control and cohort studies and variations in the assessment of cruciferous vegetable intake across studies may have introduced methodological heterogeneity and measurement error, respectively. This study did not measure factors such as pesticide exposure and genetic susceptibility. The predominance of studies from North America and Asia — regions with an elevated incidence of CC — may have limited generalizability to other populations.

DISCLOSURES:

This study received no financial support. The authors declared having no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. 

A version of this article first appeared on Medscape.com.

TOPLINE:

A higher consumption of cruciferous vegetables such as broccoli and cauliflower was associated with a notably reduced risk for colon cancer (CC), with an optimal intake of 40-60 g/d providing a risk reduction of 20% to 26%.

METHODOLOGY:

• Previous meta-analyses have studied the association between the intake of cruciferous vegetables and the risk for CC; however, the quantitative dose-response relationship remained uncharacterized, limiting insights for dietary guidance.
• Researchers performed a systematic review and meta-analysis of 17 studies (seven cohort and 10 case-control studies) to analyze the dose-response association between the consumption of cruciferous vegetables and CC risk.
• Studies were included if they enrolled adults without CC at baseline (cohort studies) or adults with diagnosed cases who were matched with control individuals (case-control studies), quantified the dietary intake of cruciferous vegetables through standardized questionnaires, and included comparator groups with lower or no intake of such vegetables.
• The studies included 639,539 participants, of whom 97,595 had CC. Incident cases of CC were confirmed via medical records, pathology, registries, or validated self-report.

TAKEAWAY:

• A pooled analysis revealed that people who consumed the largest amounts of cruciferous vegetables had a 20% lower risk for CC than those who consumed the lowest amounts.
• A dose-response analysis showed that risk reduction was near maximal at an intake of 40-60 g/d (odds ratio, 0.74-0.8), with benefits plateauing beyond this range.
• The peak protective effect per gram occurred at an intake of 20-40 g/d of cruciferous vegetables and fell after 60 g/d.

IN PRACTICE:

“The pathophysiology of CC has been linked to dietary factors, specifically inadequate intake of vegetables and dietary fiber, as well as excessive alcohol and caffeine use. These empirical findings lend credence to our results, suggesting a potential chemopreventive role of CV [cruciferous vegetables] against CC development,” the authors wrote.

SOURCE:

This study, led by Bo Lai, Department of Interventional Radiology, The Second Clinical Medical School of Inner Mongolia University for the Nationalities, Yakeshi, China, was published online in BMC Gastroenterology.

LIMITATIONS:

The inclusion of both case-control and cohort studies and variations in the assessment of cruciferous vegetable intake across studies may have introduced methodological heterogeneity and measurement error, respectively. This study did not measure factors such as pesticide exposure and genetic susceptibility. The predominance of studies from North America and Asia — regions with an elevated incidence of CC — may have limited generalizability to other populations.

DISCLOSURES:

This study received no financial support. The authors declared having no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. 

A version of this article first appeared on Medscape.com.

TOPLINE:

A higher consumption of cruciferous vegetables such as broccoli and cauliflower was associated with a notably reduced risk for colon cancer (CC), with an optimal intake of 40-60 g/d providing a risk reduction of 20% to 26%.

METHODOLOGY:

• Previous meta-analyses have studied the association between the intake of cruciferous vegetables and the risk for CC; however, the quantitative dose-response relationship remained uncharacterized, limiting insights for dietary guidance.
• Researchers performed a systematic review and meta-analysis of 17 studies (seven cohort and 10 case-control studies) to analyze the dose-response association between the consumption of cruciferous vegetables and CC risk.
• Studies were included if they enrolled adults without CC at baseline (cohort studies) or adults with diagnosed cases who were matched with control individuals (case-control studies), quantified the dietary intake of cruciferous vegetables through standardized questionnaires, and included comparator groups with lower or no intake of such vegetables.
• The studies included 639,539 participants, of whom 97,595 had CC. Incident cases of CC were confirmed via medical records, pathology, registries, or validated self-report.

TAKEAWAY:

• A pooled analysis revealed that people who consumed the largest amounts of cruciferous vegetables had a 20% lower risk for CC than those who consumed the lowest amounts.
• A dose-response analysis showed that risk reduction was near maximal at an intake of 40-60 g/d (odds ratio, 0.74-0.8), with benefits plateauing beyond this range.
• The peak protective effect per gram occurred at an intake of 20-40 g/d of cruciferous vegetables and fell after 60 g/d.

IN PRACTICE:

“The pathophysiology of CC has been linked to dietary factors, specifically inadequate intake of vegetables and dietary fiber, as well as excessive alcohol and caffeine use. These empirical findings lend credence to our results, suggesting a potential chemopreventive role of CV [cruciferous vegetables] against CC development,” the authors wrote.

SOURCE:

This study, led by Bo Lai, Department of Interventional Radiology, The Second Clinical Medical School of Inner Mongolia University for the Nationalities, Yakeshi, China, was published online in BMC Gastroenterology.

LIMITATIONS:

The inclusion of both case-control and cohort studies and variations in the assessment of cruciferous vegetable intake across studies may have introduced methodological heterogeneity and measurement error, respectively. This study did not measure factors such as pesticide exposure and genetic susceptibility. The predominance of studies from North America and Asia — regions with an elevated incidence of CC — may have limited generalizability to other populations.

DISCLOSURES:

This study received no financial support. The authors declared having no competing interests.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. 

A version of this article first appeared on Medscape.com.

Cancer patients experience depression at rates > 5 times that of the general population.^1-11 Despite an increase in palliative care use, depression rates continued to rise.^2-4 Between 5% to 16% of outpatients, 4% to 14% of inpatients, and up to 49% of patients receiving palliative care experience depression.⁵ This issue also impacts families and caregivers.¹ A 2021 meta-analysis found that 23% of active military personnel and 20% of veterans experience depression.¹¹

Antidepressants approved by the US Food and Drug Administration (FDA) target the serotonin, norepinephrine, or dopamine systems and include boxed warnings about an increased risk of suicidal thoughts in adults aged 18 to 24 years.^12,13 These medications are categorized into several classes: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), tetracyclic antidepressants (TeCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin receptor modulators (SRMs), serotonin-melatonin receptor antagonists (SMRAs), and N—methyl-D-aspartate receptor antagonists (NMDARAs).^14,15 The first FDA-approved antidepressants, iproniazid (an MAOI) and imipramine (a TCA) laid the foundation for the development of newer classes like SSRIs and SNRIs.^15-17

Older antidepressants such as MAOIs and TCAs are used less due to their adverse effects (AEs) and drug interactions. MAOIs, such as iproniazid, selegiline, moclobemide, tranylcypromine, isocarboxazid, and phenelzine, have numerous AEs and drug interactions, making them unsuitable for first- or second-line treatment of depression.^14,18-21 TCAs such as doxepin, amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, trimipramine, protriptyline, maprotiline, and amoxapine have a narrow therapeutic index requiring careful monitoring for signs of toxicity such as QRS widening, tremors, or confusion. Despite the issues, TCAs are generally classified as second-line agents for major depressive disorder (MDD). TCAs have off-label uses for migraine prophylaxis, treatment of obsessive-compulsive disorder (OCD), insomnia, and chronic pain management first-line.^14,22-29

Newer antidepressants, including TeCAs and NDRIs, are typically more effective, but also come with safety concerns. TeCAs like mirtazapine interact with several medications, including MAOIs, serotonin-increasing drugs, alcohol, cannabidiol, and marijuana. Mirtazapine is FDA-approved for the treatment of moderate to severe depression in adults. It is also used off-label to treat insomnia, panic disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), headaches, and migraines. Compared to other antidepressants, mirtazapine is effective for all stages of depression and addresses a broad range of related symptoms.^14,30-34 NDRIs, such as bupropion, also interact with various medications, including MAOIs, other antidepressants, stimulants, and alcohol. Bupropion is FDA-approved for smoking cessation and to treat depression and SAD. It is also used off-label for depression- related bipolar disorder or sexual dysfunction, attention-deficit/hyperactivity disorder (ADHD), and obesity.^14,35-42

SSRIs, SNRIs, and SRMs should be used with caution. SSRIs such as sertraline, citalopram, escitalopram, fluoxetine, paroxetine, and fluvoxamine are first-line treatments for depression and various psychiatric disorders due to their safety and efficacy. Common AEs of SSRIs include sexual dysfunction, sleep disturbances, weight changes, and gastrointestinal (GI) issues. SSRIs can prolong the QT interval, posing a risk of life-threatening arrhythmia, and may interact with other medications, necessitating treatment adjustments. The FDA approved SSRIs for MDD, GAD, bulimia nervosa, bipolar depression, OCD, panic disorder, premenstrual dysphoric disorder, treatment-resistant depression, PTSD, and SAD. Off-label uses include binge eating disorder, body dysmorphic disorder, fibromyalgia, premature ejaculation, paraphilias, autism, Raynaud phenomenon, and vasomotor symptoms associated with menopause. Among SSRIs, sertraline and escitalopram are noted for their effectiveness and tolerability.^14,43-53

SNRIs, including duloxetine, venlafaxine, desvenlafaxine, milnacipran, and levomilnacipran, may increase bleeding risk, especially when taken with blood thinners. They can also elevate blood pressure, which may worsen if combined with stimulants. SNRIs may interact with other medications that affect serotonin levels, increasing the risk of serotonin syndrome when taken with triptans, pain medications, or other antidepressants.¹⁴ Desvenlafaxine has been approved by the FDA (but not by the European Medicines Agency).^54-56 Duloxetine is FDA-approved for the treatment of depression, neuropathic pain, anxiety disorders, fibromyalgia, and musculoskeletal disorders. It is used off-label to treat chemotherapy-induced peripheral neuropathy and stress urinary incontinence.^57-61 Venlafaxine is FDA-approved for depression, SAD, and panic disorder, and is prescribed off-label to treat ADHD, neuropathy, fibromyalgia, cataplexy, and PTSD, either alone or in combination with other medications.^62,63 Milnacipran is not approved for MDD; levomilnacipran received approval in 2013.⁶⁴

SRMs such as trazodone, nefazodone, vilazodone, and vortioxetine also function as serotonin reuptake inhibitors.^14,15 Trazodone is FDA-approved for MDD. It has been used off-label to treat anxiety, Alzheimer disease, substance misuse, bulimia nervosa, insomnia, fibromyalgia, and PTSD when first-line SSRIs are ineffective. A notable AE of trazodone is orthostatic hypotension, which can lead to dizziness and increase the risk of falls, especially in geriatric patients.^65-70 Nefazodone was discontinued in Europe in 2003 due to rare cases of liver toxicity but remains available in the US.^71-74 Vilazodone and vortioxetine are FDA-approved.

The latest classes of antidepressants include SMRAs and NMDARAs.¹⁴ Agomelatine, an SMRA, was approved in Europe in 2009 but rejected by the FDA in 2011 due to liver toxicity.⁷⁵ NMDARAs like esketamine and a combination of dextromethorphan and bupropion received FDA approval in 2019 and 2022, respectively.^76,77

This retrospective study analyzes noncancer drugs used during systemic chemotherapy based on a dataset of 14 antineoplastic agents. It sought to identify the most dispensed noncancer drug groups, discuss findings, compare patients with and without antidepressant prescriptions, and examine trends in antidepressant use from 2002 to 2023. This analysis expands on prior research.^78-81

Methods

The Walter Reed National Military Medical Center Institutional Review Board approved the study protocol and ensured compliance with the Health Insurance Portability and Accountability Act as an exempt protocol. The Joint Pathology Center (JPC) of the US Department of Defense (DoD) Cancer Registry Program and Military Health System (MHS) data experts from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) and Pharmacy Data Transaction Service (PDTS) provided data for the analysis.

Data Sources

The JPC DoD Cancer Registry Program contains data from 1998 to 2024. CAPER and PDTS are part of the MHS Data Repository/Management Analysis and Reporting Tool database. Each observation in CAPER represents an ambulatory encounter at a military treatment facility (MTF). CAPER records are available from 2003 to 2024. PDTS records are available from 2002 to 2004. Each observation in PDTS represents a prescription filled for an MHS beneficiary, excluding those filled at international civilian pharmacies and inpatient pharmacy prescriptions.

This cross-sectional analysis requested data extraction for specific cancer drugs from the DoD Cancer Registry, focusing on treatment details, diagnosis dates, patient demographics, and physicians’ comments on AEs. After identifying patients, CAPER was used to identify additional health conditions. PDTS was used to compile a list of prescription medications filled during systemic cancer treatment or < 2 years postdiagnosis.

The 2016 Surveillance, Epidemiology, and End Results Program Coding and Staging Manual and International Classification of Diseases for Oncology, 3rd edition, 1st revision, were used to decode disease and cancer types.^82,83 Data sorting and analysis were performed using Microsoft Excel. The percentage for the total was calculated by using the number of patients or data available within the subgroup divided by the total number of patients or data variables. To compare the mean number of dispensed antidepressants to those without antidepressants, a 2-tailed, 2-sample z test was used to calculate the P value and determine statistical significance (P < .05) using socscistatistics.com.

Data were extracted 3 times between 2021 and 2023. The initial 2021 protocol focused on erlotinib and gefitinib. A modified protocol in 2022 added paclitaxel, cisplatin, docetaxel, pemetrexed, and crizotinib; further modification in 2023 included 8 new antineoplastic agents and 2 anticoagulants. Sotorasib has not been prescribed in the MHS, and JPC lacks records for noncancer drugs. The 2023 dataset comprised 2210 patients with cancer treated with 14 antineoplastic agents; 2104 had documented diagnoses and 2113 had recorded prescriptions. Data for erlotinib, gefitinib, and paclitaxel have been published previously.^78,79

Results

Of 2113 patients with recorded prescriptions, 1297 patients (61.4%) received 109 cancer drugs, including 96 antineoplastics, 7 disease-modifying antirheumatic agents, 4 biologic response modifiers, and 2 calcitonin gene-related peptides. Fourteen antineoplastic agents had complete data from JPC, while others were noted for combination therapies or treatment switches from the PDTS (Table 1). Seventy-six cancer drugs were prescribed with antidepressants in 489 patients (eAppendix).

The JPC provided 2242 entries for 2210 patients, ranging in age from 2 months to 88 years (mean, 56 years), documenting treatment from September 1988 to January 2023. Thirty-two patients had duplicate entries due to multiple cancer locations or occurrences. Of the 2242 patients, 1541 (68.7%) were aged > 50 years, 975 patients (43.5%) had cancers that were stage III or IV, and 1267 (56.5%) had cancers that were stage 0, I, II, or not applicable/unknown. There were 51 different types of cancer: breast, lung, testicular, endometrial, and ovarian were most common (n ≥ 100 patients). Forty-two cancer types were documented among 750 patients prescribed antidepressants (Table 2).

The CAPER database recorded 8882 unique diagnoses for 2104 patients, while PDTS noted 1089 unique prescriptions within 273 therapeutic codes for 2113 patients. Nine therapeutic codes (opiate agonists, adrenals, cathartics-laxatives, nonsteroidal anti-inflammatory agents, antihistamines for GI conditions, 5-HT3 receptor antagonists, analgesics and antipyretic miscellanea, antineoplastic agents, and proton-pump inhibitors) and 8 drugs (dexamethasone, prochlorperazine, ondansetron, docusate, acetaminophen, ibuprofen, oxycodone, and polyethylene glycol 3350) were associated with > 1000 patients (≥ 50%). Patients had between 1 and 275 unique health conditions and filled 1 to 108 prescriptions. The mean (SD) number of diagnoses and prescriptions was 50 (28) and 29 (12), respectively. Of the 273 therapeutic codes, 30 groups were analyzed, with others categorized into miscellaneous groups such as lotions, vaccines, and devices. Significant differences in mean number of prescriptions were found for patients taking antidepressants compared to those not (P < .05), except for anticonvulsants and antipsychotics (P = .12 and .09, respectively) (Table 3).

Antidepressants

Of the 2113 patients with recorded prescriptions, 750 (35.5%) were dispensed 17 different antidepressants. Among these 17 antidepressants, 183 (8.7%) patients received duloxetine, 158 (7.5%) received venlafaxine, 118 (5.6%) received trazodone, and 107 (5.1%) received sertraline (Figure 1, Table 4). Of the 750 patients, 509 (67.9%) received 1 antidepressant, 168 (22.4%) received 2, 60 (8.0%) received 3, and 13 (1.7%) received > 3. Combinations varied, but only duloxetine and trazodone were prescribed to > 10 patients.

Antidepressants were prescribed annually at an overall mean (SD) rate of 23% (5%) from 2003 to 2022 (Figure 2). Patients on antidepressants during systemic therapy had a greater number of diagnosed medical conditions and received more prescription medications compared to those not taking antidepressants (P < .001) (Figure 3). The 745 patients taking antidepressants in CAPER data had between 1 and 275 diagnosed medical issues, with a mean (SD) of 55 (31) vs a range of 1 to 209 and a mean (SD) of 46 (26) for the 1359 patients not taking antidepressants. The 750 patients on antidepressants in PDTS data had between 8 and 108 prescriptions dispensed, with a mean (SD) of 32 (12), vs a range of 1 to 65 prescriptions and a mean (SD) of 29 (12) for 1363 patients not taking antidepressants.

Discussion

The JPC DoD Cancer Registry includes information on cancer types, stages, treatment regimens, and physicians’ notes, while noncancer drugs are sourced from the PDTS database. The pharmacy uses a different documentation system, leading to varied classifications.

Database reliance has its drawbacks. For example, megestrol is coded as a cancer drug, although it’s primarily used for endometrial or gynecologic cancers. Many drugs have multiple therapeutic codes assigned to them, including 10 antineoplastic agents: diclofenac, Bacillus Calmette-Guérin (BCG), megestrol acetate, tamoxifen, anastrozole, letrozole, leuprolide, goserelin, degarelix, and fluorouracil. Diclofenac, BCG, and mitomycin have been repurposed for cancer treatment.^84-87 From 2003 to 2023, diclofenac was prescribed to 350 patients for mild-to-moderate pain, with only 2 patients receiving it for cancer in 2018. FDA-approved for bladder cancer in 1990, BCG was prescribed for cancer treatment for 1 patient in 2021 after being used for vaccines between 2003 and 2018. Tamoxifen, used for hormone receptor-positive breast cancer from 2004 to 2017 with 53 patients, switched to estrogen agonist-antagonists from 2017 to 2023 with 123 patients. Only a few of the 168 patients were prescribed tamoxifen using both codes.^88-91 Anastrozole and letrozole were coded as antiestrogens for 7 and 18 patients, respectively, while leuprolide and goserelin were coded as gonadotropins for 59 and 18 patients. Degarelix was coded as antigonadotropins, fluorouracil as skin and mucous membrane agents miscellaneous, and megestrol acetate as progestins for 7, 6, and 3 patients, respectively. Duloxetine was given to 186 patients, primarily for depression from 2005 to 2023, with 7 patients treated for fibromyalgia from 2022 to 2023.

Antidepressants Observed

Tables 1 and 5 provide insight into the FDA approval of 14 antineoplastics and antidepressants and their CYP metabolic pathways.^92-122 In Table 4, the most prescribed antidepressant classes are SNRIs, SRMs, SSRIs, TeCAs, NDRIs, and TCAs. This trend highlights a preference for newer medications with weak CYP inhibition. A total of 349 patients were prescribed SSRIs, 343 SNRIs, 119 SRMs, 109 TCAs, 83 TeCAs, and 79 NDRIs. MAOIs, SMRAs, and NMDARAs were not observed in this dataset. While there are instances of dextromethorphan-bupropion and sertraline-escitalopram being dispensed together, it remains unclear whether these were NMDARA combinations.

Among the 14 specific antineoplastic agents, 10 are metabolized by CYP isoenzymes, primarily CYP3A4. Duloxetine neither inhibits nor is metabolized by CYP3A4, a reason it is often recommended, following venlafaxine.

Both duloxetine and venlafaxine are used off-label for chemotherapy-induced peripheral neuropathy related to paclitaxel and docetaxel. According to the CYP metabolized pathway, duloxetine tends to have more favorable DDIs than venlafaxine. In PDTS data, 371 patients were treated with paclitaxel and 180 with docetaxel, with respective antidepressant prescriptions of 156 and 70. Of the 156 patients dispensed paclitaxel, 62 (40%) were dispensed with duloxetine compared to 43 (28%) with venlafaxine. Of the 70 patients dispensed docetaxel, 23 (33%) received duloxetine vs 24 (34%) with venlafaxine.

Of 85 patients prescribed duloxetine, 75 received it with either paclitaxel or docetaxel (5 received both). Five patients had documented AEs (1 neuropathy related). Of 67 patients prescribed venlafaxine, 66 received it with either paclitaxel or docetaxel. Two patients had documented AEs (1 was neuropathy related, the same patient who received duloxetine). Of the 687 patients treated with paclitaxel and 337 with docetaxel in all databases, 4 experienced neuropathic AEs from both medications.⁷⁹

Antidepressants can increase the risk of bleeding, especially when combined with blood thinners, and may elevate blood pressure, particularly alongside stimulants. Of the 554 patients prescribed 9 different anticoagulants, enoxaparin, apixaban, and rivaroxaban were the most common (each > 100 patients). Among these, 201 patients (36%) received both anticoagulants and antidepressants: duloxetine for 64 patients, venlafaxine for 30, trazodone for 35, and sertraline for 26. There were no data available to assess bleeding rates related to the evaluation of DDIs between these medication classes.

Antidepressants can be prescribed for erectile dysfunction. Of the 148 patients prescribed an antidepressant for erectile dysfunction, duloxetine, trazodone, and mirtazapine were the most common. Antidepressant preferences varied by cancer type. Duloxetine was the only antidepressant used for all types of cancer. Venlafaxine, duloxetine, trazodone, sertraline, and escitalopram were the most prescribed antidepressants for breast cancer, while duloxetine, mirtazapine, citalopram, sertraline, and trazodone were the most prescribed for lung cancer. Sertraline, duloxetine, trazodone, amitriptyline, and escitalopram were most common for testicular cancer. Duloxetine, venlafaxine, trazodone, amitriptyline, and sertraline were the most prescribed for endometrial cancer, while duloxetine, venlafaxine, amitriptyline, citalopram, and sertraline were most prescribed for ovarian cancer.

The broadness of International Statistical Classification of Diseases, Tenth Revision codes made it challenging to identify nondepression diagnoses in the analyzed population. However, if all antidepressants were prescribed to treat depression, service members with cancer exhibited a higher depression rate (35%) than the general population (25%). Of 2104 patients, 191 (9.1%) had mood disorders, and 706 (33.6%) had mental disorders: 346 (49.0%) had 1 diagnosis, and 360 (51.0%) had multiple diagnoses. The percentage of diagnoses varied yearly, with notable drops in 2003, 2007, 2011, 2014, and 2018, and peaks in 2006, 2008, 2013, 2017, and 2022. This fluctuation was influenced by events like the establishment of PDTS in 2002, the 2008 economic recession, a hospital relocation in 2011, the 2014 Ebola outbreak, and the COVID-19 pandemic. Although the number of patients receiving antidepressants increased from 2019 to 2022, the overall percentage of patients receiving them did not significantly change from 2003 to 2022, aligning with previous research.^5,125

Many medications have potential uses beyond what is detailed in the prescribing information. Antidepressants can relieve pain, while pain medications may help with depression. Opioids were once thought to effectively treat depression, but this perspective has changed with a greater understanding of their risks, including misuse.^126-131 Pain is a severe and often unbearable AE of cancer. Of 2113 patients, 92% received opioids; 34% received both opioids and antidepressants; 2% received only antidepressants; and 7% received neither. This study didn’t clarify whether those on opioids alone recognized their depression or if those on both were aware of their dependence. While SSRIs are generally not addictive, they can lead to physical dependence, and any medication can be abused if not managed properly.^132-134

Conclusions

This retrospective study analyzes data from antineoplastic agents used in systemic cancer treatment between 1988 and 2023, with a particular focus on the use of antidepressants. Data on antidepressant prescriptions are incomplete and specific to these agents, which means the findings cannot be generalized to all antidepressants. Hence, the results indicate that patients taking antidepressants had more diagnosed health issues and received more medications compared to patients who were not on these drugs.

This study underscores the need for further research into the effects of antidepressants on cancer treatment, utilizing all data from the DoD Cancer Registry. Future research should explore DDIs between antidepressants and other cancer and noncancer medications, as this study did not assess AE documentation, unlike in studies involving erlotinib, gefitinib, and paclitaxel.^78,79 Further investigation is needed to evaluate the impact of discontinuing antidepressant use during cancer treatment. This comprehensive overview provides insights for clinicians to help them make informed decisions regarding the prescription of antidepressants in the context of cancer treatment.

Cancer patients experience depression at rates > 5 times that of the general population.^1-11 Despite an increase in palliative care use, depression rates continued to rise.^2-4 Between 5% to 16% of outpatients, 4% to 14% of inpatients, and up to 49% of patients receiving palliative care experience depression.⁵ This issue also impacts families and caregivers.¹ A 2021 meta-analysis found that 23% of active military personnel and 20% of veterans experience depression.¹¹

Antidepressants approved by the US Food and Drug Administration (FDA) target the serotonin, norepinephrine, or dopamine systems and include boxed warnings about an increased risk of suicidal thoughts in adults aged 18 to 24 years.^12,13 These medications are categorized into several classes: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), tetracyclic antidepressants (TeCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin receptor modulators (SRMs), serotonin-melatonin receptor antagonists (SMRAs), and N—methyl-D-aspartate receptor antagonists (NMDARAs).^14,15 The first FDA-approved antidepressants, iproniazid (an MAOI) and imipramine (a TCA) laid the foundation for the development of newer classes like SSRIs and SNRIs.^15-17

Older antidepressants such as MAOIs and TCAs are used less due to their adverse effects (AEs) and drug interactions. MAOIs, such as iproniazid, selegiline, moclobemide, tranylcypromine, isocarboxazid, and phenelzine, have numerous AEs and drug interactions, making them unsuitable for first- or second-line treatment of depression.^14,18-21 TCAs such as doxepin, amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, trimipramine, protriptyline, maprotiline, and amoxapine have a narrow therapeutic index requiring careful monitoring for signs of toxicity such as QRS widening, tremors, or confusion. Despite the issues, TCAs are generally classified as second-line agents for major depressive disorder (MDD). TCAs have off-label uses for migraine prophylaxis, treatment of obsessive-compulsive disorder (OCD), insomnia, and chronic pain management first-line.^14,22-29

Newer antidepressants, including TeCAs and NDRIs, are typically more effective, but also come with safety concerns. TeCAs like mirtazapine interact with several medications, including MAOIs, serotonin-increasing drugs, alcohol, cannabidiol, and marijuana. Mirtazapine is FDA-approved for the treatment of moderate to severe depression in adults. It is also used off-label to treat insomnia, panic disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), headaches, and migraines. Compared to other antidepressants, mirtazapine is effective for all stages of depression and addresses a broad range of related symptoms.^14,30-34 NDRIs, such as bupropion, also interact with various medications, including MAOIs, other antidepressants, stimulants, and alcohol. Bupropion is FDA-approved for smoking cessation and to treat depression and SAD. It is also used off-label for depression- related bipolar disorder or sexual dysfunction, attention-deficit/hyperactivity disorder (ADHD), and obesity.^14,35-42

SSRIs, SNRIs, and SRMs should be used with caution. SSRIs such as sertraline, citalopram, escitalopram, fluoxetine, paroxetine, and fluvoxamine are first-line treatments for depression and various psychiatric disorders due to their safety and efficacy. Common AEs of SSRIs include sexual dysfunction, sleep disturbances, weight changes, and gastrointestinal (GI) issues. SSRIs can prolong the QT interval, posing a risk of life-threatening arrhythmia, and may interact with other medications, necessitating treatment adjustments. The FDA approved SSRIs for MDD, GAD, bulimia nervosa, bipolar depression, OCD, panic disorder, premenstrual dysphoric disorder, treatment-resistant depression, PTSD, and SAD. Off-label uses include binge eating disorder, body dysmorphic disorder, fibromyalgia, premature ejaculation, paraphilias, autism, Raynaud phenomenon, and vasomotor symptoms associated with menopause. Among SSRIs, sertraline and escitalopram are noted for their effectiveness and tolerability.^14,43-53

SNRIs, including duloxetine, venlafaxine, desvenlafaxine, milnacipran, and levomilnacipran, may increase bleeding risk, especially when taken with blood thinners. They can also elevate blood pressure, which may worsen if combined with stimulants. SNRIs may interact with other medications that affect serotonin levels, increasing the risk of serotonin syndrome when taken with triptans, pain medications, or other antidepressants.¹⁴ Desvenlafaxine has been approved by the FDA (but not by the European Medicines Agency).^54-56 Duloxetine is FDA-approved for the treatment of depression, neuropathic pain, anxiety disorders, fibromyalgia, and musculoskeletal disorders. It is used off-label to treat chemotherapy-induced peripheral neuropathy and stress urinary incontinence.^57-61 Venlafaxine is FDA-approved for depression, SAD, and panic disorder, and is prescribed off-label to treat ADHD, neuropathy, fibromyalgia, cataplexy, and PTSD, either alone or in combination with other medications.^62,63 Milnacipran is not approved for MDD; levomilnacipran received approval in 2013.⁶⁴

SRMs such as trazodone, nefazodone, vilazodone, and vortioxetine also function as serotonin reuptake inhibitors.^14,15 Trazodone is FDA-approved for MDD. It has been used off-label to treat anxiety, Alzheimer disease, substance misuse, bulimia nervosa, insomnia, fibromyalgia, and PTSD when first-line SSRIs are ineffective. A notable AE of trazodone is orthostatic hypotension, which can lead to dizziness and increase the risk of falls, especially in geriatric patients.^65-70 Nefazodone was discontinued in Europe in 2003 due to rare cases of liver toxicity but remains available in the US.^71-74 Vilazodone and vortioxetine are FDA-approved.

The latest classes of antidepressants include SMRAs and NMDARAs.¹⁴ Agomelatine, an SMRA, was approved in Europe in 2009 but rejected by the FDA in 2011 due to liver toxicity.⁷⁵ NMDARAs like esketamine and a combination of dextromethorphan and bupropion received FDA approval in 2019 and 2022, respectively.^76,77

This retrospective study analyzes noncancer drugs used during systemic chemotherapy based on a dataset of 14 antineoplastic agents. It sought to identify the most dispensed noncancer drug groups, discuss findings, compare patients with and without antidepressant prescriptions, and examine trends in antidepressant use from 2002 to 2023. This analysis expands on prior research.^78-81

Methods

The Walter Reed National Military Medical Center Institutional Review Board approved the study protocol and ensured compliance with the Health Insurance Portability and Accountability Act as an exempt protocol. The Joint Pathology Center (JPC) of the US Department of Defense (DoD) Cancer Registry Program and Military Health System (MHS) data experts from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) and Pharmacy Data Transaction Service (PDTS) provided data for the analysis.

Data Sources

The JPC DoD Cancer Registry Program contains data from 1998 to 2024. CAPER and PDTS are part of the MHS Data Repository/Management Analysis and Reporting Tool database. Each observation in CAPER represents an ambulatory encounter at a military treatment facility (MTF). CAPER records are available from 2003 to 2024. PDTS records are available from 2002 to 2004. Each observation in PDTS represents a prescription filled for an MHS beneficiary, excluding those filled at international civilian pharmacies and inpatient pharmacy prescriptions.

This cross-sectional analysis requested data extraction for specific cancer drugs from the DoD Cancer Registry, focusing on treatment details, diagnosis dates, patient demographics, and physicians’ comments on AEs. After identifying patients, CAPER was used to identify additional health conditions. PDTS was used to compile a list of prescription medications filled during systemic cancer treatment or < 2 years postdiagnosis.

The 2016 Surveillance, Epidemiology, and End Results Program Coding and Staging Manual and International Classification of Diseases for Oncology, 3rd edition, 1st revision, were used to decode disease and cancer types.^82,83 Data sorting and analysis were performed using Microsoft Excel. The percentage for the total was calculated by using the number of patients or data available within the subgroup divided by the total number of patients or data variables. To compare the mean number of dispensed antidepressants to those without antidepressants, a 2-tailed, 2-sample z test was used to calculate the P value and determine statistical significance (P < .05) using socscistatistics.com.

Data were extracted 3 times between 2021 and 2023. The initial 2021 protocol focused on erlotinib and gefitinib. A modified protocol in 2022 added paclitaxel, cisplatin, docetaxel, pemetrexed, and crizotinib; further modification in 2023 included 8 new antineoplastic agents and 2 anticoagulants. Sotorasib has not been prescribed in the MHS, and JPC lacks records for noncancer drugs. The 2023 dataset comprised 2210 patients with cancer treated with 14 antineoplastic agents; 2104 had documented diagnoses and 2113 had recorded prescriptions. Data for erlotinib, gefitinib, and paclitaxel have been published previously.^78,79

Results

Of 2113 patients with recorded prescriptions, 1297 patients (61.4%) received 109 cancer drugs, including 96 antineoplastics, 7 disease-modifying antirheumatic agents, 4 biologic response modifiers, and 2 calcitonin gene-related peptides. Fourteen antineoplastic agents had complete data from JPC, while others were noted for combination therapies or treatment switches from the PDTS (Table 1). Seventy-six cancer drugs were prescribed with antidepressants in 489 patients (eAppendix).

The JPC provided 2242 entries for 2210 patients, ranging in age from 2 months to 88 years (mean, 56 years), documenting treatment from September 1988 to January 2023. Thirty-two patients had duplicate entries due to multiple cancer locations or occurrences. Of the 2242 patients, 1541 (68.7%) were aged > 50 years, 975 patients (43.5%) had cancers that were stage III or IV, and 1267 (56.5%) had cancers that were stage 0, I, II, or not applicable/unknown. There were 51 different types of cancer: breast, lung, testicular, endometrial, and ovarian were most common (n ≥ 100 patients). Forty-two cancer types were documented among 750 patients prescribed antidepressants (Table 2).

The CAPER database recorded 8882 unique diagnoses for 2104 patients, while PDTS noted 1089 unique prescriptions within 273 therapeutic codes for 2113 patients. Nine therapeutic codes (opiate agonists, adrenals, cathartics-laxatives, nonsteroidal anti-inflammatory agents, antihistamines for GI conditions, 5-HT3 receptor antagonists, analgesics and antipyretic miscellanea, antineoplastic agents, and proton-pump inhibitors) and 8 drugs (dexamethasone, prochlorperazine, ondansetron, docusate, acetaminophen, ibuprofen, oxycodone, and polyethylene glycol 3350) were associated with > 1000 patients (≥ 50%). Patients had between 1 and 275 unique health conditions and filled 1 to 108 prescriptions. The mean (SD) number of diagnoses and prescriptions was 50 (28) and 29 (12), respectively. Of the 273 therapeutic codes, 30 groups were analyzed, with others categorized into miscellaneous groups such as lotions, vaccines, and devices. Significant differences in mean number of prescriptions were found for patients taking antidepressants compared to those not (P < .05), except for anticonvulsants and antipsychotics (P = .12 and .09, respectively) (Table 3).

Antidepressants

Of the 2113 patients with recorded prescriptions, 750 (35.5%) were dispensed 17 different antidepressants. Among these 17 antidepressants, 183 (8.7%) patients received duloxetine, 158 (7.5%) received venlafaxine, 118 (5.6%) received trazodone, and 107 (5.1%) received sertraline (Figure 1, Table 4). Of the 750 patients, 509 (67.9%) received 1 antidepressant, 168 (22.4%) received 2, 60 (8.0%) received 3, and 13 (1.7%) received > 3. Combinations varied, but only duloxetine and trazodone were prescribed to > 10 patients.

Antidepressants were prescribed annually at an overall mean (SD) rate of 23% (5%) from 2003 to 2022 (Figure 2). Patients on antidepressants during systemic therapy had a greater number of diagnosed medical conditions and received more prescription medications compared to those not taking antidepressants (P < .001) (Figure 3). The 745 patients taking antidepressants in CAPER data had between 1 and 275 diagnosed medical issues, with a mean (SD) of 55 (31) vs a range of 1 to 209 and a mean (SD) of 46 (26) for the 1359 patients not taking antidepressants. The 750 patients on antidepressants in PDTS data had between 8 and 108 prescriptions dispensed, with a mean (SD) of 32 (12), vs a range of 1 to 65 prescriptions and a mean (SD) of 29 (12) for 1363 patients not taking antidepressants.

Discussion

The JPC DoD Cancer Registry includes information on cancer types, stages, treatment regimens, and physicians’ notes, while noncancer drugs are sourced from the PDTS database. The pharmacy uses a different documentation system, leading to varied classifications.

Database reliance has its drawbacks. For example, megestrol is coded as a cancer drug, although it’s primarily used for endometrial or gynecologic cancers. Many drugs have multiple therapeutic codes assigned to them, including 10 antineoplastic agents: diclofenac, Bacillus Calmette-Guérin (BCG), megestrol acetate, tamoxifen, anastrozole, letrozole, leuprolide, goserelin, degarelix, and fluorouracil. Diclofenac, BCG, and mitomycin have been repurposed for cancer treatment.^84-87 From 2003 to 2023, diclofenac was prescribed to 350 patients for mild-to-moderate pain, with only 2 patients receiving it for cancer in 2018. FDA-approved for bladder cancer in 1990, BCG was prescribed for cancer treatment for 1 patient in 2021 after being used for vaccines between 2003 and 2018. Tamoxifen, used for hormone receptor-positive breast cancer from 2004 to 2017 with 53 patients, switched to estrogen agonist-antagonists from 2017 to 2023 with 123 patients. Only a few of the 168 patients were prescribed tamoxifen using both codes.^88-91 Anastrozole and letrozole were coded as antiestrogens for 7 and 18 patients, respectively, while leuprolide and goserelin were coded as gonadotropins for 59 and 18 patients. Degarelix was coded as antigonadotropins, fluorouracil as skin and mucous membrane agents miscellaneous, and megestrol acetate as progestins for 7, 6, and 3 patients, respectively. Duloxetine was given to 186 patients, primarily for depression from 2005 to 2023, with 7 patients treated for fibromyalgia from 2022 to 2023.

Antidepressants Observed

Tables 1 and 5 provide insight into the FDA approval of 14 antineoplastics and antidepressants and their CYP metabolic pathways.^92-122 In Table 4, the most prescribed antidepressant classes are SNRIs, SRMs, SSRIs, TeCAs, NDRIs, and TCAs. This trend highlights a preference for newer medications with weak CYP inhibition. A total of 349 patients were prescribed SSRIs, 343 SNRIs, 119 SRMs, 109 TCAs, 83 TeCAs, and 79 NDRIs. MAOIs, SMRAs, and NMDARAs were not observed in this dataset. While there are instances of dextromethorphan-bupropion and sertraline-escitalopram being dispensed together, it remains unclear whether these were NMDARA combinations.

Among the 14 specific antineoplastic agents, 10 are metabolized by CYP isoenzymes, primarily CYP3A4. Duloxetine neither inhibits nor is metabolized by CYP3A4, a reason it is often recommended, following venlafaxine.

Both duloxetine and venlafaxine are used off-label for chemotherapy-induced peripheral neuropathy related to paclitaxel and docetaxel. According to the CYP metabolized pathway, duloxetine tends to have more favorable DDIs than venlafaxine. In PDTS data, 371 patients were treated with paclitaxel and 180 with docetaxel, with respective antidepressant prescriptions of 156 and 70. Of the 156 patients dispensed paclitaxel, 62 (40%) were dispensed with duloxetine compared to 43 (28%) with venlafaxine. Of the 70 patients dispensed docetaxel, 23 (33%) received duloxetine vs 24 (34%) with venlafaxine.

Of 85 patients prescribed duloxetine, 75 received it with either paclitaxel or docetaxel (5 received both). Five patients had documented AEs (1 neuropathy related). Of 67 patients prescribed venlafaxine, 66 received it with either paclitaxel or docetaxel. Two patients had documented AEs (1 was neuropathy related, the same patient who received duloxetine). Of the 687 patients treated with paclitaxel and 337 with docetaxel in all databases, 4 experienced neuropathic AEs from both medications.⁷⁹

Antidepressants can increase the risk of bleeding, especially when combined with blood thinners, and may elevate blood pressure, particularly alongside stimulants. Of the 554 patients prescribed 9 different anticoagulants, enoxaparin, apixaban, and rivaroxaban were the most common (each > 100 patients). Among these, 201 patients (36%) received both anticoagulants and antidepressants: duloxetine for 64 patients, venlafaxine for 30, trazodone for 35, and sertraline for 26. There were no data available to assess bleeding rates related to the evaluation of DDIs between these medication classes.

Antidepressants can be prescribed for erectile dysfunction. Of the 148 patients prescribed an antidepressant for erectile dysfunction, duloxetine, trazodone, and mirtazapine were the most common. Antidepressant preferences varied by cancer type. Duloxetine was the only antidepressant used for all types of cancer. Venlafaxine, duloxetine, trazodone, sertraline, and escitalopram were the most prescribed antidepressants for breast cancer, while duloxetine, mirtazapine, citalopram, sertraline, and trazodone were the most prescribed for lung cancer. Sertraline, duloxetine, trazodone, amitriptyline, and escitalopram were most common for testicular cancer. Duloxetine, venlafaxine, trazodone, amitriptyline, and sertraline were the most prescribed for endometrial cancer, while duloxetine, venlafaxine, amitriptyline, citalopram, and sertraline were most prescribed for ovarian cancer.

The broadness of International Statistical Classification of Diseases, Tenth Revision codes made it challenging to identify nondepression diagnoses in the analyzed population. However, if all antidepressants were prescribed to treat depression, service members with cancer exhibited a higher depression rate (35%) than the general population (25%). Of 2104 patients, 191 (9.1%) had mood disorders, and 706 (33.6%) had mental disorders: 346 (49.0%) had 1 diagnosis, and 360 (51.0%) had multiple diagnoses. The percentage of diagnoses varied yearly, with notable drops in 2003, 2007, 2011, 2014, and 2018, and peaks in 2006, 2008, 2013, 2017, and 2022. This fluctuation was influenced by events like the establishment of PDTS in 2002, the 2008 economic recession, a hospital relocation in 2011, the 2014 Ebola outbreak, and the COVID-19 pandemic. Although the number of patients receiving antidepressants increased from 2019 to 2022, the overall percentage of patients receiving them did not significantly change from 2003 to 2022, aligning with previous research.^5,125

Many medications have potential uses beyond what is detailed in the prescribing information. Antidepressants can relieve pain, while pain medications may help with depression. Opioids were once thought to effectively treat depression, but this perspective has changed with a greater understanding of their risks, including misuse.^126-131 Pain is a severe and often unbearable AE of cancer. Of 2113 patients, 92% received opioids; 34% received both opioids and antidepressants; 2% received only antidepressants; and 7% received neither. This study didn’t clarify whether those on opioids alone recognized their depression or if those on both were aware of their dependence. While SSRIs are generally not addictive, they can lead to physical dependence, and any medication can be abused if not managed properly.^132-134

Conclusions

This retrospective study analyzes data from antineoplastic agents used in systemic cancer treatment between 1988 and 2023, with a particular focus on the use of antidepressants. Data on antidepressant prescriptions are incomplete and specific to these agents, which means the findings cannot be generalized to all antidepressants. Hence, the results indicate that patients taking antidepressants had more diagnosed health issues and received more medications compared to patients who were not on these drugs.

This study underscores the need for further research into the effects of antidepressants on cancer treatment, utilizing all data from the DoD Cancer Registry. Future research should explore DDIs between antidepressants and other cancer and noncancer medications, as this study did not assess AE documentation, unlike in studies involving erlotinib, gefitinib, and paclitaxel.^78,79 Further investigation is needed to evaluate the impact of discontinuing antidepressant use during cancer treatment. This comprehensive overview provides insights for clinicians to help them make informed decisions regarding the prescription of antidepressants in the context of cancer treatment.

Cancer patients experience depression at rates > 5 times that of the general population.^1-11 Despite an increase in palliative care use, depression rates continued to rise.^2-4 Between 5% to 16% of outpatients, 4% to 14% of inpatients, and up to 49% of patients receiving palliative care experience depression.⁵ This issue also impacts families and caregivers.¹ A 2021 meta-analysis found that 23% of active military personnel and 20% of veterans experience depression.¹¹

Antidepressants approved by the US Food and Drug Administration (FDA) target the serotonin, norepinephrine, or dopamine systems and include boxed warnings about an increased risk of suicidal thoughts in adults aged 18 to 24 years.^12,13 These medications are categorized into several classes: monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (TCAs), tetracyclic antidepressants (TeCAs), norepinephrine-dopamine reuptake inhibitors (NDRIs), selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), serotonin receptor modulators (SRMs), serotonin-melatonin receptor antagonists (SMRAs), and N—methyl-D-aspartate receptor antagonists (NMDARAs).^14,15 The first FDA-approved antidepressants, iproniazid (an MAOI) and imipramine (a TCA) laid the foundation for the development of newer classes like SSRIs and SNRIs.^15-17

Older antidepressants such as MAOIs and TCAs are used less due to their adverse effects (AEs) and drug interactions. MAOIs, such as iproniazid, selegiline, moclobemide, tranylcypromine, isocarboxazid, and phenelzine, have numerous AEs and drug interactions, making them unsuitable for first- or second-line treatment of depression.^14,18-21 TCAs such as doxepin, amitriptyline, nortriptyline, imipramine, desipramine, clomipramine, trimipramine, protriptyline, maprotiline, and amoxapine have a narrow therapeutic index requiring careful monitoring for signs of toxicity such as QRS widening, tremors, or confusion. Despite the issues, TCAs are generally classified as second-line agents for major depressive disorder (MDD). TCAs have off-label uses for migraine prophylaxis, treatment of obsessive-compulsive disorder (OCD), insomnia, and chronic pain management first-line.^14,22-29

Newer antidepressants, including TeCAs and NDRIs, are typically more effective, but also come with safety concerns. TeCAs like mirtazapine interact with several medications, including MAOIs, serotonin-increasing drugs, alcohol, cannabidiol, and marijuana. Mirtazapine is FDA-approved for the treatment of moderate to severe depression in adults. It is also used off-label to treat insomnia, panic disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder (GAD), social anxiety disorder (SAD), headaches, and migraines. Compared to other antidepressants, mirtazapine is effective for all stages of depression and addresses a broad range of related symptoms.^14,30-34 NDRIs, such as bupropion, also interact with various medications, including MAOIs, other antidepressants, stimulants, and alcohol. Bupropion is FDA-approved for smoking cessation and to treat depression and SAD. It is also used off-label for depression- related bipolar disorder or sexual dysfunction, attention-deficit/hyperactivity disorder (ADHD), and obesity.^14,35-42

SSRIs, SNRIs, and SRMs should be used with caution. SSRIs such as sertraline, citalopram, escitalopram, fluoxetine, paroxetine, and fluvoxamine are first-line treatments for depression and various psychiatric disorders due to their safety and efficacy. Common AEs of SSRIs include sexual dysfunction, sleep disturbances, weight changes, and gastrointestinal (GI) issues. SSRIs can prolong the QT interval, posing a risk of life-threatening arrhythmia, and may interact with other medications, necessitating treatment adjustments. The FDA approved SSRIs for MDD, GAD, bulimia nervosa, bipolar depression, OCD, panic disorder, premenstrual dysphoric disorder, treatment-resistant depression, PTSD, and SAD. Off-label uses include binge eating disorder, body dysmorphic disorder, fibromyalgia, premature ejaculation, paraphilias, autism, Raynaud phenomenon, and vasomotor symptoms associated with menopause. Among SSRIs, sertraline and escitalopram are noted for their effectiveness and tolerability.^14,43-53

SNRIs, including duloxetine, venlafaxine, desvenlafaxine, milnacipran, and levomilnacipran, may increase bleeding risk, especially when taken with blood thinners. They can also elevate blood pressure, which may worsen if combined with stimulants. SNRIs may interact with other medications that affect serotonin levels, increasing the risk of serotonin syndrome when taken with triptans, pain medications, or other antidepressants.¹⁴ Desvenlafaxine has been approved by the FDA (but not by the European Medicines Agency).^54-56 Duloxetine is FDA-approved for the treatment of depression, neuropathic pain, anxiety disorders, fibromyalgia, and musculoskeletal disorders. It is used off-label to treat chemotherapy-induced peripheral neuropathy and stress urinary incontinence.^57-61 Venlafaxine is FDA-approved for depression, SAD, and panic disorder, and is prescribed off-label to treat ADHD, neuropathy, fibromyalgia, cataplexy, and PTSD, either alone or in combination with other medications.^62,63 Milnacipran is not approved for MDD; levomilnacipran received approval in 2013.⁶⁴

SRMs such as trazodone, nefazodone, vilazodone, and vortioxetine also function as serotonin reuptake inhibitors.^14,15 Trazodone is FDA-approved for MDD. It has been used off-label to treat anxiety, Alzheimer disease, substance misuse, bulimia nervosa, insomnia, fibromyalgia, and PTSD when first-line SSRIs are ineffective. A notable AE of trazodone is orthostatic hypotension, which can lead to dizziness and increase the risk of falls, especially in geriatric patients.^65-70 Nefazodone was discontinued in Europe in 2003 due to rare cases of liver toxicity but remains available in the US.^71-74 Vilazodone and vortioxetine are FDA-approved.

The latest classes of antidepressants include SMRAs and NMDARAs.¹⁴ Agomelatine, an SMRA, was approved in Europe in 2009 but rejected by the FDA in 2011 due to liver toxicity.⁷⁵ NMDARAs like esketamine and a combination of dextromethorphan and bupropion received FDA approval in 2019 and 2022, respectively.^76,77

This retrospective study analyzes noncancer drugs used during systemic chemotherapy based on a dataset of 14 antineoplastic agents. It sought to identify the most dispensed noncancer drug groups, discuss findings, compare patients with and without antidepressant prescriptions, and examine trends in antidepressant use from 2002 to 2023. This analysis expands on prior research.^78-81

Methods

The Walter Reed National Military Medical Center Institutional Review Board approved the study protocol and ensured compliance with the Health Insurance Portability and Accountability Act as an exempt protocol. The Joint Pathology Center (JPC) of the US Department of Defense (DoD) Cancer Registry Program and Military Health System (MHS) data experts from the Comprehensive Ambulatory/Professional Encounter Record (CAPER) and Pharmacy Data Transaction Service (PDTS) provided data for the analysis.

Data Sources

The JPC DoD Cancer Registry Program contains data from 1998 to 2024. CAPER and PDTS are part of the MHS Data Repository/Management Analysis and Reporting Tool database. Each observation in CAPER represents an ambulatory encounter at a military treatment facility (MTF). CAPER records are available from 2003 to 2024. PDTS records are available from 2002 to 2004. Each observation in PDTS represents a prescription filled for an MHS beneficiary, excluding those filled at international civilian pharmacies and inpatient pharmacy prescriptions.

This cross-sectional analysis requested data extraction for specific cancer drugs from the DoD Cancer Registry, focusing on treatment details, diagnosis dates, patient demographics, and physicians’ comments on AEs. After identifying patients, CAPER was used to identify additional health conditions. PDTS was used to compile a list of prescription medications filled during systemic cancer treatment or < 2 years postdiagnosis.

The 2016 Surveillance, Epidemiology, and End Results Program Coding and Staging Manual and International Classification of Diseases for Oncology, 3rd edition, 1st revision, were used to decode disease and cancer types.^82,83 Data sorting and analysis were performed using Microsoft Excel. The percentage for the total was calculated by using the number of patients or data available within the subgroup divided by the total number of patients or data variables. To compare the mean number of dispensed antidepressants to those without antidepressants, a 2-tailed, 2-sample z test was used to calculate the P value and determine statistical significance (P < .05) using socscistatistics.com.

Data were extracted 3 times between 2021 and 2023. The initial 2021 protocol focused on erlotinib and gefitinib. A modified protocol in 2022 added paclitaxel, cisplatin, docetaxel, pemetrexed, and crizotinib; further modification in 2023 included 8 new antineoplastic agents and 2 anticoagulants. Sotorasib has not been prescribed in the MHS, and JPC lacks records for noncancer drugs. The 2023 dataset comprised 2210 patients with cancer treated with 14 antineoplastic agents; 2104 had documented diagnoses and 2113 had recorded prescriptions. Data for erlotinib, gefitinib, and paclitaxel have been published previously.^78,79

Results

Of 2113 patients with recorded prescriptions, 1297 patients (61.4%) received 109 cancer drugs, including 96 antineoplastics, 7 disease-modifying antirheumatic agents, 4 biologic response modifiers, and 2 calcitonin gene-related peptides. Fourteen antineoplastic agents had complete data from JPC, while others were noted for combination therapies or treatment switches from the PDTS (Table 1). Seventy-six cancer drugs were prescribed with antidepressants in 489 patients (eAppendix).

The JPC provided 2242 entries for 2210 patients, ranging in age from 2 months to 88 years (mean, 56 years), documenting treatment from September 1988 to January 2023. Thirty-two patients had duplicate entries due to multiple cancer locations or occurrences. Of the 2242 patients, 1541 (68.7%) were aged > 50 years, 975 patients (43.5%) had cancers that were stage III or IV, and 1267 (56.5%) had cancers that were stage 0, I, II, or not applicable/unknown. There were 51 different types of cancer: breast, lung, testicular, endometrial, and ovarian were most common (n ≥ 100 patients). Forty-two cancer types were documented among 750 patients prescribed antidepressants (Table 2).

The CAPER database recorded 8882 unique diagnoses for 2104 patients, while PDTS noted 1089 unique prescriptions within 273 therapeutic codes for 2113 patients. Nine therapeutic codes (opiate agonists, adrenals, cathartics-laxatives, nonsteroidal anti-inflammatory agents, antihistamines for GI conditions, 5-HT3 receptor antagonists, analgesics and antipyretic miscellanea, antineoplastic agents, and proton-pump inhibitors) and 8 drugs (dexamethasone, prochlorperazine, ondansetron, docusate, acetaminophen, ibuprofen, oxycodone, and polyethylene glycol 3350) were associated with > 1000 patients (≥ 50%). Patients had between 1 and 275 unique health conditions and filled 1 to 108 prescriptions. The mean (SD) number of diagnoses and prescriptions was 50 (28) and 29 (12), respectively. Of the 273 therapeutic codes, 30 groups were analyzed, with others categorized into miscellaneous groups such as lotions, vaccines, and devices. Significant differences in mean number of prescriptions were found for patients taking antidepressants compared to those not (P < .05), except for anticonvulsants and antipsychotics (P = .12 and .09, respectively) (Table 3).

Antidepressants

Of the 2113 patients with recorded prescriptions, 750 (35.5%) were dispensed 17 different antidepressants. Among these 17 antidepressants, 183 (8.7%) patients received duloxetine, 158 (7.5%) received venlafaxine, 118 (5.6%) received trazodone, and 107 (5.1%) received sertraline (Figure 1, Table 4). Of the 750 patients, 509 (67.9%) received 1 antidepressant, 168 (22.4%) received 2, 60 (8.0%) received 3, and 13 (1.7%) received > 3. Combinations varied, but only duloxetine and trazodone were prescribed to > 10 patients.

Antidepressants were prescribed annually at an overall mean (SD) rate of 23% (5%) from 2003 to 2022 (Figure 2). Patients on antidepressants during systemic therapy had a greater number of diagnosed medical conditions and received more prescription medications compared to those not taking antidepressants (P < .001) (Figure 3). The 745 patients taking antidepressants in CAPER data had between 1 and 275 diagnosed medical issues, with a mean (SD) of 55 (31) vs a range of 1 to 209 and a mean (SD) of 46 (26) for the 1359 patients not taking antidepressants. The 750 patients on antidepressants in PDTS data had between 8 and 108 prescriptions dispensed, with a mean (SD) of 32 (12), vs a range of 1 to 65 prescriptions and a mean (SD) of 29 (12) for 1363 patients not taking antidepressants.

Discussion

The JPC DoD Cancer Registry includes information on cancer types, stages, treatment regimens, and physicians’ notes, while noncancer drugs are sourced from the PDTS database. The pharmacy uses a different documentation system, leading to varied classifications.

Database reliance has its drawbacks. For example, megestrol is coded as a cancer drug, although it’s primarily used for endometrial or gynecologic cancers. Many drugs have multiple therapeutic codes assigned to them, including 10 antineoplastic agents: diclofenac, Bacillus Calmette-Guérin (BCG), megestrol acetate, tamoxifen, anastrozole, letrozole, leuprolide, goserelin, degarelix, and fluorouracil. Diclofenac, BCG, and mitomycin have been repurposed for cancer treatment.^84-87 From 2003 to 2023, diclofenac was prescribed to 350 patients for mild-to-moderate pain, with only 2 patients receiving it for cancer in 2018. FDA-approved for bladder cancer in 1990, BCG was prescribed for cancer treatment for 1 patient in 2021 after being used for vaccines between 2003 and 2018. Tamoxifen, used for hormone receptor-positive breast cancer from 2004 to 2017 with 53 patients, switched to estrogen agonist-antagonists from 2017 to 2023 with 123 patients. Only a few of the 168 patients were prescribed tamoxifen using both codes.^88-91 Anastrozole and letrozole were coded as antiestrogens for 7 and 18 patients, respectively, while leuprolide and goserelin were coded as gonadotropins for 59 and 18 patients. Degarelix was coded as antigonadotropins, fluorouracil as skin and mucous membrane agents miscellaneous, and megestrol acetate as progestins for 7, 6, and 3 patients, respectively. Duloxetine was given to 186 patients, primarily for depression from 2005 to 2023, with 7 patients treated for fibromyalgia from 2022 to 2023.

Antidepressants Observed

Tables 1 and 5 provide insight into the FDA approval of 14 antineoplastics and antidepressants and their CYP metabolic pathways.^92-122 In Table 4, the most prescribed antidepressant classes are SNRIs, SRMs, SSRIs, TeCAs, NDRIs, and TCAs. This trend highlights a preference for newer medications with weak CYP inhibition. A total of 349 patients were prescribed SSRIs, 343 SNRIs, 119 SRMs, 109 TCAs, 83 TeCAs, and 79 NDRIs. MAOIs, SMRAs, and NMDARAs were not observed in this dataset. While there are instances of dextromethorphan-bupropion and sertraline-escitalopram being dispensed together, it remains unclear whether these were NMDARA combinations.

Among the 14 specific antineoplastic agents, 10 are metabolized by CYP isoenzymes, primarily CYP3A4. Duloxetine neither inhibits nor is metabolized by CYP3A4, a reason it is often recommended, following venlafaxine.

Both duloxetine and venlafaxine are used off-label for chemotherapy-induced peripheral neuropathy related to paclitaxel and docetaxel. According to the CYP metabolized pathway, duloxetine tends to have more favorable DDIs than venlafaxine. In PDTS data, 371 patients were treated with paclitaxel and 180 with docetaxel, with respective antidepressant prescriptions of 156 and 70. Of the 156 patients dispensed paclitaxel, 62 (40%) were dispensed with duloxetine compared to 43 (28%) with venlafaxine. Of the 70 patients dispensed docetaxel, 23 (33%) received duloxetine vs 24 (34%) with venlafaxine.

Of 85 patients prescribed duloxetine, 75 received it with either paclitaxel or docetaxel (5 received both). Five patients had documented AEs (1 neuropathy related). Of 67 patients prescribed venlafaxine, 66 received it with either paclitaxel or docetaxel. Two patients had documented AEs (1 was neuropathy related, the same patient who received duloxetine). Of the 687 patients treated with paclitaxel and 337 with docetaxel in all databases, 4 experienced neuropathic AEs from both medications.⁷⁹

Antidepressants can increase the risk of bleeding, especially when combined with blood thinners, and may elevate blood pressure, particularly alongside stimulants. Of the 554 patients prescribed 9 different anticoagulants, enoxaparin, apixaban, and rivaroxaban were the most common (each > 100 patients). Among these, 201 patients (36%) received both anticoagulants and antidepressants: duloxetine for 64 patients, venlafaxine for 30, trazodone for 35, and sertraline for 26. There were no data available to assess bleeding rates related to the evaluation of DDIs between these medication classes.

Antidepressants can be prescribed for erectile dysfunction. Of the 148 patients prescribed an antidepressant for erectile dysfunction, duloxetine, trazodone, and mirtazapine were the most common. Antidepressant preferences varied by cancer type. Duloxetine was the only antidepressant used for all types of cancer. Venlafaxine, duloxetine, trazodone, sertraline, and escitalopram were the most prescribed antidepressants for breast cancer, while duloxetine, mirtazapine, citalopram, sertraline, and trazodone were the most prescribed for lung cancer. Sertraline, duloxetine, trazodone, amitriptyline, and escitalopram were most common for testicular cancer. Duloxetine, venlafaxine, trazodone, amitriptyline, and sertraline were the most prescribed for endometrial cancer, while duloxetine, venlafaxine, amitriptyline, citalopram, and sertraline were most prescribed for ovarian cancer.

The broadness of International Statistical Classification of Diseases, Tenth Revision codes made it challenging to identify nondepression diagnoses in the analyzed population. However, if all antidepressants were prescribed to treat depression, service members with cancer exhibited a higher depression rate (35%) than the general population (25%). Of 2104 patients, 191 (9.1%) had mood disorders, and 706 (33.6%) had mental disorders: 346 (49.0%) had 1 diagnosis, and 360 (51.0%) had multiple diagnoses. The percentage of diagnoses varied yearly, with notable drops in 2003, 2007, 2011, 2014, and 2018, and peaks in 2006, 2008, 2013, 2017, and 2022. This fluctuation was influenced by events like the establishment of PDTS in 2002, the 2008 economic recession, a hospital relocation in 2011, the 2014 Ebola outbreak, and the COVID-19 pandemic. Although the number of patients receiving antidepressants increased from 2019 to 2022, the overall percentage of patients receiving them did not significantly change from 2003 to 2022, aligning with previous research.^5,125

Many medications have potential uses beyond what is detailed in the prescribing information. Antidepressants can relieve pain, while pain medications may help with depression. Opioids were once thought to effectively treat depression, but this perspective has changed with a greater understanding of their risks, including misuse.^126-131 Pain is a severe and often unbearable AE of cancer. Of 2113 patients, 92% received opioids; 34% received both opioids and antidepressants; 2% received only antidepressants; and 7% received neither. This study didn’t clarify whether those on opioids alone recognized their depression or if those on both were aware of their dependence. While SSRIs are generally not addictive, they can lead to physical dependence, and any medication can be abused if not managed properly.^132-134

Conclusions

This retrospective study analyzes data from antineoplastic agents used in systemic cancer treatment between 1988 and 2023, with a particular focus on the use of antidepressants. Data on antidepressant prescriptions are incomplete and specific to these agents, which means the findings cannot be generalized to all antidepressants. Hence, the results indicate that patients taking antidepressants had more diagnosed health issues and received more medications compared to patients who were not on these drugs.

This study underscores the need for further research into the effects of antidepressants on cancer treatment, utilizing all data from the DoD Cancer Registry. Future research should explore DDIs between antidepressants and other cancer and noncancer medications, as this study did not assess AE documentation, unlike in studies involving erlotinib, gefitinib, and paclitaxel.^78,79 Further investigation is needed to evaluate the impact of discontinuing antidepressant use during cancer treatment. This comprehensive overview provides insights for clinicians to help them make informed decisions regarding the prescription of antidepressants in the context of cancer treatment.

Screening for colorectal cancer (CRC) with colonoscopy enables the identification and removal of CRC precursors (colonic adenomas) and has been associated with reduced risk of CRC incidence and mortality.^1-3 Furthermore, there is consensus that diet and lifestyle may be associated with forestalling CRC pathogenesis at the intermediate adenoma stages.^4-7 However, studies have shown that US veterans have poorer diet quality and a higher risk for neoplasia compared with nonveterans, reinforcing the need for tailored clinical approaches.^8,9 Combining screening with conversations about modifiable environmental and lifestyle risk factors, such as poor diet, is a highly relevant and possibly easily leveraged prevention for those at high risk. However, there is limited evidence for any particular dietary patterns or dietary features that are most important over time.⁷

Several dietary components have been shown to be associated with CRC risk,10 either as potentially chemopreventive (fiber, fruits and vegetables,¹¹ dairy,¹² supplemental vitamin D,¹³ calcium,¹⁴ and multivitamins¹⁵) or carcinogenic (red meat¹⁶ and alcohol¹⁷). Previous studies of veterans have similarly shown that higher intake of fiber and vitamin D reduced risk, and red meat is associated with an increased risk for finding CRC precursors during colonoscopy.¹⁸ However, these dietary categories are often analyzed in isolation. Studying healthy dietary patterns in aggregate may be more clinically relevant and easier to implement for prevention of CRC and its precursors.^19-21 Healthy dietary patterns, such as the US Dietary Guidelines for Americans represented by the Healthy Eating Index (HEI), the Mediterranean diet (MD), and the Dietary Approaches to Stop Hypertension (DASH) diet, have been associated with lower risk for chronic disease.^22-24 Despite the extant literature, no known studies have compared these dietary patterns for associations with risk of CRC precursor or CRC development among US veterans undergoing long-term screening and follow-up after a baseline colonoscopy.

The objective of this study was to test for associations between baseline scores of healthy dietary patterns and the most severe colonoscopy findings (MSCFs) over ≥ 10 years following a baseline screening colonoscopy in veterans.

Methods

Participants in the Cooperative Studies Program (CSP) #380 cohort study included 3121 asymptomatic veterans aged 50 to 75 years at baseline who had consented to initial screening colonoscopy between 1994 and 1997, with subsequent follow-up and surveillance.²⁵ Prior to their colonoscopy, all participants completed a baseline study survey that included questions about cancer risk factors including family history of CRC, diet, physical activity, and medication use.

Included in this cross-sectional analysis were data from a sample of veteran participants of the CSP #380 cohort with 1 baseline colonoscopy, follow-up surveillance through 2009, a cancer risk factor survey collected at baseline, and complete demographic and clinical indicator data. Excluded from the analysis were 67 participants with insufficient responses to the dietary food frequency questionnaire (FFQ) and 31 participants with missing body mass index (BMI), 3023 veterans.

Measures

MSCF. The outcome of interest in this study was the MSCF recorded across all participant colonoscopies during the study period. MSCF was categorized as either (1) no neoplasia; (2) < 2 nonadvanced adenomas, including small adenomas (diameter < 10 mm) with tubular histology; or (3) advanced neoplasia (AN), which is characterized by adenomas > 10 mm in diameter, with villous histology, with high-grade dysplasia, or CRC.

Dietary patterns. Dietary pattern scores representing dietary quality and calculated based on recommendations of the US Dietary Guidelines for Americans using the HEI, MD, and DASH diets were independent variables.^26-28 These 3 dietary patterns were chosen for their hypothesized relationship with CRC risk, but each weighs food categories differently (Appendix 1).^22-24,29 Dietary pattern scores were calculated using the CSP #380 self-reported responses to 129 baseline survey questions adapted from a well-established and previously validated semiquantitative FFQ.³⁰ The form was administered by mail twice to a sample of 127 participants at baseline and at 1 year. During this interval, men completed 1-week diet records twice, spaced about 6 months apart. Mean values for intake of most nutrients assessed by the 2 methods were similar. Intraclass correlation coefficients for the baseline and 1-year FFQ-assessed nutrient intakes that ranged from 0.47 for vitamin E (without supplements) to 0.80 for vitamin C (with supplements). Correlation coefficients between the energy-adjusted nutrient intakes were measured by diet records and the 1-year FFQ, which asked about diet during the year encompassing the diet records. Higher raw and percent scores indicated better alignment with recommendations from each respective dietary pattern. Percent scores were calculated as a standardizing method and used in analyses for ease of comparing the dietary patterns. Scoring can be found in Appendix 2.

Demographic characteristics and clinical indicators. Demographic characteristics included age categories, sex, and race/ethnicity. Clinical indicators included BMI, the number of comorbid conditions used to calculate the Charlson Comorbidity Index, family history of CRC in first-degree relatives, number of follow-up colonoscopies across the study period, and food-based vitamin D intake.³¹ These variables were chosen for their applicability found in previous CSP #380 cohort studies.^18,32,33 Self-reported race and ethnicity were collapsed due to small numbers in some groups. The authors acknowledge these are distinct concepts and the variable has limited utility other than for controlling for systemic racism in the model.

Statistical Analyses

Descriptive statistics were used to describe distributional assumptions for all variables, including demographics, clinical indicators, colonoscopy results, and dietary patterns. Pairwise correlations between the total dietary pattern scores and food category scores were calculated with Pearson correlation (r).

Multinomial logistic regression models were created using SAS procedure LOGISTIC with the outcome of the categorical MSCF (no neoplasia, nonadvanced adenoma, or AN).³⁴ A model was created for each independent predictor variable of interest (ie, the HEI, MD, or DASH percentage-standardized dietary pattern score and each food category comprising each dietary pattern score). All models were adjusted for age, sex, race/ethnicity, BMI, number of comorbidities, family history of CRC, number of follow-up colonoscopies, and estimated daily food-derived vitamin D intake. The demographic and clinical indicators were included in the models as they are known to be associated with CRC risk.¹⁸ The number of colonoscopies was included to control for surveillance intensity presuming risk for AN is reduced as polyps are removed. Because colonoscopy findings from an initial screening have unique clinical implications compared with follow- up and surveillance, MSCF was observed in 2 ways in sensitivity analyses: (1) baseline and (2) aggregate follow-up and surveillance only, excluding baseline findings.

Adjusted odds ratios (aORs) and 95% CIs for each of the MSCF outcomes with a reference finding of no neoplasia for the models are presented. We chose not to adjust for multiple comparisons across the different dietary patterns given the correlation between dietary pattern total and category scores but did adjust for multiple comparisons for dietary categories within each dietary pattern. Tests for statistical significance used α= .05 for the dietary pattern total scores and P values for the dietary category scores for each dietary pattern controlled for false discovery rate using the MULTTEST SAS procedure.35 All data manipulations and analyses were performed using SAS version 9.4.

Results

The study included 3023 patients. All were aged 50 to 75 years, 2923 (96.7%) were male and 2532 (83.8%) were non-Hispanic White (Table 1). Most participants were overweight or obese (n = 2535 [83.8%]), 2024 (67.0%) had ≤ 2 comorbidities, and 2602 (86.1%) had no family history of CRC. The MSCF for 1628 patients (53.9%) was no neoplasia, 966 patients (32.0%) was nonadvanced adenoma, and 429 participants (14.2%) had AN.

Mean percent scores were 58.5% for HEI, 38.2% for MD, and 63.1% for the DASH diet, with higher percentages indicating greater alignment with the recommendations for each diet (Table 2). All 3 dietary patterns scores standardized to percentages were strongly and significantly correlated in pairwise comparisons: HEI:MD, r = 0.62 (P < .001); HEI:DASH, r = 0.60 (P < .001); and MD:DASH, r = 0.72 (P < .001). Likewise, food category scores were significantly correlated across dietary patterns. For example, whole grain and fiber values from each dietary score were strongly correlated in pairwise comparisons: HEI Whole Grain:MD Grain, r = 0.64 (P < .001); HEI Whole Grain:DASH Fiber, r = 0.71 (P < .001); and MD Grain:DASH Fiber, r = 0.70 (P < .001).

Associations between individual participants' dietary pattern scores and the outcome of their pooled MSCF from baseline screening and ≥ 10 years of surveillance are presented in Table 3. For each single-point increases in dietary pattern scores (reflecting better dietary quality), aORs for nonadvanced adenoma vs no neoplasia were slightly lower but not statistically significantly: HEI, aOR, 1.00 (95% CI, 0.99-1.01); MD, aOR, 0.98 (95% CI, 0.94-1.02); and DASH, aOR, 0.99 (95% CI, 0.99-1.00). aORs for AN vs no neoplasia were slightly lower for each dietary pattern assessed, and only the MD and DASH scores were significantly different from 1.00: HEI, aOR, 1.00 (95% CI, 0.99-1.01); MD, aOR, 0.95 (95% CI, 0.90-1.00); and DASH, aOR, 0.99 (95% CI, 0.98-1.00).

We observed lower odds for nonadvanced adenoma and AN among all these dietary patterns when there was greater alignment with the recommended intake of whole grains and fiber. In separate models conducted using food categories comprising the dietary patterns as independent variables and after correcting for multiple tests, higher scores for the HEI Refined Grain category were associated with higher odds for nonadvanced adenoma (aOR, 1.03 [95% CI, 1.01-1.05]; P = .01) and AN (aOR, 1.05 [95% CI, 1.02-1.08]; P < .001). Higher scores for the HEI Whole Grain category were associated with lower odds for nonadvanced adenoma (aOR, 0.97 [95% CI, 0.95-0.99]; P = .01) and AN (aOR, 0.96 [95% CI, 0.93-0.99]; P = .01). Higher scores for the MD Grain category were significantly associated with lower odds for nonadvanced adenoma (aOR, 0.44 [95% CI, 0.26-0.75]; P = .002) and AN (aOR, 0.29 [95% CI, 0.14-0.62]; P = .001). The DASH Grains category also was significantly associated with lower odds for AN (aOR, 0.86 [95% CI, 0.78-0.95]; P = .002).

Discussion

In this study of 3023 veterans undergoing first-time screening colonoscopy and ≥ 10 years of surveillance, we found that healthy dietary patterns, as assessed by the MD and DASH diet, were significantly associated with lower risk of AN. Additionally, we identified lower odds for AN and nonadvanced adenoma compared with no neoplasia for higher grain scores for all the dietary patterns studied. Other food categories that comprise the dietary pattern scores had mixed associations with the MSCF outcomes. Several other studies have examined associations between dietary patterns and risk for CRC but to our knowledge, no studies have explored these associations among US veterans.

These results also indicate study participants had better than average (based on a 50% threshold) dietary quality according to the HEI and DASH diet scoring methods we used, but poor dietary quality according to the MD scoring method. The mean HEI scores for the present study were higher than a US Department of Agriculture study by Dong et al that compared dietary quality between veterans and nonveterans using the HEI, for which veterans’ expected HEI score was 45.6 of 100.⁸ This could be explained by the fact that the participants needed to be healthy to be eligible and those with healthier behaviors overall may have self-selected into the study due to motivation for screening during a time when screening was not yet commonplace. ³⁶ Similarly, participants of the present study had higher adherence to the DASH diet (63.1%) than adolescents with diabetes in a study by Günther et al. Conversely, firefighters who were coached to use a Mediterranean-style dietary pattern and dietary had higher adherence to MD than did participants in this study.²⁷

A closer examination of specific food category component scores that comprise the 3 distinct dietary patterns revealed mixed results from the multinomial modeling, which may have to do with the guideline thresholds used to calculate the dietary scores. When analyzed separately in the logistic regression models for their associations with nonadvanced adenomas and AN compared with no neoplasia, higher MD and DASH fruit scores (but not HEI fruit scores) were found to be significant. Other studies have had mixed findings when attempting to test for associations of fruit intake with adenoma recurrence.^10,37

This study had some unexpected findings. Vegetable intake was not associated with nonadvanced adenomas or AN risk. Studies of food categories have consistently found vegetable (specifically cruciferous ones) intake to be linked with lower odds for cancers.³⁸ Likewise, the red meat category, which was only a unique food category in the MD score, was not associated with nonadvanced adenomas or AN. Despite consistent literature suggesting higher intake of red meat and processed meats increases CRC risk, in 2019 the Nutritional Recommendations Consortium indicated that the evidence was weak.^39,40 This study showed higher DASH diet scores for low-fat dairy, which were maximized when participants reported at least 50% of their dairy servings per day as being low-fat, had lower odds for AN. Yet, the MD scores for low-fat dairy had no association with either outcome; their calculation was based on total number of servings per week. This difference in findings suggests the fat intake ratio may be more relevant to CRC risk than intake quantity.

The literature is mixed regarding fatty acid intake and CRC risk, which may be relevant to both dairy and meat intake. One systematic review and meta-analysis found dietary fat and types of fatty acid intake had no association with CRC risk.⁴¹ However, a more recent meta-analysis that assessed both dietary intake and plasma levels of fatty acids did find some statistically significant differences for various types of fatty acids and CRC risk.⁴²

The findings in the present study that grain intake is associated with lower odds for more severe colonoscopy findings among veterans are notable.⁴³ Lieberman et al, using the CSP #380 data, found that cereal fiber intake was associated with a lower odds for AN compared with hyperplastic polyps (OR, 0.98 [95% CI, 0.96- 1.00]).¹⁸ Similarly, Hullings et al determined that older adults in the highest quintile of cereal fiber intake had significantly lower odds of CRC than those in lower odds for CRC when compared with lowest quintile (OR, 0.89 [95% CI, 0.83- 0.96]; P < .001).⁴⁴ These findings support existing guidance that prioritizes whole grains as a key source of dietary fiber for CRC prevention.

A recent literature review on fiber, fat, and CRC risk suggested a consensus regarding one protective mechanism: dietary fiber from grains modulates the gut microbiota by promoting butyrate synthesis.⁴⁵ Butyrate is a short-chain fatty acid that supports energy production in colonocytes and has tumor-suppressing properties.⁴⁶ Our findings suggest there could be more to learn about the relationship between butyrate production and reduction of CRC risk through metabolomic studies that use measurements of plasma butyrate. These studies may examine associations between not just a singular food or food category, but rather food patterns that include fruits, vegetables, nuts and seeds, and whole grains known to promote butyrate production and plasma butyrate.⁴⁷

Improved understanding of mechanisms and risk-modifying lifestyle factors such as dietary patterns may enhance prevention strategies. Identifying the collective chemopreventive characteristics of a specific dietary pattern (eg, MD) will be helpful to clinicians and health care staff to promote healthy eating to reduce cancer risk. More studies are needed to understand whether such promotion is more clinically applicable and effective for patients, as compared with eating more or less of specific foods (eg, more whole grains, less red meat). Furthermore, considering important environmental factors collectively beyond dietary patterns may offer a way to better tailor screening and implement a variety of lifestyle interventions. In the literature, this is often referred to as a teachable moment when patients’ attentions are captured and may position them to be more receptive to guidance.⁴⁸

Limitations

This study has several important limitations and leaves opportunities for future studies that explore the role of dietary patterns and AN or CRC risk. First, the FFQ data used to calculate dietary pattern scores used in analysis were only captured at baseline, and there are nearly 3 decades across the study period. However, it is widely assumed that the diets of older adults, like those included in this study, remain stable over time which is appropriate given our sample population was aged 50 to 75 years when the baseline FFQ data were collected.^49-51 Additionally, while the HEI is a well-documented, standard scoring method for dietary quality, there are multitudes of dietary pattern scoring approaches for MD and DASH.^23,52,53 Finally, findings from this study using the sample of veterans may not be generalizable to a broader population. Future longitudinal studies that test for a clinically significant change threshold are warranted.

Conclusion

Results of this study suggest future research should further explore the effects of dietary patterns, particularly intake of specific food groups in combination, as opposed to individual nutrients or food items, on AN and CRC risk. Possible studies might explore these dietary patterns for their mechanistic role in altering the microbiome metabolism, which may influence CRC outcomes or include diet in a more comprehensive, holistic risk score that could be used to predict colonic neoplasia risk or in intervention studies that assess the effects of dietary changes on long-term CRC prevention. We suggest there are differences in people’s dietary intake patterns that might be important to consider when implementing tailored approaches to CRC risk mitigation.

Screening for colorectal cancer (CRC) with colonoscopy enables the identification and removal of CRC precursors (colonic adenomas) and has been associated with reduced risk of CRC incidence and mortality.^1-3 Furthermore, there is consensus that diet and lifestyle may be associated with forestalling CRC pathogenesis at the intermediate adenoma stages.^4-7 However, studies have shown that US veterans have poorer diet quality and a higher risk for neoplasia compared with nonveterans, reinforcing the need for tailored clinical approaches.^8,9 Combining screening with conversations about modifiable environmental and lifestyle risk factors, such as poor diet, is a highly relevant and possibly easily leveraged prevention for those at high risk. However, there is limited evidence for any particular dietary patterns or dietary features that are most important over time.⁷

Several dietary components have been shown to be associated with CRC risk,10 either as potentially chemopreventive (fiber, fruits and vegetables,¹¹ dairy,¹² supplemental vitamin D,¹³ calcium,¹⁴ and multivitamins¹⁵) or carcinogenic (red meat¹⁶ and alcohol¹⁷). Previous studies of veterans have similarly shown that higher intake of fiber and vitamin D reduced risk, and red meat is associated with an increased risk for finding CRC precursors during colonoscopy.¹⁸ However, these dietary categories are often analyzed in isolation. Studying healthy dietary patterns in aggregate may be more clinically relevant and easier to implement for prevention of CRC and its precursors.^19-21 Healthy dietary patterns, such as the US Dietary Guidelines for Americans represented by the Healthy Eating Index (HEI), the Mediterranean diet (MD), and the Dietary Approaches to Stop Hypertension (DASH) diet, have been associated with lower risk for chronic disease.^22-24 Despite the extant literature, no known studies have compared these dietary patterns for associations with risk of CRC precursor or CRC development among US veterans undergoing long-term screening and follow-up after a baseline colonoscopy.

The objective of this study was to test for associations between baseline scores of healthy dietary patterns and the most severe colonoscopy findings (MSCFs) over ≥ 10 years following a baseline screening colonoscopy in veterans.

Methods

Participants in the Cooperative Studies Program (CSP) #380 cohort study included 3121 asymptomatic veterans aged 50 to 75 years at baseline who had consented to initial screening colonoscopy between 1994 and 1997, with subsequent follow-up and surveillance.²⁵ Prior to their colonoscopy, all participants completed a baseline study survey that included questions about cancer risk factors including family history of CRC, diet, physical activity, and medication use.

Included in this cross-sectional analysis were data from a sample of veteran participants of the CSP #380 cohort with 1 baseline colonoscopy, follow-up surveillance through 2009, a cancer risk factor survey collected at baseline, and complete demographic and clinical indicator data. Excluded from the analysis were 67 participants with insufficient responses to the dietary food frequency questionnaire (FFQ) and 31 participants with missing body mass index (BMI), 3023 veterans.

Measures

MSCF. The outcome of interest in this study was the MSCF recorded across all participant colonoscopies during the study period. MSCF was categorized as either (1) no neoplasia; (2) < 2 nonadvanced adenomas, including small adenomas (diameter < 10 mm) with tubular histology; or (3) advanced neoplasia (AN), which is characterized by adenomas > 10 mm in diameter, with villous histology, with high-grade dysplasia, or CRC.

Dietary patterns. Dietary pattern scores representing dietary quality and calculated based on recommendations of the US Dietary Guidelines for Americans using the HEI, MD, and DASH diets were independent variables.^26-28 These 3 dietary patterns were chosen for their hypothesized relationship with CRC risk, but each weighs food categories differently (Appendix 1).^22-24,29 Dietary pattern scores were calculated using the CSP #380 self-reported responses to 129 baseline survey questions adapted from a well-established and previously validated semiquantitative FFQ.³⁰ The form was administered by mail twice to a sample of 127 participants at baseline and at 1 year. During this interval, men completed 1-week diet records twice, spaced about 6 months apart. Mean values for intake of most nutrients assessed by the 2 methods were similar. Intraclass correlation coefficients for the baseline and 1-year FFQ-assessed nutrient intakes that ranged from 0.47 for vitamin E (without supplements) to 0.80 for vitamin C (with supplements). Correlation coefficients between the energy-adjusted nutrient intakes were measured by diet records and the 1-year FFQ, which asked about diet during the year encompassing the diet records. Higher raw and percent scores indicated better alignment with recommendations from each respective dietary pattern. Percent scores were calculated as a standardizing method and used in analyses for ease of comparing the dietary patterns. Scoring can be found in Appendix 2.

Demographic characteristics and clinical indicators. Demographic characteristics included age categories, sex, and race/ethnicity. Clinical indicators included BMI, the number of comorbid conditions used to calculate the Charlson Comorbidity Index, family history of CRC in first-degree relatives, number of follow-up colonoscopies across the study period, and food-based vitamin D intake.³¹ These variables were chosen for their applicability found in previous CSP #380 cohort studies.^18,32,33 Self-reported race and ethnicity were collapsed due to small numbers in some groups. The authors acknowledge these are distinct concepts and the variable has limited utility other than for controlling for systemic racism in the model.

Statistical Analyses

Descriptive statistics were used to describe distributional assumptions for all variables, including demographics, clinical indicators, colonoscopy results, and dietary patterns. Pairwise correlations between the total dietary pattern scores and food category scores were calculated with Pearson correlation (r).

Multinomial logistic regression models were created using SAS procedure LOGISTIC with the outcome of the categorical MSCF (no neoplasia, nonadvanced adenoma, or AN).³⁴ A model was created for each independent predictor variable of interest (ie, the HEI, MD, or DASH percentage-standardized dietary pattern score and each food category comprising each dietary pattern score). All models were adjusted for age, sex, race/ethnicity, BMI, number of comorbidities, family history of CRC, number of follow-up colonoscopies, and estimated daily food-derived vitamin D intake. The demographic and clinical indicators were included in the models as they are known to be associated with CRC risk.¹⁸ The number of colonoscopies was included to control for surveillance intensity presuming risk for AN is reduced as polyps are removed. Because colonoscopy findings from an initial screening have unique clinical implications compared with follow- up and surveillance, MSCF was observed in 2 ways in sensitivity analyses: (1) baseline and (2) aggregate follow-up and surveillance only, excluding baseline findings.

Adjusted odds ratios (aORs) and 95% CIs for each of the MSCF outcomes with a reference finding of no neoplasia for the models are presented. We chose not to adjust for multiple comparisons across the different dietary patterns given the correlation between dietary pattern total and category scores but did adjust for multiple comparisons for dietary categories within each dietary pattern. Tests for statistical significance used α= .05 for the dietary pattern total scores and P values for the dietary category scores for each dietary pattern controlled for false discovery rate using the MULTTEST SAS procedure.35 All data manipulations and analyses were performed using SAS version 9.4.

Results

The study included 3023 patients. All were aged 50 to 75 years, 2923 (96.7%) were male and 2532 (83.8%) were non-Hispanic White (Table 1). Most participants were overweight or obese (n = 2535 [83.8%]), 2024 (67.0%) had ≤ 2 comorbidities, and 2602 (86.1%) had no family history of CRC. The MSCF for 1628 patients (53.9%) was no neoplasia, 966 patients (32.0%) was nonadvanced adenoma, and 429 participants (14.2%) had AN.

Mean percent scores were 58.5% for HEI, 38.2% for MD, and 63.1% for the DASH diet, with higher percentages indicating greater alignment with the recommendations for each diet (Table 2). All 3 dietary patterns scores standardized to percentages were strongly and significantly correlated in pairwise comparisons: HEI:MD, r = 0.62 (P < .001); HEI:DASH, r = 0.60 (P < .001); and MD:DASH, r = 0.72 (P < .001). Likewise, food category scores were significantly correlated across dietary patterns. For example, whole grain and fiber values from each dietary score were strongly correlated in pairwise comparisons: HEI Whole Grain:MD Grain, r = 0.64 (P < .001); HEI Whole Grain:DASH Fiber, r = 0.71 (P < .001); and MD Grain:DASH Fiber, r = 0.70 (P < .001).

Associations between individual participants' dietary pattern scores and the outcome of their pooled MSCF from baseline screening and ≥ 10 years of surveillance are presented in Table 3. For each single-point increases in dietary pattern scores (reflecting better dietary quality), aORs for nonadvanced adenoma vs no neoplasia were slightly lower but not statistically significantly: HEI, aOR, 1.00 (95% CI, 0.99-1.01); MD, aOR, 0.98 (95% CI, 0.94-1.02); and DASH, aOR, 0.99 (95% CI, 0.99-1.00). aORs for AN vs no neoplasia were slightly lower for each dietary pattern assessed, and only the MD and DASH scores were significantly different from 1.00: HEI, aOR, 1.00 (95% CI, 0.99-1.01); MD, aOR, 0.95 (95% CI, 0.90-1.00); and DASH, aOR, 0.99 (95% CI, 0.98-1.00).

We observed lower odds for nonadvanced adenoma and AN among all these dietary patterns when there was greater alignment with the recommended intake of whole grains and fiber. In separate models conducted using food categories comprising the dietary patterns as independent variables and after correcting for multiple tests, higher scores for the HEI Refined Grain category were associated with higher odds for nonadvanced adenoma (aOR, 1.03 [95% CI, 1.01-1.05]; P = .01) and AN (aOR, 1.05 [95% CI, 1.02-1.08]; P < .001). Higher scores for the HEI Whole Grain category were associated with lower odds for nonadvanced adenoma (aOR, 0.97 [95% CI, 0.95-0.99]; P = .01) and AN (aOR, 0.96 [95% CI, 0.93-0.99]; P = .01). Higher scores for the MD Grain category were significantly associated with lower odds for nonadvanced adenoma (aOR, 0.44 [95% CI, 0.26-0.75]; P = .002) and AN (aOR, 0.29 [95% CI, 0.14-0.62]; P = .001). The DASH Grains category also was significantly associated with lower odds for AN (aOR, 0.86 [95% CI, 0.78-0.95]; P = .002).

Discussion

In this study of 3023 veterans undergoing first-time screening colonoscopy and ≥ 10 years of surveillance, we found that healthy dietary patterns, as assessed by the MD and DASH diet, were significantly associated with lower risk of AN. Additionally, we identified lower odds for AN and nonadvanced adenoma compared with no neoplasia for higher grain scores for all the dietary patterns studied. Other food categories that comprise the dietary pattern scores had mixed associations with the MSCF outcomes. Several other studies have examined associations between dietary patterns and risk for CRC but to our knowledge, no studies have explored these associations among US veterans.

These results also indicate study participants had better than average (based on a 50% threshold) dietary quality according to the HEI and DASH diet scoring methods we used, but poor dietary quality according to the MD scoring method. The mean HEI scores for the present study were higher than a US Department of Agriculture study by Dong et al that compared dietary quality between veterans and nonveterans using the HEI, for which veterans’ expected HEI score was 45.6 of 100.⁸ This could be explained by the fact that the participants needed to be healthy to be eligible and those with healthier behaviors overall may have self-selected into the study due to motivation for screening during a time when screening was not yet commonplace. ³⁶ Similarly, participants of the present study had higher adherence to the DASH diet (63.1%) than adolescents with diabetes in a study by Günther et al. Conversely, firefighters who were coached to use a Mediterranean-style dietary pattern and dietary had higher adherence to MD than did participants in this study.²⁷

A closer examination of specific food category component scores that comprise the 3 distinct dietary patterns revealed mixed results from the multinomial modeling, which may have to do with the guideline thresholds used to calculate the dietary scores. When analyzed separately in the logistic regression models for their associations with nonadvanced adenomas and AN compared with no neoplasia, higher MD and DASH fruit scores (but not HEI fruit scores) were found to be significant. Other studies have had mixed findings when attempting to test for associations of fruit intake with adenoma recurrence.^10,37

This study had some unexpected findings. Vegetable intake was not associated with nonadvanced adenomas or AN risk. Studies of food categories have consistently found vegetable (specifically cruciferous ones) intake to be linked with lower odds for cancers.³⁸ Likewise, the red meat category, which was only a unique food category in the MD score, was not associated with nonadvanced adenomas or AN. Despite consistent literature suggesting higher intake of red meat and processed meats increases CRC risk, in 2019 the Nutritional Recommendations Consortium indicated that the evidence was weak.^39,40 This study showed higher DASH diet scores for low-fat dairy, which were maximized when participants reported at least 50% of their dairy servings per day as being low-fat, had lower odds for AN. Yet, the MD scores for low-fat dairy had no association with either outcome; their calculation was based on total number of servings per week. This difference in findings suggests the fat intake ratio may be more relevant to CRC risk than intake quantity.

The literature is mixed regarding fatty acid intake and CRC risk, which may be relevant to both dairy and meat intake. One systematic review and meta-analysis found dietary fat and types of fatty acid intake had no association with CRC risk.⁴¹ However, a more recent meta-analysis that assessed both dietary intake and plasma levels of fatty acids did find some statistically significant differences for various types of fatty acids and CRC risk.⁴²

The findings in the present study that grain intake is associated with lower odds for more severe colonoscopy findings among veterans are notable.⁴³ Lieberman et al, using the CSP #380 data, found that cereal fiber intake was associated with a lower odds for AN compared with hyperplastic polyps (OR, 0.98 [95% CI, 0.96- 1.00]).¹⁸ Similarly, Hullings et al determined that older adults in the highest quintile of cereal fiber intake had significantly lower odds of CRC than those in lower odds for CRC when compared with lowest quintile (OR, 0.89 [95% CI, 0.83- 0.96]; P < .001).⁴⁴ These findings support existing guidance that prioritizes whole grains as a key source of dietary fiber for CRC prevention.

A recent literature review on fiber, fat, and CRC risk suggested a consensus regarding one protective mechanism: dietary fiber from grains modulates the gut microbiota by promoting butyrate synthesis.⁴⁵ Butyrate is a short-chain fatty acid that supports energy production in colonocytes and has tumor-suppressing properties.⁴⁶ Our findings suggest there could be more to learn about the relationship between butyrate production and reduction of CRC risk through metabolomic studies that use measurements of plasma butyrate. These studies may examine associations between not just a singular food or food category, but rather food patterns that include fruits, vegetables, nuts and seeds, and whole grains known to promote butyrate production and plasma butyrate.⁴⁷

Improved understanding of mechanisms and risk-modifying lifestyle factors such as dietary patterns may enhance prevention strategies. Identifying the collective chemopreventive characteristics of a specific dietary pattern (eg, MD) will be helpful to clinicians and health care staff to promote healthy eating to reduce cancer risk. More studies are needed to understand whether such promotion is more clinically applicable and effective for patients, as compared with eating more or less of specific foods (eg, more whole grains, less red meat). Furthermore, considering important environmental factors collectively beyond dietary patterns may offer a way to better tailor screening and implement a variety of lifestyle interventions. In the literature, this is often referred to as a teachable moment when patients’ attentions are captured and may position them to be more receptive to guidance.⁴⁸

Limitations

This study has several important limitations and leaves opportunities for future studies that explore the role of dietary patterns and AN or CRC risk. First, the FFQ data used to calculate dietary pattern scores used in analysis were only captured at baseline, and there are nearly 3 decades across the study period. However, it is widely assumed that the diets of older adults, like those included in this study, remain stable over time which is appropriate given our sample population was aged 50 to 75 years when the baseline FFQ data were collected.^49-51 Additionally, while the HEI is a well-documented, standard scoring method for dietary quality, there are multitudes of dietary pattern scoring approaches for MD and DASH.^23,52,53 Finally, findings from this study using the sample of veterans may not be generalizable to a broader population. Future longitudinal studies that test for a clinically significant change threshold are warranted.

Conclusion

Results of this study suggest future research should further explore the effects of dietary patterns, particularly intake of specific food groups in combination, as opposed to individual nutrients or food items, on AN and CRC risk. Possible studies might explore these dietary patterns for their mechanistic role in altering the microbiome metabolism, which may influence CRC outcomes or include diet in a more comprehensive, holistic risk score that could be used to predict colonic neoplasia risk or in intervention studies that assess the effects of dietary changes on long-term CRC prevention. We suggest there are differences in people’s dietary intake patterns that might be important to consider when implementing tailored approaches to CRC risk mitigation.

Screening for colorectal cancer (CRC) with colonoscopy enables the identification and removal of CRC precursors (colonic adenomas) and has been associated with reduced risk of CRC incidence and mortality.^1-3 Furthermore, there is consensus that diet and lifestyle may be associated with forestalling CRC pathogenesis at the intermediate adenoma stages.^4-7 However, studies have shown that US veterans have poorer diet quality and a higher risk for neoplasia compared with nonveterans, reinforcing the need for tailored clinical approaches.^8,9 Combining screening with conversations about modifiable environmental and lifestyle risk factors, such as poor diet, is a highly relevant and possibly easily leveraged prevention for those at high risk. However, there is limited evidence for any particular dietary patterns or dietary features that are most important over time.⁷

Several dietary components have been shown to be associated with CRC risk,10 either as potentially chemopreventive (fiber, fruits and vegetables,¹¹ dairy,¹² supplemental vitamin D,¹³ calcium,¹⁴ and multivitamins¹⁵) or carcinogenic (red meat¹⁶ and alcohol¹⁷). Previous studies of veterans have similarly shown that higher intake of fiber and vitamin D reduced risk, and red meat is associated with an increased risk for finding CRC precursors during colonoscopy.¹⁸ However, these dietary categories are often analyzed in isolation. Studying healthy dietary patterns in aggregate may be more clinically relevant and easier to implement for prevention of CRC and its precursors.^19-21 Healthy dietary patterns, such as the US Dietary Guidelines for Americans represented by the Healthy Eating Index (HEI), the Mediterranean diet (MD), and the Dietary Approaches to Stop Hypertension (DASH) diet, have been associated with lower risk for chronic disease.^22-24 Despite the extant literature, no known studies have compared these dietary patterns for associations with risk of CRC precursor or CRC development among US veterans undergoing long-term screening and follow-up after a baseline colonoscopy.

The objective of this study was to test for associations between baseline scores of healthy dietary patterns and the most severe colonoscopy findings (MSCFs) over ≥ 10 years following a baseline screening colonoscopy in veterans.

Methods

Participants in the Cooperative Studies Program (CSP) #380 cohort study included 3121 asymptomatic veterans aged 50 to 75 years at baseline who had consented to initial screening colonoscopy between 1994 and 1997, with subsequent follow-up and surveillance.²⁵ Prior to their colonoscopy, all participants completed a baseline study survey that included questions about cancer risk factors including family history of CRC, diet, physical activity, and medication use.

Included in this cross-sectional analysis were data from a sample of veteran participants of the CSP #380 cohort with 1 baseline colonoscopy, follow-up surveillance through 2009, a cancer risk factor survey collected at baseline, and complete demographic and clinical indicator data. Excluded from the analysis were 67 participants with insufficient responses to the dietary food frequency questionnaire (FFQ) and 31 participants with missing body mass index (BMI), 3023 veterans.

Measures

MSCF. The outcome of interest in this study was the MSCF recorded across all participant colonoscopies during the study period. MSCF was categorized as either (1) no neoplasia; (2) < 2 nonadvanced adenomas, including small adenomas (diameter < 10 mm) with tubular histology; or (3) advanced neoplasia (AN), which is characterized by adenomas > 10 mm in diameter, with villous histology, with high-grade dysplasia, or CRC.

Dietary patterns. Dietary pattern scores representing dietary quality and calculated based on recommendations of the US Dietary Guidelines for Americans using the HEI, MD, and DASH diets were independent variables.^26-28 These 3 dietary patterns were chosen for their hypothesized relationship with CRC risk, but each weighs food categories differently (Appendix 1).^22-24,29 Dietary pattern scores were calculated using the CSP #380 self-reported responses to 129 baseline survey questions adapted from a well-established and previously validated semiquantitative FFQ.³⁰ The form was administered by mail twice to a sample of 127 participants at baseline and at 1 year. During this interval, men completed 1-week diet records twice, spaced about 6 months apart. Mean values for intake of most nutrients assessed by the 2 methods were similar. Intraclass correlation coefficients for the baseline and 1-year FFQ-assessed nutrient intakes that ranged from 0.47 for vitamin E (without supplements) to 0.80 for vitamin C (with supplements). Correlation coefficients between the energy-adjusted nutrient intakes were measured by diet records and the 1-year FFQ, which asked about diet during the year encompassing the diet records. Higher raw and percent scores indicated better alignment with recommendations from each respective dietary pattern. Percent scores were calculated as a standardizing method and used in analyses for ease of comparing the dietary patterns. Scoring can be found in Appendix 2.

Demographic characteristics and clinical indicators. Demographic characteristics included age categories, sex, and race/ethnicity. Clinical indicators included BMI, the number of comorbid conditions used to calculate the Charlson Comorbidity Index, family history of CRC in first-degree relatives, number of follow-up colonoscopies across the study period, and food-based vitamin D intake.³¹ These variables were chosen for their applicability found in previous CSP #380 cohort studies.^18,32,33 Self-reported race and ethnicity were collapsed due to small numbers in some groups. The authors acknowledge these are distinct concepts and the variable has limited utility other than for controlling for systemic racism in the model.

Statistical Analyses

Descriptive statistics were used to describe distributional assumptions for all variables, including demographics, clinical indicators, colonoscopy results, and dietary patterns. Pairwise correlations between the total dietary pattern scores and food category scores were calculated with Pearson correlation (r).

Multinomial logistic regression models were created using SAS procedure LOGISTIC with the outcome of the categorical MSCF (no neoplasia, nonadvanced adenoma, or AN).³⁴ A model was created for each independent predictor variable of interest (ie, the HEI, MD, or DASH percentage-standardized dietary pattern score and each food category comprising each dietary pattern score). All models were adjusted for age, sex, race/ethnicity, BMI, number of comorbidities, family history of CRC, number of follow-up colonoscopies, and estimated daily food-derived vitamin D intake. The demographic and clinical indicators were included in the models as they are known to be associated with CRC risk.¹⁸ The number of colonoscopies was included to control for surveillance intensity presuming risk for AN is reduced as polyps are removed. Because colonoscopy findings from an initial screening have unique clinical implications compared with follow- up and surveillance, MSCF was observed in 2 ways in sensitivity analyses: (1) baseline and (2) aggregate follow-up and surveillance only, excluding baseline findings.

Adjusted odds ratios (aORs) and 95% CIs for each of the MSCF outcomes with a reference finding of no neoplasia for the models are presented. We chose not to adjust for multiple comparisons across the different dietary patterns given the correlation between dietary pattern total and category scores but did adjust for multiple comparisons for dietary categories within each dietary pattern. Tests for statistical significance used α= .05 for the dietary pattern total scores and P values for the dietary category scores for each dietary pattern controlled for false discovery rate using the MULTTEST SAS procedure.35 All data manipulations and analyses were performed using SAS version 9.4.

Results

The study included 3023 patients. All were aged 50 to 75 years, 2923 (96.7%) were male and 2532 (83.8%) were non-Hispanic White (Table 1). Most participants were overweight or obese (n = 2535 [83.8%]), 2024 (67.0%) had ≤ 2 comorbidities, and 2602 (86.1%) had no family history of CRC. The MSCF for 1628 patients (53.9%) was no neoplasia, 966 patients (32.0%) was nonadvanced adenoma, and 429 participants (14.2%) had AN.

Mean percent scores were 58.5% for HEI, 38.2% for MD, and 63.1% for the DASH diet, with higher percentages indicating greater alignment with the recommendations for each diet (Table 2). All 3 dietary patterns scores standardized to percentages were strongly and significantly correlated in pairwise comparisons: HEI:MD, r = 0.62 (P < .001); HEI:DASH, r = 0.60 (P < .001); and MD:DASH, r = 0.72 (P < .001). Likewise, food category scores were significantly correlated across dietary patterns. For example, whole grain and fiber values from each dietary score were strongly correlated in pairwise comparisons: HEI Whole Grain:MD Grain, r = 0.64 (P < .001); HEI Whole Grain:DASH Fiber, r = 0.71 (P < .001); and MD Grain:DASH Fiber, r = 0.70 (P < .001).

Associations between individual participants' dietary pattern scores and the outcome of their pooled MSCF from baseline screening and ≥ 10 years of surveillance are presented in Table 3. For each single-point increases in dietary pattern scores (reflecting better dietary quality), aORs for nonadvanced adenoma vs no neoplasia were slightly lower but not statistically significantly: HEI, aOR, 1.00 (95% CI, 0.99-1.01); MD, aOR, 0.98 (95% CI, 0.94-1.02); and DASH, aOR, 0.99 (95% CI, 0.99-1.00). aORs for AN vs no neoplasia were slightly lower for each dietary pattern assessed, and only the MD and DASH scores were significantly different from 1.00: HEI, aOR, 1.00 (95% CI, 0.99-1.01); MD, aOR, 0.95 (95% CI, 0.90-1.00); and DASH, aOR, 0.99 (95% CI, 0.98-1.00).

We observed lower odds for nonadvanced adenoma and AN among all these dietary patterns when there was greater alignment with the recommended intake of whole grains and fiber. In separate models conducted using food categories comprising the dietary patterns as independent variables and after correcting for multiple tests, higher scores for the HEI Refined Grain category were associated with higher odds for nonadvanced adenoma (aOR, 1.03 [95% CI, 1.01-1.05]; P = .01) and AN (aOR, 1.05 [95% CI, 1.02-1.08]; P < .001). Higher scores for the HEI Whole Grain category were associated with lower odds for nonadvanced adenoma (aOR, 0.97 [95% CI, 0.95-0.99]; P = .01) and AN (aOR, 0.96 [95% CI, 0.93-0.99]; P = .01). Higher scores for the MD Grain category were significantly associated with lower odds for nonadvanced adenoma (aOR, 0.44 [95% CI, 0.26-0.75]; P = .002) and AN (aOR, 0.29 [95% CI, 0.14-0.62]; P = .001). The DASH Grains category also was significantly associated with lower odds for AN (aOR, 0.86 [95% CI, 0.78-0.95]; P = .002).

Discussion

In this study of 3023 veterans undergoing first-time screening colonoscopy and ≥ 10 years of surveillance, we found that healthy dietary patterns, as assessed by the MD and DASH diet, were significantly associated with lower risk of AN. Additionally, we identified lower odds for AN and nonadvanced adenoma compared with no neoplasia for higher grain scores for all the dietary patterns studied. Other food categories that comprise the dietary pattern scores had mixed associations with the MSCF outcomes. Several other studies have examined associations between dietary patterns and risk for CRC but to our knowledge, no studies have explored these associations among US veterans.

These results also indicate study participants had better than average (based on a 50% threshold) dietary quality according to the HEI and DASH diet scoring methods we used, but poor dietary quality according to the MD scoring method. The mean HEI scores for the present study were higher than a US Department of Agriculture study by Dong et al that compared dietary quality between veterans and nonveterans using the HEI, for which veterans’ expected HEI score was 45.6 of 100.⁸ This could be explained by the fact that the participants needed to be healthy to be eligible and those with healthier behaviors overall may have self-selected into the study due to motivation for screening during a time when screening was not yet commonplace. ³⁶ Similarly, participants of the present study had higher adherence to the DASH diet (63.1%) than adolescents with diabetes in a study by Günther et al. Conversely, firefighters who were coached to use a Mediterranean-style dietary pattern and dietary had higher adherence to MD than did participants in this study.²⁷

A closer examination of specific food category component scores that comprise the 3 distinct dietary patterns revealed mixed results from the multinomial modeling, which may have to do with the guideline thresholds used to calculate the dietary scores. When analyzed separately in the logistic regression models for their associations with nonadvanced adenomas and AN compared with no neoplasia, higher MD and DASH fruit scores (but not HEI fruit scores) were found to be significant. Other studies have had mixed findings when attempting to test for associations of fruit intake with adenoma recurrence.^10,37

This study had some unexpected findings. Vegetable intake was not associated with nonadvanced adenomas or AN risk. Studies of food categories have consistently found vegetable (specifically cruciferous ones) intake to be linked with lower odds for cancers.³⁸ Likewise, the red meat category, which was only a unique food category in the MD score, was not associated with nonadvanced adenomas or AN. Despite consistent literature suggesting higher intake of red meat and processed meats increases CRC risk, in 2019 the Nutritional Recommendations Consortium indicated that the evidence was weak.^39,40 This study showed higher DASH diet scores for low-fat dairy, which were maximized when participants reported at least 50% of their dairy servings per day as being low-fat, had lower odds for AN. Yet, the MD scores for low-fat dairy had no association with either outcome; their calculation was based on total number of servings per week. This difference in findings suggests the fat intake ratio may be more relevant to CRC risk than intake quantity.

The literature is mixed regarding fatty acid intake and CRC risk, which may be relevant to both dairy and meat intake. One systematic review and meta-analysis found dietary fat and types of fatty acid intake had no association with CRC risk.⁴¹ However, a more recent meta-analysis that assessed both dietary intake and plasma levels of fatty acids did find some statistically significant differences for various types of fatty acids and CRC risk.⁴²

The findings in the present study that grain intake is associated with lower odds for more severe colonoscopy findings among veterans are notable.⁴³ Lieberman et al, using the CSP #380 data, found that cereal fiber intake was associated with a lower odds for AN compared with hyperplastic polyps (OR, 0.98 [95% CI, 0.96- 1.00]).¹⁸ Similarly, Hullings et al determined that older adults in the highest quintile of cereal fiber intake had significantly lower odds of CRC than those in lower odds for CRC when compared with lowest quintile (OR, 0.89 [95% CI, 0.83- 0.96]; P < .001).⁴⁴ These findings support existing guidance that prioritizes whole grains as a key source of dietary fiber for CRC prevention.

A recent literature review on fiber, fat, and CRC risk suggested a consensus regarding one protective mechanism: dietary fiber from grains modulates the gut microbiota by promoting butyrate synthesis.⁴⁵ Butyrate is a short-chain fatty acid that supports energy production in colonocytes and has tumor-suppressing properties.⁴⁶ Our findings suggest there could be more to learn about the relationship between butyrate production and reduction of CRC risk through metabolomic studies that use measurements of plasma butyrate. These studies may examine associations between not just a singular food or food category, but rather food patterns that include fruits, vegetables, nuts and seeds, and whole grains known to promote butyrate production and plasma butyrate.⁴⁷

Improved understanding of mechanisms and risk-modifying lifestyle factors such as dietary patterns may enhance prevention strategies. Identifying the collective chemopreventive characteristics of a specific dietary pattern (eg, MD) will be helpful to clinicians and health care staff to promote healthy eating to reduce cancer risk. More studies are needed to understand whether such promotion is more clinically applicable and effective for patients, as compared with eating more or less of specific foods (eg, more whole grains, less red meat). Furthermore, considering important environmental factors collectively beyond dietary patterns may offer a way to better tailor screening and implement a variety of lifestyle interventions. In the literature, this is often referred to as a teachable moment when patients’ attentions are captured and may position them to be more receptive to guidance.⁴⁸

Limitations

This study has several important limitations and leaves opportunities for future studies that explore the role of dietary patterns and AN or CRC risk. First, the FFQ data used to calculate dietary pattern scores used in analysis were only captured at baseline, and there are nearly 3 decades across the study period. However, it is widely assumed that the diets of older adults, like those included in this study, remain stable over time which is appropriate given our sample population was aged 50 to 75 years when the baseline FFQ data were collected.^49-51 Additionally, while the HEI is a well-documented, standard scoring method for dietary quality, there are multitudes of dietary pattern scoring approaches for MD and DASH.^23,52,53 Finally, findings from this study using the sample of veterans may not be generalizable to a broader population. Future longitudinal studies that test for a clinically significant change threshold are warranted.

Conclusion

Results of this study suggest future research should further explore the effects of dietary patterns, particularly intake of specific food groups in combination, as opposed to individual nutrients or food items, on AN and CRC risk. Possible studies might explore these dietary patterns for their mechanistic role in altering the microbiome metabolism, which may influence CRC outcomes or include diet in a more comprehensive, holistic risk score that could be used to predict colonic neoplasia risk or in intervention studies that assess the effects of dietary changes on long-term CRC prevention. We suggest there are differences in people’s dietary intake patterns that might be important to consider when implementing tailored approaches to CRC risk mitigation.