Randy Dotinga

Cardiac rehabilitation (CR) remains dramatically underused among US veterans, as < 11% of eligible patients attend a single session and usage appears to be declining over time, a recently published retrospective cohort study reported. 

CR use is much lower among eligible patients across the US Department of Veterans Affairs (VA) compared with Medicare (10.4% vs. 28%, respectively), reported researchers at Veterans Affairs Connecticut Healthcare System and Yale School of Medicine, in JACC: Advances. 

The overall CR rate in the VA was lower than the 13.2% reported in a 2018 study. And while there was no significant difference in use between men and women, veterans from the poorest neighborhoods were less likely to take advantage of CR compared with veterans from the wealthiest neighborhoods (adjusted odds ratio, 0.82; P < .001).

“As providers, the time to act is now,” Merilyn Varghese, MD, MSc, said in an interview with Federal Practitioner. “We need to urgently get more of our veterans to cardiac rehab.”

As Varghese explained, “CR is a preventive intervention that has been shown to improve quality of life and reduce mortality and hospitalizations for patients with specific cardiac conditions.”

Patients may be eligible if they have experienced myocardial infarction (MI), percutaneous coronary intervention (PCI), coronary artery bypass surgery (CABG), heart transplant, valve surgery, stable angina, or stable heart failure. 

“CR combines multiple aspects of cardiac care such as exercise training, medication management, and behavioral assessments,” Varghese said. “For example, patients who have had a heart attack may have challenges in getting back to an exercise routine, managing new medications, and adjusting to life after such an event. CR can help bridge the gap between hospital to home.” In-person CR typically includes 3 sessions per week for 12 weeks.  

In 2024, a systematic review and meta-analysis reported that CR reduces all-cause mortality (relative risk, 0.74): “These results support the utilization of CR as a critical element in the management of further secondary prevention of CVDs (cardiovascular diseases).”

Examining VA Data

Researchers conducted the 2026 study “to better understand the current landscape of CR among veterans, particularly among women veterans who comprise a significant part of the veteran population but have previously been underrepresented in research,” Varghese said.

“Women veterans also share a different burden of cardiovascular risk factors, so understanding CR participation among both women and men veterans was of particular interest.”

The study tracked 82,496 VA-enrolled veterans eligible for CR from 2021-2023 (3.6% women). Average age of participants were 64.0 years among women and 71.5 years among men. Among women, 58.3% were White, and 31.8% were Black, and 2.24% were Asian. Among men, 71.9% were White, 18.8% were Black, and 2.3% were Asian. 

The rates of CR participation were low among both men (10.4%) and women (10.2%). Older people and Black patients were less likely to take part in CR than younger people and White patients, according to the study. Those who underwent CABG and PCI were more likely to participate in CR compared with those who had heart attacks only.

As for the gap in use between the wealthiest and poorest neighborhoods, Varghese said: “Area deprivation may compound some of the other barriers to CR access, including transportation difficulties, work responsibilities, and out-of-pocket costs.”

How can CR uptake be improved? “A key first step is understanding who can be referred, and second, to spend time discussing the importance of attending with veterans,” Varghese said. “Studies have shown that provider engagement and championing of CR are important positive facilitators that encourage CR participation.

“The VA has been at the forefront of innovation with the home-based CR program that offers veterans a way to attend CR remotely,” she added. “Expanding such novel methods of CR delivery is likely part of the solution to expand CR access.”

Outside Perspective: Make Referrals the Default

Justin Bachmann, MD, MPH, staff physician and research scientist at VA Tennessee Valley Healthcare System, told Federal Practitioner that CR is an American College of Cardiology/American Heart Association Class I recommended secondary prevention therapy following MI, PCI, and CABG “with strong evidence for reduced cardiovascular mortality and improved function and quality of life.”

Still, CR “has been persistently underused for decades as travel, cost, scheduling, and uneven geographic capacity create real logistical barriers,” said Bachmann, who serves as the medical director of a VA Office of Rural Health home-based CR program. 

Bachmann praised the study methodology and offered this advice to colleagues: “Embed CR referral in the post-MI, post-PCI, and post-CABG order sets so that referral is the default. Scale home-based CR well beyond the roughly 40 sites where it is currently available, and track facility-level referral and enrollment rates as quality measures.”

Preventive cardiology specialist Randal J. Thomas, MD, professor of Medicine at the Mayo Clinic in Rochester, Minn., echoed the importance of physician referral to Federal Practitioner.

“Patients can’t actually participate [directly] in most programs. They must have a physician referral,” he said. “The physician referral and the strength of referral is key. If a physician says, ‘You can go there if you want, but it’s not that important,’ the patients aren’t going to go.”

Outside Perspective: VA Deserves Blame

“The VA lags far behind most medical systems,” according to Quinn R. Pack, MD, associate professor of medicine at the University of Massachusetts Chan Medical School-Baystate. “Some of this is probably the patient population—more mental health problems, more smoking, more disease. But I’d squarely put most of this on the VA health system. They haven’t created the systems of care that make attending cardiac rehabilitation easy, reliable, and consistent.”

He noted that that automatic referral combined with a bedside visit by a liaison such as a representative of a CR program can double or triple enrollment.

“When physicians and nurses really encourage patients to go [to CR], these words are powerful,” Pack said. “When a patient enrolls in cardiac rehabilitation, we help them form new habits of exercise.”

No study fundings are reported. The Varghese discloses a relationship with the Veterans Health Administration. Other study authors had no disclosures. Bachmann disclosed a relationship with the VA. Pack and Thomas have no disclosures. 

Cardiac rehabilitation (CR) remains dramatically underused among US veterans, as < 11% of eligible patients attend a single session and usage appears to be declining over time, a recently published retrospective cohort study reported. 

CR use is much lower among eligible patients across the US Department of Veterans Affairs (VA) compared with Medicare (10.4% vs. 28%, respectively), reported researchers at Veterans Affairs Connecticut Healthcare System and Yale School of Medicine, in JACC: Advances. 

The overall CR rate in the VA was lower than the 13.2% reported in a 2018 study. And while there was no significant difference in use between men and women, veterans from the poorest neighborhoods were less likely to take advantage of CR compared with veterans from the wealthiest neighborhoods (adjusted odds ratio, 0.82; P < .001).

“As providers, the time to act is now,” Merilyn Varghese, MD, MSc, said in an interview with Federal Practitioner. “We need to urgently get more of our veterans to cardiac rehab.”

As Varghese explained, “CR is a preventive intervention that has been shown to improve quality of life and reduce mortality and hospitalizations for patients with specific cardiac conditions.”

Patients may be eligible if they have experienced myocardial infarction (MI), percutaneous coronary intervention (PCI), coronary artery bypass surgery (CABG), heart transplant, valve surgery, stable angina, or stable heart failure. 

“CR combines multiple aspects of cardiac care such as exercise training, medication management, and behavioral assessments,” Varghese said. “For example, patients who have had a heart attack may have challenges in getting back to an exercise routine, managing new medications, and adjusting to life after such an event. CR can help bridge the gap between hospital to home.” In-person CR typically includes 3 sessions per week for 12 weeks.  

In 2024, a systematic review and meta-analysis reported that CR reduces all-cause mortality (relative risk, 0.74): “These results support the utilization of CR as a critical element in the management of further secondary prevention of CVDs (cardiovascular diseases).”

Examining VA Data

Researchers conducted the 2026 study “to better understand the current landscape of CR among veterans, particularly among women veterans who comprise a significant part of the veteran population but have previously been underrepresented in research,” Varghese said.

“Women veterans also share a different burden of cardiovascular risk factors, so understanding CR participation among both women and men veterans was of particular interest.”

The study tracked 82,496 VA-enrolled veterans eligible for CR from 2021-2023 (3.6% women). Average age of participants were 64.0 years among women and 71.5 years among men. Among women, 58.3% were White, and 31.8% were Black, and 2.24% were Asian. Among men, 71.9% were White, 18.8% were Black, and 2.3% were Asian. 

The rates of CR participation were low among both men (10.4%) and women (10.2%). Older people and Black patients were less likely to take part in CR than younger people and White patients, according to the study. Those who underwent CABG and PCI were more likely to participate in CR compared with those who had heart attacks only.

As for the gap in use between the wealthiest and poorest neighborhoods, Varghese said: “Area deprivation may compound some of the other barriers to CR access, including transportation difficulties, work responsibilities, and out-of-pocket costs.”

How can CR uptake be improved? “A key first step is understanding who can be referred, and second, to spend time discussing the importance of attending with veterans,” Varghese said. “Studies have shown that provider engagement and championing of CR are important positive facilitators that encourage CR participation.

“The VA has been at the forefront of innovation with the home-based CR program that offers veterans a way to attend CR remotely,” she added. “Expanding such novel methods of CR delivery is likely part of the solution to expand CR access.”

Outside Perspective: Make Referrals the Default

Justin Bachmann, MD, MPH, staff physician and research scientist at VA Tennessee Valley Healthcare System, told Federal Practitioner that CR is an American College of Cardiology/American Heart Association Class I recommended secondary prevention therapy following MI, PCI, and CABG “with strong evidence for reduced cardiovascular mortality and improved function and quality of life.”

Still, CR “has been persistently underused for decades as travel, cost, scheduling, and uneven geographic capacity create real logistical barriers,” said Bachmann, who serves as the medical director of a VA Office of Rural Health home-based CR program. 

Bachmann praised the study methodology and offered this advice to colleagues: “Embed CR referral in the post-MI, post-PCI, and post-CABG order sets so that referral is the default. Scale home-based CR well beyond the roughly 40 sites where it is currently available, and track facility-level referral and enrollment rates as quality measures.”

Preventive cardiology specialist Randal J. Thomas, MD, professor of Medicine at the Mayo Clinic in Rochester, Minn., echoed the importance of physician referral to Federal Practitioner.

“Patients can’t actually participate [directly] in most programs. They must have a physician referral,” he said. “The physician referral and the strength of referral is key. If a physician says, ‘You can go there if you want, but it’s not that important,’ the patients aren’t going to go.”

Outside Perspective: VA Deserves Blame

“The VA lags far behind most medical systems,” according to Quinn R. Pack, MD, associate professor of medicine at the University of Massachusetts Chan Medical School-Baystate. “Some of this is probably the patient population—more mental health problems, more smoking, more disease. But I’d squarely put most of this on the VA health system. They haven’t created the systems of care that make attending cardiac rehabilitation easy, reliable, and consistent.”

He noted that that automatic referral combined with a bedside visit by a liaison such as a representative of a CR program can double or triple enrollment.

“When physicians and nurses really encourage patients to go [to CR], these words are powerful,” Pack said. “When a patient enrolls in cardiac rehabilitation, we help them form new habits of exercise.”

No study fundings are reported. The Varghese discloses a relationship with the Veterans Health Administration. Other study authors had no disclosures. Bachmann disclosed a relationship with the VA. Pack and Thomas have no disclosures. 

Cardiac rehabilitation (CR) remains dramatically underused among US veterans, as < 11% of eligible patients attend a single session and usage appears to be declining over time, a recently published retrospective cohort study reported. 

CR use is much lower among eligible patients across the US Department of Veterans Affairs (VA) compared with Medicare (10.4% vs. 28%, respectively), reported researchers at Veterans Affairs Connecticut Healthcare System and Yale School of Medicine, in JACC: Advances. 

The overall CR rate in the VA was lower than the 13.2% reported in a 2018 study. And while there was no significant difference in use between men and women, veterans from the poorest neighborhoods were less likely to take advantage of CR compared with veterans from the wealthiest neighborhoods (adjusted odds ratio, 0.82; P < .001).

“As providers, the time to act is now,” Merilyn Varghese, MD, MSc, said in an interview with Federal Practitioner. “We need to urgently get more of our veterans to cardiac rehab.”

As Varghese explained, “CR is a preventive intervention that has been shown to improve quality of life and reduce mortality and hospitalizations for patients with specific cardiac conditions.”

Patients may be eligible if they have experienced myocardial infarction (MI), percutaneous coronary intervention (PCI), coronary artery bypass surgery (CABG), heart transplant, valve surgery, stable angina, or stable heart failure. 

“CR combines multiple aspects of cardiac care such as exercise training, medication management, and behavioral assessments,” Varghese said. “For example, patients who have had a heart attack may have challenges in getting back to an exercise routine, managing new medications, and adjusting to life after such an event. CR can help bridge the gap between hospital to home.” In-person CR typically includes 3 sessions per week for 12 weeks.  

In 2024, a systematic review and meta-analysis reported that CR reduces all-cause mortality (relative risk, 0.74): “These results support the utilization of CR as a critical element in the management of further secondary prevention of CVDs (cardiovascular diseases).”

Examining VA Data

Researchers conducted the 2026 study “to better understand the current landscape of CR among veterans, particularly among women veterans who comprise a significant part of the veteran population but have previously been underrepresented in research,” Varghese said.

“Women veterans also share a different burden of cardiovascular risk factors, so understanding CR participation among both women and men veterans was of particular interest.”

The study tracked 82,496 VA-enrolled veterans eligible for CR from 2021-2023 (3.6% women). Average age of participants were 64.0 years among women and 71.5 years among men. Among women, 58.3% were White, and 31.8% were Black, and 2.24% were Asian. Among men, 71.9% were White, 18.8% were Black, and 2.3% were Asian. 

The rates of CR participation were low among both men (10.4%) and women (10.2%). Older people and Black patients were less likely to take part in CR than younger people and White patients, according to the study. Those who underwent CABG and PCI were more likely to participate in CR compared with those who had heart attacks only.

As for the gap in use between the wealthiest and poorest neighborhoods, Varghese said: “Area deprivation may compound some of the other barriers to CR access, including transportation difficulties, work responsibilities, and out-of-pocket costs.”

How can CR uptake be improved? “A key first step is understanding who can be referred, and second, to spend time discussing the importance of attending with veterans,” Varghese said. “Studies have shown that provider engagement and championing of CR are important positive facilitators that encourage CR participation.

“The VA has been at the forefront of innovation with the home-based CR program that offers veterans a way to attend CR remotely,” she added. “Expanding such novel methods of CR delivery is likely part of the solution to expand CR access.”

Outside Perspective: Make Referrals the Default

Justin Bachmann, MD, MPH, staff physician and research scientist at VA Tennessee Valley Healthcare System, told Federal Practitioner that CR is an American College of Cardiology/American Heart Association Class I recommended secondary prevention therapy following MI, PCI, and CABG “with strong evidence for reduced cardiovascular mortality and improved function and quality of life.”

Still, CR “has been persistently underused for decades as travel, cost, scheduling, and uneven geographic capacity create real logistical barriers,” said Bachmann, who serves as the medical director of a VA Office of Rural Health home-based CR program. 

Bachmann praised the study methodology and offered this advice to colleagues: “Embed CR referral in the post-MI, post-PCI, and post-CABG order sets so that referral is the default. Scale home-based CR well beyond the roughly 40 sites where it is currently available, and track facility-level referral and enrollment rates as quality measures.”

Preventive cardiology specialist Randal J. Thomas, MD, professor of Medicine at the Mayo Clinic in Rochester, Minn., echoed the importance of physician referral to Federal Practitioner.

“Patients can’t actually participate [directly] in most programs. They must have a physician referral,” he said. “The physician referral and the strength of referral is key. If a physician says, ‘You can go there if you want, but it’s not that important,’ the patients aren’t going to go.”

Outside Perspective: VA Deserves Blame

“The VA lags far behind most medical systems,” according to Quinn R. Pack, MD, associate professor of medicine at the University of Massachusetts Chan Medical School-Baystate. “Some of this is probably the patient population—more mental health problems, more smoking, more disease. But I’d squarely put most of this on the VA health system. They haven’t created the systems of care that make attending cardiac rehabilitation easy, reliable, and consistent.”

He noted that that automatic referral combined with a bedside visit by a liaison such as a representative of a CR program can double or triple enrollment.

“When physicians and nurses really encourage patients to go [to CR], these words are powerful,” Pack said. “When a patient enrolls in cardiac rehabilitation, we help them form new habits of exercise.”

No study fundings are reported. The Varghese discloses a relationship with the Veterans Health Administration. Other study authors had no disclosures. Bachmann disclosed a relationship with the VA. Pack and Thomas have no disclosures. 

Quality measures for primary care in the US Department of Veterans Affairs (VA) remained stable when telehealth was mixed with in-person visits, but influenza vaccination fell among patients who relied on online visits the most, a retrospective cohort study finds.

Analysis of the medical records for 744,599 veterans from federal fiscal years 2022 and 2023 revealed that patients aged 19-65 years who relied on telehealth for at least half of their primary care visits were less likely to receive an influenza vaccine (37.9%) compared with those seen only in person (50.0%, P < .001). The study was lead by researchers at VA Puget Sound and published in JAMA Network Open. 

There was also an influenza vaccination gap in patients aged ≥ 66 years: 62.8% in patients who received some care via telehealth telehealth vs 71.5% seen only in person, respectively (P < .001). 

“Our study showed that primary care quality at the VA is quite high,” Jonathan Staloff, MD, MSc, a family medicine physician with VA Puget Sound told Federal Practitioner. “And we found that for almost all quality measures, having a low proportion of care via telehealth was associated with the same quality as in-person care.”

As Staloff explained, “telehealth in primary care, as well as in general, has emerged as an additional means of preserving access to care for veterans. Evidence suggests that veterans have a high degree of satisfaction with telehealth but it’s mixed as it relates to quality outcome differences between those who receive any via telehealth vs none.”

For the study, Staloff said, “we wanted to see if there was a dose-response relationship between telehealth utilization and care quality and if certain hybrid models could help optimize quality of care. To our knowledge, this study was the first national evaluation to investigate primary care telehealth and care quality in this way.”

Reassuring Findings About Low Telehealth Use

For the study, researchers tracked a national sample of patient data from the Veterans Health Administration (VHA) Support Service Center Capital Assets Databases, Primary Care Management Module, and VHA Corporate Data Warehouse (mean age, 65 years; 86% male; 63% White, 22% Black, 10% Hispanic). 

The study defined categories of primary-care telehealth use as no telehealth, low telehealth (> 0.0% to < 28.6%), intermediate telehealth (28.6% to < 50.0%), and high telehealth (> 50.0%).

Highest Telehealth Use Raises Red Flags

The differences in influenza vaccine rates between the no-telehealth and high-telehealth groups held up in an adjusted analysis.

The study found small but statistically significant worsening of several quality measures in the high-telehealth use vs no-telehealth use cohorts: hypertension control, statin therapy and adherence, and annual screening for depression, alcohol use, and tobacco use.

The study cites limitations such as reliance on patients with ≥ 3 or more evaluation-and- management visits and lack of information about influenza vaccines delivered outside the VA. 

In a statement, VA Telehealth Services said it is “encouraged” the study demonstrates “equivalence in many clinical measures among veterans using telehealth. This study reinforces the potential of telehealth to provide high-quality health care to veterans.”

The organization added that it’s “committed to better understanding potential gaps highlighted in this study,” and “it is critical that research databases capture care rendered outside VA … and whether care was offered during a telehealth visit.”

Batching In-Person Services May Be Helpful

As for messages from the study for clinicians, Staloff said there are some preventive care measures that may be more difficult to deliver through telehealth.

“Clinicians should consider batching these in-person services for patients that have a high reliance on telehealth when they have an opportunity to see these patients in-person,” Staloff said. “Health systems may need new workflows to optimize hybrid care, particularly for those that receive most of their care via telehealth.”

Outside Perspective: ‘Access is Not the Same as Quality’

After reviewing the study findings, Ilana Graetz, PhD, a professor who studies health policy at the Emory University Rollins School of Public Health, praised the research design and said the results overall are “more reassuring than alarming.” However, she did caution that there could potentially be ways these patients differ that could not be categorized by the data.

“Patients with higher telehealth use may differ from those with lower telehealth use in important ways not fully captured in the data — barriers to in-person care, the complexity of the visit, patient preferences, or care received outside the system,” Graetz said.

As for the influenza vaccine, Graetz said patients need to be physically present: “Patients seen mostly by telehealth will have fewer opportunities to receive any preventive care that can only be delivered in person.”

Graetz said the study is timely given ongoing debates over COVID-19 pandemic-era telehealth flexibilities.

“The findings suggest that telehealth can function well as part of a hybrid primary care model,” she said, “but health systems still need to ensure that preventive services, chronic disease management, and follow-up care are not lost in the shift to virtual care.”

VHA Primary Care Analytics Team supported the study with funding from the VHA Office of Primary Care. Staloff has no disclosures. One coauthor disclosed a relationship with the US Department of Veterans Affairs. 

Graetz disclosed relationships the Donaghue Foundation, Pfizer, PRIME Education, and the National Institutes of Health. 

Quality measures for primary care in the US Department of Veterans Affairs (VA) remained stable when telehealth was mixed with in-person visits, but influenza vaccination fell among patients who relied on online visits the most, a retrospective cohort study finds.

Analysis of the medical records for 744,599 veterans from federal fiscal years 2022 and 2023 revealed that patients aged 19-65 years who relied on telehealth for at least half of their primary care visits were less likely to receive an influenza vaccine (37.9%) compared with those seen only in person (50.0%, P < .001). The study was lead by researchers at VA Puget Sound and published in JAMA Network Open. 

There was also an influenza vaccination gap in patients aged ≥ 66 years: 62.8% in patients who received some care via telehealth telehealth vs 71.5% seen only in person, respectively (P < .001). 

“Our study showed that primary care quality at the VA is quite high,” Jonathan Staloff, MD, MSc, a family medicine physician with VA Puget Sound told Federal Practitioner. “And we found that for almost all quality measures, having a low proportion of care via telehealth was associated with the same quality as in-person care.”

As Staloff explained, “telehealth in primary care, as well as in general, has emerged as an additional means of preserving access to care for veterans. Evidence suggests that veterans have a high degree of satisfaction with telehealth but it’s mixed as it relates to quality outcome differences between those who receive any via telehealth vs none.”

For the study, Staloff said, “we wanted to see if there was a dose-response relationship between telehealth utilization and care quality and if certain hybrid models could help optimize quality of care. To our knowledge, this study was the first national evaluation to investigate primary care telehealth and care quality in this way.”

Reassuring Findings About Low Telehealth Use

For the study, researchers tracked a national sample of patient data from the Veterans Health Administration (VHA) Support Service Center Capital Assets Databases, Primary Care Management Module, and VHA Corporate Data Warehouse (mean age, 65 years; 86% male; 63% White, 22% Black, 10% Hispanic). 

The study defined categories of primary-care telehealth use as no telehealth, low telehealth (> 0.0% to < 28.6%), intermediate telehealth (28.6% to < 50.0%), and high telehealth (> 50.0%).

Highest Telehealth Use Raises Red Flags

The differences in influenza vaccine rates between the no-telehealth and high-telehealth groups held up in an adjusted analysis.

The study found small but statistically significant worsening of several quality measures in the high-telehealth use vs no-telehealth use cohorts: hypertension control, statin therapy and adherence, and annual screening for depression, alcohol use, and tobacco use.

The study cites limitations such as reliance on patients with ≥ 3 or more evaluation-and- management visits and lack of information about influenza vaccines delivered outside the VA. 

In a statement, VA Telehealth Services said it is “encouraged” the study demonstrates “equivalence in many clinical measures among veterans using telehealth. This study reinforces the potential of telehealth to provide high-quality health care to veterans.”

The organization added that it’s “committed to better understanding potential gaps highlighted in this study,” and “it is critical that research databases capture care rendered outside VA … and whether care was offered during a telehealth visit.”

Batching In-Person Services May Be Helpful

As for messages from the study for clinicians, Staloff said there are some preventive care measures that may be more difficult to deliver through telehealth.

“Clinicians should consider batching these in-person services for patients that have a high reliance on telehealth when they have an opportunity to see these patients in-person,” Staloff said. “Health systems may need new workflows to optimize hybrid care, particularly for those that receive most of their care via telehealth.”

Outside Perspective: ‘Access is Not the Same as Quality’

After reviewing the study findings, Ilana Graetz, PhD, a professor who studies health policy at the Emory University Rollins School of Public Health, praised the research design and said the results overall are “more reassuring than alarming.” However, she did caution that there could potentially be ways these patients differ that could not be categorized by the data.

“Patients with higher telehealth use may differ from those with lower telehealth use in important ways not fully captured in the data — barriers to in-person care, the complexity of the visit, patient preferences, or care received outside the system,” Graetz said.

As for the influenza vaccine, Graetz said patients need to be physically present: “Patients seen mostly by telehealth will have fewer opportunities to receive any preventive care that can only be delivered in person.”

Graetz said the study is timely given ongoing debates over COVID-19 pandemic-era telehealth flexibilities.

“The findings suggest that telehealth can function well as part of a hybrid primary care model,” she said, “but health systems still need to ensure that preventive services, chronic disease management, and follow-up care are not lost in the shift to virtual care.”

VHA Primary Care Analytics Team supported the study with funding from the VHA Office of Primary Care. Staloff has no disclosures. One coauthor disclosed a relationship with the US Department of Veterans Affairs. 

Graetz disclosed relationships the Donaghue Foundation, Pfizer, PRIME Education, and the National Institutes of Health. 

Quality measures for primary care in the US Department of Veterans Affairs (VA) remained stable when telehealth was mixed with in-person visits, but influenza vaccination fell among patients who relied on online visits the most, a retrospective cohort study finds.

Analysis of the medical records for 744,599 veterans from federal fiscal years 2022 and 2023 revealed that patients aged 19-65 years who relied on telehealth for at least half of their primary care visits were less likely to receive an influenza vaccine (37.9%) compared with those seen only in person (50.0%, P < .001). The study was lead by researchers at VA Puget Sound and published in JAMA Network Open. 

There was also an influenza vaccination gap in patients aged ≥ 66 years: 62.8% in patients who received some care via telehealth telehealth vs 71.5% seen only in person, respectively (P < .001). 

“Our study showed that primary care quality at the VA is quite high,” Jonathan Staloff, MD, MSc, a family medicine physician with VA Puget Sound told Federal Practitioner. “And we found that for almost all quality measures, having a low proportion of care via telehealth was associated with the same quality as in-person care.”

As Staloff explained, “telehealth in primary care, as well as in general, has emerged as an additional means of preserving access to care for veterans. Evidence suggests that veterans have a high degree of satisfaction with telehealth but it’s mixed as it relates to quality outcome differences between those who receive any via telehealth vs none.”

For the study, Staloff said, “we wanted to see if there was a dose-response relationship between telehealth utilization and care quality and if certain hybrid models could help optimize quality of care. To our knowledge, this study was the first national evaluation to investigate primary care telehealth and care quality in this way.”

Reassuring Findings About Low Telehealth Use

For the study, researchers tracked a national sample of patient data from the Veterans Health Administration (VHA) Support Service Center Capital Assets Databases, Primary Care Management Module, and VHA Corporate Data Warehouse (mean age, 65 years; 86% male; 63% White, 22% Black, 10% Hispanic). 

The study defined categories of primary-care telehealth use as no telehealth, low telehealth (> 0.0% to < 28.6%), intermediate telehealth (28.6% to < 50.0%), and high telehealth (> 50.0%).

Highest Telehealth Use Raises Red Flags

The differences in influenza vaccine rates between the no-telehealth and high-telehealth groups held up in an adjusted analysis.

The study found small but statistically significant worsening of several quality measures in the high-telehealth use vs no-telehealth use cohorts: hypertension control, statin therapy and adherence, and annual screening for depression, alcohol use, and tobacco use.

The study cites limitations such as reliance on patients with ≥ 3 or more evaluation-and- management visits and lack of information about influenza vaccines delivered outside the VA. 

In a statement, VA Telehealth Services said it is “encouraged” the study demonstrates “equivalence in many clinical measures among veterans using telehealth. This study reinforces the potential of telehealth to provide high-quality health care to veterans.”

The organization added that it’s “committed to better understanding potential gaps highlighted in this study,” and “it is critical that research databases capture care rendered outside VA … and whether care was offered during a telehealth visit.”

Batching In-Person Services May Be Helpful

As for messages from the study for clinicians, Staloff said there are some preventive care measures that may be more difficult to deliver through telehealth.

“Clinicians should consider batching these in-person services for patients that have a high reliance on telehealth when they have an opportunity to see these patients in-person,” Staloff said. “Health systems may need new workflows to optimize hybrid care, particularly for those that receive most of their care via telehealth.”

Outside Perspective: ‘Access is Not the Same as Quality’

After reviewing the study findings, Ilana Graetz, PhD, a professor who studies health policy at the Emory University Rollins School of Public Health, praised the research design and said the results overall are “more reassuring than alarming.” However, she did caution that there could potentially be ways these patients differ that could not be categorized by the data.

“Patients with higher telehealth use may differ from those with lower telehealth use in important ways not fully captured in the data — barriers to in-person care, the complexity of the visit, patient preferences, or care received outside the system,” Graetz said.

As for the influenza vaccine, Graetz said patients need to be physically present: “Patients seen mostly by telehealth will have fewer opportunities to receive any preventive care that can only be delivered in person.”

Graetz said the study is timely given ongoing debates over COVID-19 pandemic-era telehealth flexibilities.

“The findings suggest that telehealth can function well as part of a hybrid primary care model,” she said, “but health systems still need to ensure that preventive services, chronic disease management, and follow-up care are not lost in the shift to virtual care.”

VHA Primary Care Analytics Team supported the study with funding from the VHA Office of Primary Care. Staloff has no disclosures. One coauthor disclosed a relationship with the US Department of Veterans Affairs. 

Graetz disclosed relationships the Donaghue Foundation, Pfizer, PRIME Education, and the National Institutes of Health. 

SAN FRANCISCO – Treatment for follicular lymphoma (FL) continues to evolve, according to a US Department of Veterans Affairs (VA) hematologist-oncologist, as second-line regimens emerge but the withdrawal of a recently approved agent complicates the picture.

“The future for our understanding and treatment of follicular lymphoma remains bright,” said Gerald Hsu, MD, PhD, of the University of California at San Francisco and the San Francisco VA Health Care System, during a presentation at the March Association of VA Hematology/Oncology (AVAHO) regional meeting on lymphoma.

By the Numbers

About 16,500 people in the US are diagnosed with FL each year. The median age of diagnosis is 64 years, and the 5-year survival rate from 2015-2021 was 89.0%, according to the National Cancer Institute. 

FL is slow-growing and indolent, Hsu said.

“[That] means that we tend to see patients who are older when they are diagnosed,” he added. “They tend to live a long time, and they’re not usually curable.”

A better understanding of the biology of FL has allowed for the development of new markers and ways of measuring residual disease, Hsu said. Additional insight may allow clinicians to identify which patients could benefit most from specific therapies.

Frontline Options

Hsu highlighted the VA Oncology Clinical Pathway for FL, which offers step-by-step guidance regarding therapy and was updated in March 2026. “It walks you through the pathway, but it’s not something that you are beholden to,” he said.

If the patient has classic FL grades 1-3A, is not at risk of transformation to aggressive lymphoma, is not in stage 1 or continuous stage lymphoma, and is indicated for therapy, the guideline recommends lenalidomide plus rituximab (R² or R-Len) or rituximab-bendamustine (R-Benda). 

“There’s a lot of data to support R-Benda,” Hsu said, pointing to a pair of studies with large numbers of patients with FL. The 2013 StiL trial tracked > 500 patients with indolent or mantle cell lymphoma (46% high risk). Those on R-Benda displayed better progression-free survival (PFS) than those taking the combination rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP; hazard ratio [HR], 0.61).

In a 5-year update of the BRIGHT trial, which enrolled > 500 patients with indolent or mantle cell lymphoma (9% high risk), the R-Benda group had better PFS than patients on R-CHOP or rituximab plus cyclophosphamide, vincristine, and prednisone (HR, 0.61).

R² is a somewhat newer regimen, Hsu said. Data from the 2018 RELEVANCE study (> 1000 patients) found R² to be nonsuperior to 3 rituximab-plus-chemotherapy regimens but with a lower rate of grade 3-4 neutropenia (32% vs 50% for the other regimens). 

However, R² is “not an FDA-approved regimen in the frontline because it did not demonstrate superiority” over other treatments, Hsu said. 

Selecting the Right Therapy

Which therapy is best? It’s a bit of a wash, Hsu said. 

He noted that R², R-Benda, and another therapy that’s not yet in the VA pathway (R-CHOP) appear to be noninferior to one another, although R-Benda has the edge. R² is better regarding neutropenia risk, although it lacks FDA approval.

“I think about these 3 regimens as appropriate and good,” Hsu said. “It’s nice having 3 wonderful regimens.”

Hsu highlighted the importance of complete remission (CR) as a goal. He pointed to a 2022 analysis of > 5,200 patients that showed progression within 24 months greatly boosted the risk of death vs no-progression (HR, 3.03). Progression within 24 months also lowered estimated 5-year overall survival to 71%.

“Timing really does matter,” Hsu said. “We often worry about transformation to diffuse large B-cell in patients who relapse, particularly this early.”

Second-Line Therapy Options

Two regimens have recently achieved National Comprehensive Cancer Network Category 1 preferred status in the second-line setting, Hsu said, although neither appears in the VA pathway. 

One is tafasitamab plus R², which was shown to extend median PFS to 22.4 months vs 13.9 months for R² alone in the 2026 inMIND study (HR, 0.43), but without an overall survival benefit. 

The other therapy is epcoritamab plus R²: Data from the 2026 EPCORE FL-1 study showed an overall response rate (ORR) of 95% for the combination vs 79% for R² alone and an estimated 16-month PFS of 85.5% for the combination vs 40.2% for R².

Hsu cautioned about the adverse event profile for community infusion centers. The combination carried higher rates of grade ≥ 3 infections (33% vs 16%) and neutropenia (69% vs 42%) compared with R² alone. However, grade ≥ 3 cytokine release syndrome was absent. 

“Stay alert to higher risk for infections and neutropenia here,” Hsu said.

Beyond Second Line: Biospecifics and CAR-T

The biospecifics mosunetuzumab and epcoritamab are now FDA-approved for patients who have relapsed ≥ 2 times. Mosunetuzumab showed ORR of 78% and CR rate of 60% in a 2025 study, while epcoritamab monotherapy showed ORR of 82% and CR of 63% in a 2024 study.

Mosunetuzumab had a 2.2% rate of cytokine release syndrome and a 4.4% rate of immune effector cell-associated neurotoxicity syndrome; epcoritamab had 0% rates of both.

“Think of these 2 options as getting you to the same place, potentially, but maybe with slightly different rates of toxicity,” Hsu said. 

Meanwhile, CAR-T therapy has shown “impressive results for the right patient,” Hsu said. 

Tazemetostat Withdrawn

Hsu noted that tazemetostat, an EZH2 inhibitor that was FDA-approved for relapsed/refractory FL with EZH2 mutations and patients with FL and no satisfactory alternative options, was withdrawn from the market by Eisai in March 2026. The cause of withdrawal was increased rates of secondary hematologic malignancies. 

Meanwhile, patients enrolled in the ongoing SYMPHONY-1 trial will be switched to R².

The withdrawal was “unfortunate,” Hsu said, “but the concept is important. Identifying new targets for therapy and developing those is how we make progress.”

SAN FRANCISCO – Treatment for follicular lymphoma (FL) continues to evolve, according to a US Department of Veterans Affairs (VA) hematologist-oncologist, as second-line regimens emerge but the withdrawal of a recently approved agent complicates the picture.

“The future for our understanding and treatment of follicular lymphoma remains bright,” said Gerald Hsu, MD, PhD, of the University of California at San Francisco and the San Francisco VA Health Care System, during a presentation at the March Association of VA Hematology/Oncology (AVAHO) regional meeting on lymphoma.

By the Numbers

About 16,500 people in the US are diagnosed with FL each year. The median age of diagnosis is 64 years, and the 5-year survival rate from 2015-2021 was 89.0%, according to the National Cancer Institute. 

FL is slow-growing and indolent, Hsu said.

“[That] means that we tend to see patients who are older when they are diagnosed,” he added. “They tend to live a long time, and they’re not usually curable.”

A better understanding of the biology of FL has allowed for the development of new markers and ways of measuring residual disease, Hsu said. Additional insight may allow clinicians to identify which patients could benefit most from specific therapies.

Frontline Options

Hsu highlighted the VA Oncology Clinical Pathway for FL, which offers step-by-step guidance regarding therapy and was updated in March 2026. “It walks you through the pathway, but it’s not something that you are beholden to,” he said.

If the patient has classic FL grades 1-3A, is not at risk of transformation to aggressive lymphoma, is not in stage 1 or continuous stage lymphoma, and is indicated for therapy, the guideline recommends lenalidomide plus rituximab (R² or R-Len) or rituximab-bendamustine (R-Benda). 

“There’s a lot of data to support R-Benda,” Hsu said, pointing to a pair of studies with large numbers of patients with FL. The 2013 StiL trial tracked > 500 patients with indolent or mantle cell lymphoma (46% high risk). Those on R-Benda displayed better progression-free survival (PFS) than those taking the combination rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP; hazard ratio [HR], 0.61).

In a 5-year update of the BRIGHT trial, which enrolled > 500 patients with indolent or mantle cell lymphoma (9% high risk), the R-Benda group had better PFS than patients on R-CHOP or rituximab plus cyclophosphamide, vincristine, and prednisone (HR, 0.61).

R² is a somewhat newer regimen, Hsu said. Data from the 2018 RELEVANCE study (> 1000 patients) found R² to be nonsuperior to 3 rituximab-plus-chemotherapy regimens but with a lower rate of grade 3-4 neutropenia (32% vs 50% for the other regimens). 

However, R² is “not an FDA-approved regimen in the frontline because it did not demonstrate superiority” over other treatments, Hsu said. 

Selecting the Right Therapy

Which therapy is best? It’s a bit of a wash, Hsu said. 

He noted that R², R-Benda, and another therapy that’s not yet in the VA pathway (R-CHOP) appear to be noninferior to one another, although R-Benda has the edge. R² is better regarding neutropenia risk, although it lacks FDA approval.

“I think about these 3 regimens as appropriate and good,” Hsu said. “It’s nice having 3 wonderful regimens.”

Hsu highlighted the importance of complete remission (CR) as a goal. He pointed to a 2022 analysis of > 5,200 patients that showed progression within 24 months greatly boosted the risk of death vs no-progression (HR, 3.03). Progression within 24 months also lowered estimated 5-year overall survival to 71%.

“Timing really does matter,” Hsu said. “We often worry about transformation to diffuse large B-cell in patients who relapse, particularly this early.”

Second-Line Therapy Options

Two regimens have recently achieved National Comprehensive Cancer Network Category 1 preferred status in the second-line setting, Hsu said, although neither appears in the VA pathway. 

One is tafasitamab plus R², which was shown to extend median PFS to 22.4 months vs 13.9 months for R² alone in the 2026 inMIND study (HR, 0.43), but without an overall survival benefit. 

The other therapy is epcoritamab plus R²: Data from the 2026 EPCORE FL-1 study showed an overall response rate (ORR) of 95% for the combination vs 79% for R² alone and an estimated 16-month PFS of 85.5% for the combination vs 40.2% for R².

Hsu cautioned about the adverse event profile for community infusion centers. The combination carried higher rates of grade ≥ 3 infections (33% vs 16%) and neutropenia (69% vs 42%) compared with R² alone. However, grade ≥ 3 cytokine release syndrome was absent. 

“Stay alert to higher risk for infections and neutropenia here,” Hsu said.

Beyond Second Line: Biospecifics and CAR-T

The biospecifics mosunetuzumab and epcoritamab are now FDA-approved for patients who have relapsed ≥ 2 times. Mosunetuzumab showed ORR of 78% and CR rate of 60% in a 2025 study, while epcoritamab monotherapy showed ORR of 82% and CR of 63% in a 2024 study.

Mosunetuzumab had a 2.2% rate of cytokine release syndrome and a 4.4% rate of immune effector cell-associated neurotoxicity syndrome; epcoritamab had 0% rates of both.

“Think of these 2 options as getting you to the same place, potentially, but maybe with slightly different rates of toxicity,” Hsu said. 

Meanwhile, CAR-T therapy has shown “impressive results for the right patient,” Hsu said. 

Tazemetostat Withdrawn

Hsu noted that tazemetostat, an EZH2 inhibitor that was FDA-approved for relapsed/refractory FL with EZH2 mutations and patients with FL and no satisfactory alternative options, was withdrawn from the market by Eisai in March 2026. The cause of withdrawal was increased rates of secondary hematologic malignancies. 

Meanwhile, patients enrolled in the ongoing SYMPHONY-1 trial will be switched to R².

The withdrawal was “unfortunate,” Hsu said, “but the concept is important. Identifying new targets for therapy and developing those is how we make progress.”

SAN FRANCISCO – Treatment for follicular lymphoma (FL) continues to evolve, according to a US Department of Veterans Affairs (VA) hematologist-oncologist, as second-line regimens emerge but the withdrawal of a recently approved agent complicates the picture.

“The future for our understanding and treatment of follicular lymphoma remains bright,” said Gerald Hsu, MD, PhD, of the University of California at San Francisco and the San Francisco VA Health Care System, during a presentation at the March Association of VA Hematology/Oncology (AVAHO) regional meeting on lymphoma.

By the Numbers

About 16,500 people in the US are diagnosed with FL each year. The median age of diagnosis is 64 years, and the 5-year survival rate from 2015-2021 was 89.0%, according to the National Cancer Institute. 

FL is slow-growing and indolent, Hsu said.

“[That] means that we tend to see patients who are older when they are diagnosed,” he added. “They tend to live a long time, and they’re not usually curable.”

A better understanding of the biology of FL has allowed for the development of new markers and ways of measuring residual disease, Hsu said. Additional insight may allow clinicians to identify which patients could benefit most from specific therapies.

Frontline Options

Hsu highlighted the VA Oncology Clinical Pathway for FL, which offers step-by-step guidance regarding therapy and was updated in March 2026. “It walks you through the pathway, but it’s not something that you are beholden to,” he said.

If the patient has classic FL grades 1-3A, is not at risk of transformation to aggressive lymphoma, is not in stage 1 or continuous stage lymphoma, and is indicated for therapy, the guideline recommends lenalidomide plus rituximab (R² or R-Len) or rituximab-bendamustine (R-Benda). 

“There’s a lot of data to support R-Benda,” Hsu said, pointing to a pair of studies with large numbers of patients with FL. The 2013 StiL trial tracked > 500 patients with indolent or mantle cell lymphoma (46% high risk). Those on R-Benda displayed better progression-free survival (PFS) than those taking the combination rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP; hazard ratio [HR], 0.61).

In a 5-year update of the BRIGHT trial, which enrolled > 500 patients with indolent or mantle cell lymphoma (9% high risk), the R-Benda group had better PFS than patients on R-CHOP or rituximab plus cyclophosphamide, vincristine, and prednisone (HR, 0.61).

R² is a somewhat newer regimen, Hsu said. Data from the 2018 RELEVANCE study (> 1000 patients) found R² to be nonsuperior to 3 rituximab-plus-chemotherapy regimens but with a lower rate of grade 3-4 neutropenia (32% vs 50% for the other regimens). 

However, R² is “not an FDA-approved regimen in the frontline because it did not demonstrate superiority” over other treatments, Hsu said. 

Selecting the Right Therapy

Which therapy is best? It’s a bit of a wash, Hsu said. 

He noted that R², R-Benda, and another therapy that’s not yet in the VA pathway (R-CHOP) appear to be noninferior to one another, although R-Benda has the edge. R² is better regarding neutropenia risk, although it lacks FDA approval.

“I think about these 3 regimens as appropriate and good,” Hsu said. “It’s nice having 3 wonderful regimens.”

Hsu highlighted the importance of complete remission (CR) as a goal. He pointed to a 2022 analysis of > 5,200 patients that showed progression within 24 months greatly boosted the risk of death vs no-progression (HR, 3.03). Progression within 24 months also lowered estimated 5-year overall survival to 71%.

“Timing really does matter,” Hsu said. “We often worry about transformation to diffuse large B-cell in patients who relapse, particularly this early.”

Second-Line Therapy Options

Two regimens have recently achieved National Comprehensive Cancer Network Category 1 preferred status in the second-line setting, Hsu said, although neither appears in the VA pathway. 

One is tafasitamab plus R², which was shown to extend median PFS to 22.4 months vs 13.9 months for R² alone in the 2026 inMIND study (HR, 0.43), but without an overall survival benefit. 

The other therapy is epcoritamab plus R²: Data from the 2026 EPCORE FL-1 study showed an overall response rate (ORR) of 95% for the combination vs 79% for R² alone and an estimated 16-month PFS of 85.5% for the combination vs 40.2% for R².

Hsu cautioned about the adverse event profile for community infusion centers. The combination carried higher rates of grade ≥ 3 infections (33% vs 16%) and neutropenia (69% vs 42%) compared with R² alone. However, grade ≥ 3 cytokine release syndrome was absent. 

“Stay alert to higher risk for infections and neutropenia here,” Hsu said.

Beyond Second Line: Biospecifics and CAR-T

The biospecifics mosunetuzumab and epcoritamab are now FDA-approved for patients who have relapsed ≥ 2 times. Mosunetuzumab showed ORR of 78% and CR rate of 60% in a 2025 study, while epcoritamab monotherapy showed ORR of 82% and CR of 63% in a 2024 study.

Mosunetuzumab had a 2.2% rate of cytokine release syndrome and a 4.4% rate of immune effector cell-associated neurotoxicity syndrome; epcoritamab had 0% rates of both.

“Think of these 2 options as getting you to the same place, potentially, but maybe with slightly different rates of toxicity,” Hsu said. 

Meanwhile, CAR-T therapy has shown “impressive results for the right patient,” Hsu said. 

Tazemetostat Withdrawn

Hsu noted that tazemetostat, an EZH2 inhibitor that was FDA-approved for relapsed/refractory FL with EZH2 mutations and patients with FL and no satisfactory alternative options, was withdrawn from the market by Eisai in March 2026. The cause of withdrawal was increased rates of secondary hematologic malignancies. 

Meanwhile, patients enrolled in the ongoing SYMPHONY-1 trial will be switched to R².

The withdrawal was “unfortunate,” Hsu said, “but the concept is important. Identifying new targets for therapy and developing those is how we make progress.”

Male veterans are less likely than their female counterparts to be referred for follow-up questions when initial screening suggests they may be at risk of intimate partner violence (IPV), a recent large cross-sectional study finds. 

Among 67,379 patients from 131 US Department of Veterans Affairs (VA) medical centers who screened positive for risk of IPV from October 2022 through September 2023, 17.7% failed to receive a mandated secondary screen to determine whether they were in danger of lethal violence, reported Galina A. Portnoy, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in JAMA Network Open. The rate was higher for men with initial positive screens than women (19.3% vs 12.1%, respectively, adjusted odds ratio [AOR], 1.42, P < .001).

Overall, women who underwent secondary screening were more likely to be considered in lethal danger from IPV than men (27.9% vs 13.3%, respectively, AOR 2.29, P < .001).

“While women face higher lethality risk, men’s IPV experiences are often overlooked, underscoring the need for consistent and reliable screening practices to identify all high-risk patients and connect them to life-saving services,” Portnoy told Federal Practitioner.

“IPV is one of the strongest predictors of homicide with risk escalating over time and especially high during periods of separation.” 

“IPV among men is often underreported, unrecognized, and inadequately addressed in clinical settings,” Portnoy noted. “Men who experience IPV often face barriers to reporting—stigma, shame, and concerns about not being taken seriously.”

The VA has implemented annual screening of IPV in women of reproductive age using a modified version of the 5-question Hurt, Insult, Threaten, Scream (HITS) tool. HITS asks how often a woman’s partner had screamed, cursed, insulted, or talked down to them; threatened to harm or physically hurt them, or forced or pressured them to “have sexual contact against your will, or when you were unable to say no” in the last year.

If a patient answers yes to any of these questions, clinicians should follow up with a secondary lethality screen with 3 questions:

• Has the IPV behavior increased in frequency/severity in the past 6 months?

• Has your partner ever choked or strangled you? and

• Do you believe your partner may kill you?

The test is considered positive if a patient answers yes to any question. 

The study focused on 67,379 patients out of 1,265,115 at the VA who scored positive on HITS (mean age, 52.3 years; 23% women; 62.9% White; 8.2% Hispanic/Latino). More than two-thirds (69.0%) had a service-connected disability rating > 50%.

Portnoy said there are several possible reasons for the gender disparity in misclassification such as time constraints, discomfort, limited resources, and lack of training. Clinician bias can be a factor, too, “with IPV still widely seen as primarily a women’s issue.”

“We don’t know whether IPV screening tools work the same for men as they do for women,” Portnoy added. “The HITS tool was developed and validated using samples of women who experienced IPV, and research is needed to test whether it performs as effectively in men.”

Bethany L. Backes, PhD, associate professor and lead, Violence Against Women Faculty Cluster, University of Central Florida, Orlando, is familiar with the study findings and said in an interview that discomfort among clinicians is a significant factor in preventing follow-up IPV screening. 

“When you’re asking about this and someone says ‘yes,’ how do you respond? You just go to the next thing, the next question: ‘How many drinks have you had in the last week?’” Backes told Federal Practitioner. “We’ve talked about creating some scripts for our student health clinicians on campus about how to talk to someone when they disclose, how to then engage or provide resources.”

This is especially important because “it’s hard for people to admit that they’re experiencing this, and then when they do and it’s brushed over, they’re less likely to tell someone again,” Backes added.

C. Nadine Wathen, PhD, a professor who studies IPV at Western University in London, is also familiar with the study findings, but critiqued the HITS, calling it a “terrible name.” The tool, she said, asks about very different behaviors–being screamed or cursed, for example, and forced sexual contact,” she explained to Federal Practitioner.

“If you’re a physician and you’re asking a man, ‘Does she scream or curse at you?’ and he says ‘Yeah, she screams all the time,’ a provider might say, ‘I’m not actually thinking that he’s experiencing intimate partner violence,” Wathen said. “He might be experiencing a bad relationship.’”

That could be true, Wathen said. Couples may scream and throw things at each other, and “you probably could benefit with some couples counseling on how to have a better relationship and manage stress and anger in your relationship. But that is different than ‘intimate partner terrorism,’ where there‘s a pattern of control.”

Wathen prefers a screening tool she helped develop called the Composite Abuse Scale, which she considers more sensitive and specific than HITS. It differentiates the types of abuse that people experience, and “it also recognizes that men in relationships with other men can experience those forms of intimate terrorism, and women can also be the perpetrator of those forms.”

Recognizing that VA clinicians may not have a choice of screening tool, Wathen suggested they follow up the question about screaming and cursing question this query: “Does that make you afraid?”

The study was funded by US Department of Veterans Affairs Quality Enhancement Research Initiative and the Veterans Health Administration’s Care Management and Social Work Service via the Intimate Partner Violence Center for Implementation, Research, and Evaluation.

Portnoy has no disclosures. One author discloses relationships with the National Council on Family Relations and Military Family Research Institute. Backes and Wathen have no disclosures.

Male veterans are less likely than their female counterparts to be referred for follow-up questions when initial screening suggests they may be at risk of intimate partner violence (IPV), a recent large cross-sectional study finds. 

Among 67,379 patients from 131 US Department of Veterans Affairs (VA) medical centers who screened positive for risk of IPV from October 2022 through September 2023, 17.7% failed to receive a mandated secondary screen to determine whether they were in danger of lethal violence, reported Galina A. Portnoy, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in JAMA Network Open. The rate was higher for men with initial positive screens than women (19.3% vs 12.1%, respectively, adjusted odds ratio [AOR], 1.42, P < .001).

Overall, women who underwent secondary screening were more likely to be considered in lethal danger from IPV than men (27.9% vs 13.3%, respectively, AOR 2.29, P < .001).

“While women face higher lethality risk, men’s IPV experiences are often overlooked, underscoring the need for consistent and reliable screening practices to identify all high-risk patients and connect them to life-saving services,” Portnoy told Federal Practitioner.

“IPV is one of the strongest predictors of homicide with risk escalating over time and especially high during periods of separation.” 

“IPV among men is often underreported, unrecognized, and inadequately addressed in clinical settings,” Portnoy noted. “Men who experience IPV often face barriers to reporting—stigma, shame, and concerns about not being taken seriously.”

The VA has implemented annual screening of IPV in women of reproductive age using a modified version of the 5-question Hurt, Insult, Threaten, Scream (HITS) tool. HITS asks how often a woman’s partner had screamed, cursed, insulted, or talked down to them; threatened to harm or physically hurt them, or forced or pressured them to “have sexual contact against your will, or when you were unable to say no” in the last year.

If a patient answers yes to any of these questions, clinicians should follow up with a secondary lethality screen with 3 questions:

• Has the IPV behavior increased in frequency/severity in the past 6 months?

• Has your partner ever choked or strangled you? and

• Do you believe your partner may kill you?

The test is considered positive if a patient answers yes to any question. 

The study focused on 67,379 patients out of 1,265,115 at the VA who scored positive on HITS (mean age, 52.3 years; 23% women; 62.9% White; 8.2% Hispanic/Latino). More than two-thirds (69.0%) had a service-connected disability rating > 50%.

Portnoy said there are several possible reasons for the gender disparity in misclassification such as time constraints, discomfort, limited resources, and lack of training. Clinician bias can be a factor, too, “with IPV still widely seen as primarily a women’s issue.”

“We don’t know whether IPV screening tools work the same for men as they do for women,” Portnoy added. “The HITS tool was developed and validated using samples of women who experienced IPV, and research is needed to test whether it performs as effectively in men.”

Bethany L. Backes, PhD, associate professor and lead, Violence Against Women Faculty Cluster, University of Central Florida, Orlando, is familiar with the study findings and said in an interview that discomfort among clinicians is a significant factor in preventing follow-up IPV screening. 

“When you’re asking about this and someone says ‘yes,’ how do you respond? You just go to the next thing, the next question: ‘How many drinks have you had in the last week?’” Backes told Federal Practitioner. “We’ve talked about creating some scripts for our student health clinicians on campus about how to talk to someone when they disclose, how to then engage or provide resources.”

This is especially important because “it’s hard for people to admit that they’re experiencing this, and then when they do and it’s brushed over, they’re less likely to tell someone again,” Backes added.

C. Nadine Wathen, PhD, a professor who studies IPV at Western University in London, is also familiar with the study findings, but critiqued the HITS, calling it a “terrible name.” The tool, she said, asks about very different behaviors–being screamed or cursed, for example, and forced sexual contact,” she explained to Federal Practitioner.

“If you’re a physician and you’re asking a man, ‘Does she scream or curse at you?’ and he says ‘Yeah, she screams all the time,’ a provider might say, ‘I’m not actually thinking that he’s experiencing intimate partner violence,” Wathen said. “He might be experiencing a bad relationship.’”

That could be true, Wathen said. Couples may scream and throw things at each other, and “you probably could benefit with some couples counseling on how to have a better relationship and manage stress and anger in your relationship. But that is different than ‘intimate partner terrorism,’ where there‘s a pattern of control.”

Wathen prefers a screening tool she helped develop called the Composite Abuse Scale, which she considers more sensitive and specific than HITS. It differentiates the types of abuse that people experience, and “it also recognizes that men in relationships with other men can experience those forms of intimate terrorism, and women can also be the perpetrator of those forms.”

Recognizing that VA clinicians may not have a choice of screening tool, Wathen suggested they follow up the question about screaming and cursing question this query: “Does that make you afraid?”

The study was funded by US Department of Veterans Affairs Quality Enhancement Research Initiative and the Veterans Health Administration’s Care Management and Social Work Service via the Intimate Partner Violence Center for Implementation, Research, and Evaluation.

Portnoy has no disclosures. One author discloses relationships with the National Council on Family Relations and Military Family Research Institute. Backes and Wathen have no disclosures.

Male veterans are less likely than their female counterparts to be referred for follow-up questions when initial screening suggests they may be at risk of intimate partner violence (IPV), a recent large cross-sectional study finds. 

Among 67,379 patients from 131 US Department of Veterans Affairs (VA) medical centers who screened positive for risk of IPV from October 2022 through September 2023, 17.7% failed to receive a mandated secondary screen to determine whether they were in danger of lethal violence, reported Galina A. Portnoy, PhD, of VA Connecticut Healthcare System and Yale School of Medicine, et al in JAMA Network Open. The rate was higher for men with initial positive screens than women (19.3% vs 12.1%, respectively, adjusted odds ratio [AOR], 1.42, P < .001).

Overall, women who underwent secondary screening were more likely to be considered in lethal danger from IPV than men (27.9% vs 13.3%, respectively, AOR 2.29, P < .001).

“While women face higher lethality risk, men’s IPV experiences are often overlooked, underscoring the need for consistent and reliable screening practices to identify all high-risk patients and connect them to life-saving services,” Portnoy told Federal Practitioner.

“IPV is one of the strongest predictors of homicide with risk escalating over time and especially high during periods of separation.” 

“IPV among men is often underreported, unrecognized, and inadequately addressed in clinical settings,” Portnoy noted. “Men who experience IPV often face barriers to reporting—stigma, shame, and concerns about not being taken seriously.”

The VA has implemented annual screening of IPV in women of reproductive age using a modified version of the 5-question Hurt, Insult, Threaten, Scream (HITS) tool. HITS asks how often a woman’s partner had screamed, cursed, insulted, or talked down to them; threatened to harm or physically hurt them, or forced or pressured them to “have sexual contact against your will, or when you were unable to say no” in the last year.

If a patient answers yes to any of these questions, clinicians should follow up with a secondary lethality screen with 3 questions:

• Has the IPV behavior increased in frequency/severity in the past 6 months?

• Has your partner ever choked or strangled you? and

• Do you believe your partner may kill you?

The test is considered positive if a patient answers yes to any question. 

The study focused on 67,379 patients out of 1,265,115 at the VA who scored positive on HITS (mean age, 52.3 years; 23% women; 62.9% White; 8.2% Hispanic/Latino). More than two-thirds (69.0%) had a service-connected disability rating > 50%.

Portnoy said there are several possible reasons for the gender disparity in misclassification such as time constraints, discomfort, limited resources, and lack of training. Clinician bias can be a factor, too, “with IPV still widely seen as primarily a women’s issue.”

“We don’t know whether IPV screening tools work the same for men as they do for women,” Portnoy added. “The HITS tool was developed and validated using samples of women who experienced IPV, and research is needed to test whether it performs as effectively in men.”

Bethany L. Backes, PhD, associate professor and lead, Violence Against Women Faculty Cluster, University of Central Florida, Orlando, is familiar with the study findings and said in an interview that discomfort among clinicians is a significant factor in preventing follow-up IPV screening. 

“When you’re asking about this and someone says ‘yes,’ how do you respond? You just go to the next thing, the next question: ‘How many drinks have you had in the last week?’” Backes told Federal Practitioner. “We’ve talked about creating some scripts for our student health clinicians on campus about how to talk to someone when they disclose, how to then engage or provide resources.”

This is especially important because “it’s hard for people to admit that they’re experiencing this, and then when they do and it’s brushed over, they’re less likely to tell someone again,” Backes added.

C. Nadine Wathen, PhD, a professor who studies IPV at Western University in London, is also familiar with the study findings, but critiqued the HITS, calling it a “terrible name.” The tool, she said, asks about very different behaviors–being screamed or cursed, for example, and forced sexual contact,” she explained to Federal Practitioner.

“If you’re a physician and you’re asking a man, ‘Does she scream or curse at you?’ and he says ‘Yeah, she screams all the time,’ a provider might say, ‘I’m not actually thinking that he’s experiencing intimate partner violence,” Wathen said. “He might be experiencing a bad relationship.’”

That could be true, Wathen said. Couples may scream and throw things at each other, and “you probably could benefit with some couples counseling on how to have a better relationship and manage stress and anger in your relationship. But that is different than ‘intimate partner terrorism,’ where there‘s a pattern of control.”

Wathen prefers a screening tool she helped develop called the Composite Abuse Scale, which she considers more sensitive and specific than HITS. It differentiates the types of abuse that people experience, and “it also recognizes that men in relationships with other men can experience those forms of intimate terrorism, and women can also be the perpetrator of those forms.”

Recognizing that VA clinicians may not have a choice of screening tool, Wathen suggested they follow up the question about screaming and cursing question this query: “Does that make you afraid?”

The study was funded by US Department of Veterans Affairs Quality Enhancement Research Initiative and the Veterans Health Administration’s Care Management and Social Work Service via the Intimate Partner Violence Center for Implementation, Research, and Evaluation.

Portnoy has no disclosures. One author discloses relationships with the National Council on Family Relations and Military Family Research Institute. Backes and Wathen have no disclosures.

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

Though end-of-life care for veterans with chronic obstructive pulmonary disease (COPD) in the US Department of Veterans Affairs (VA) has become more prevalent in recent years, a recent retrospective cohort study found that most patients do not receive palliative care or inpatient VA hospice over the past year of life, with rates lower than for other terminal illnesses. 

Among 332,770 decedents traced from 2010 through 2020, only 16.8% received either palliative or inpatient hospice care in the year before their death. The median time between their first palliative care appointment and death was 46 days, reported pulmonologist Natalia Smirnova, MD, assistant professor of medicine, Emory School of Medicine, Atlanta, et al in CHEST Pulmonary. 

A total of 15.9% of the decedents received inpatient hospice care from the VA. 

“These findings point to an opportunity to improve access to palliative care and hospice services for veterans with COPD, including earlier identification of need and stronger access pathways across care settings,” Smirnova told Federal Practitioner.

COPD Common Among Vets

An estimated 8%-19% of US veterans have COPD, higher than the estimated rate of 6% in adults from the general population. The condition is believed to be underdiagnosed in veterans. 

“Palliative care should be integrated early into routine care, when symptoms start,” Kathleen Lindell, PhD, RN, associate professor and chair, Palliative Care Health, School of Nursing, Medical University of South Carolina, Charleston, explained in a Federal Practitioner interview. “COPD is a serious respiratory illness, and patients experience progressively debilitating dyspnea or shortness of breath, frequent hospitalizations. And they frequently experience high rates of anxiety and depression,” 

Lindell is familiar with the study findings but didn’t take part in the research. 

“Early palliative care,” she said, “addresses symptom management and advance care planning to reduce suffering and ensure what matters most to the patient as the disease progresses.”

Smirnova noted that “hospice is a related but distinct service for veterans with a terminal condition, generally when life expectancy is < 6 months and the veteran is no longer seeking treatment other than palliative care.”

The study analyzed electronic health records and patterns of palliative and hospice care in the year before death. The 332,770 patients were mostly male (98.1%) and White (81.0%). Many had comorbidities such as congestive heart failure (30.0%), depression (26.0%), coronary artery disease (25.5%), anxiety (13.4%), and lung cancer (12.1%).

Researchers found that palliative care was mostly (61.6% of encounters) delivered in the inpatient setting, where it occurred a median 30 days before death. In the outpatient setting, it began a median of 71 days before death. 

From 2010 through 2020, the prevalence of palliative care increased from 10.4% to 16.0%, and the prevalence of VA inpatient hospice care increased from 15.0% to 18.0%. Some veterans may have received hospice services in other settings; in-home hospice is common.

Who is More Likely to Receive Palliative Care?

Black patients (adjusted odds ratio [AOR], 1.21), Latino/Hispanic ethnicity (AOR, 1.22), patients with housing instability (AOR, 1.38) and who were underweight (AOR, 1.75) were linked to more palliative care use. Black patients were especially likely to get inpatient palliative care, a fact that “may, in part, be driven by increased care intensity at the end of life, as has been demonstrated in prior studies,” the authors noted.

Marriage (AOR, 0.88) was linked to less palliative care use, while patients with lung cancer were especially likely to receive it (AOR, 2.48). There were similar differences in use of hospice care apart from higher use for Black patients. 

Smirnova said the study was not designed to determine the causes of patterns in palliative care use. However, important factors appear to include hospitalization, comorbidities, and access to care at health care sites. (Usage rates were lower at rural centers and higher at more complex centers.)

COPD vs Other Terminal Diseases

“The modest increases in utilization of palliative care and VA inpatient hospice from 2010 to 2020 align with previous work [research] in inpatients with COPD and heart failure,” the researchers wrote, “possibly reflecting the effect of international professional society guidelines, increased acceptance of palliative care, improvements related to VA end-of-life care and life-sustaining treatment decisions initiatives, and increases in the specialist palliative care workforce.”

Still, there appears to be a major discrepancy regarding the use of palliative care for COPD within the VA compared with other diseases. A study of data from 2014 through 2017 found that for patients with several comorbidities—including COPD, heart failure, cancer, and dementia—inpatient palliative care was introduced a median of 58 days before death and outpatient care 160 days before death. 

“This suggests that veterans with COPD receive palliative care later than those with other serious illnesses,” the authors argued. 

Don’t Wait for the ‘Right Time’

Sarah Miller, PhD, RN, associate professor, and assistant dean, PhD Nursing Science Program, School of Nursing, Medical University of South Carolina, Charleston, praised the study in an interview and noted that uncertainty about the “right time” to refer patients to palliative care could play a role in the findings. Miller is familiar with the study but did not participate in the research.

Lindell, the chair of Palliative Care Health, agreed.

“With COPD—a chronic, progressive disease—decline can be gradual, which makes it difficult to identify a clear transition point,” Lindell told Federal Practitioner. “This has contributed to many palliative referrals happening only when patients are clearly deteriorating or nearing the end of life. But palliative care should not be introduced reactively; it should be integrated early, alongside disease-directed treatment.”

For her part, Miller noted that “many veterans with COPD are navigating complex comorbidities and fragmented care across settings. Diseases like COPD don’t follow a predictable path, so referrals don’t always happen like they should.”

Moving forward, “if symptoms are present, early palliative care is appropriate,” Lindell said. These conversations should happen early and over time.

“The VA should prioritize early referral and access to palliative care for patients with COPD to provide the best care for these individuals.”

No study funding was reported. Smirnova discloses relationships with the CHEST Foundation and National Heart, Lung, and Blood Institute. Other authors disclose relationships with various grantors. 

Miller discloses a relationship with AstraZeneca. Lindell discloses relationships with Boehringer Ingelheim and Heart & Lung: The Journal of Acute and Critical Care. 

Metabolic dysfunction-associated steatotic liver disease (MASLD) has surpassed hepatitis C virus (HCV) infection as the leading cause of cirrhosis among veterans, according to a recently published retrospective analysis. This trend suggests a major shift in the causes of chronic liver disease due to effective HCV therapy and the continued rise of obesity and diabetes.

The analysis also found an increase in overall cirrhosis among veterans despite a massive dropoff in HCV. The data also hint that alcohol-related cases are on the rise.

Among new cirrhosis cases in the US Department of Veterans Affairs (VA) tracked annually from 2014 to 2023, the percentage due to HCV alone fell from 36.1% to 8.7%, while cases linked to MASLD rose from 26.8% to 41.0%, Pedro Ochoa-Allemant, MD, MSCE, a clinical fellow in advanced/transplant hepatology at the University of Pennsylvania, et al, reported in the American Journal of Gastroenterology.

Cases due to alcohol use rose from 12.5% to 22.5%; those linked to metabolic dysfunction and alcohol use combined increased from 8.1% to 16.6%.

“This shift represents a major public health challenge,” Ochoa-Allemant told Federal Practitioner, noting that metabolic- and alcohol-related forms of cirrhosis require long-term care, unlike HCV, which has a cure.

“For this reason, we should move towards better strategies for early identification, risk stratification, and prevention, particularly in primary care where most patients are seen,” he said.

New Nomenclature, Rising Cases

Ochoa-Allemant et al launched the study to better understand the etiology of cirrhosis in light of the lack of new population-based research using recently revised steatotic liver disease nomenclature. In 2023, liver specialists removed “nonalcoholic fatty liver disease” and “nonalcoholic steatohepatitis” from the taxonomy, dismissing them as “exclusionary, negative” terms that “used potentially stigmatizing language.”

The study analyzed the Veterans Outcomes and Costs Associated with Liver Disease cohort, which includes > 1300 Veterans Health Administration (VHA) facilities.

In 2014, 0.84% of 5.7 million veterans who were actively treated at the VHA had cirrhosis. The prevalence grew to 1.29% of 6.0 million veterans in 2023, reflecting a direct increase in overall cases.

Hepatitis C Declines, Obesity Rises

Ochoa-Allemant attributed the changing picture of cirrhosis to available antiviral cures for HCV and the rising burden of obesity and diabetes in the general population.

“This shift means that prevention of cirrhosis is no longer primarily about treating HCV infection, but it now requires our focus on managing cardiometabolic risk factors and increased alcohol use,” he said.

He also noted that the study reported information on new cases of cirrhosis vs deaths that suggests MASLD rates are stabilizing while cases related to alcohol continue to rise.

A March 2026 study in The Lancet Gastroenterology & Hepatology reported similar trends. The analysis of 41,100 US adults with cirrhosis from 1988 to 2023 identified a significant increase in the prevalence of MASLD among those with steatotic liver disease (12.69% to 28.16%)

Alcohol-Related Cases May Be Undercounted

Elliot B. Tapper, MD, research professor of hepatology and associate professor of internal medicine at the University of Michigan Medical School, told Federal Practitioner that the findings are “striking, but not entirely unexpected given the obesity and diabetes epidemics.”

Tapper is familiar with the study but did not participate in it, added that the impact of alcohol may be even larger due to misclassification. The figures regarding alcohol-related cases “should probably be interpreted as a floor rather than a ceiling,” he said in an interview.

Moving forward, Tapper said “multidisciplinary collaboration with endocrinology, addiction medicine, and primary care is no longer optional. I would go further. Hepatologists cannot defer management to others.”

New Therapies for Metabolic-Related Liver Disease

Heather M. Patton, MD, chief of the Gastrointestinal Section at VA San Diego Healthcare System and clinical professor of medicine at the University of California at San Diego, told Federal Practitioner that “it is essential to ensure that patients with chronic HCV infection and advanced fibrosis continue to receive appropriate care following HCV cure, inclusive of liver cancer screening."

As for cases related to metabolic syndrome, Patton – who also is familiar with the study findings but did not take part – highlighted the role of newly approved therapies for metabolic-associated steatohepatitis. Most recently, the US Food and Drug Administration approved the GLP-1 agonist semaglutide for the condition.

The treatments represent “a tremendous opportunity to decrease incident cirrhosis,” Patton said in an interview. She also noted that primary care physicians and endocrinologists should recognize that “metabolic health is a major risk factor for liver disease, and utilizing liver health screening tools such as the FIB-4 score has the opportunity to save lives."

The authors of the new study cited limitations regarding generalizability such as male predominance and higher psychosocial comorbidity. They also noted that the decline in HCV-related cirrhosis probably occurred earlier in the VA system than elsewhere due to “greater identification and access to antiviral therapy.”

They also noted that attribution of cases to alcohol may be underestimated due to self-reporting.

No study funding is reported. Ochoa-Allemant discloses a relationship with the National Institutes of Health. Other authors disclose relationships with the National Institutes of Health, Grifols, National Institute on Aging, and the VA. Tapper discloses relationships with Madrigal, Resolution, Korro, Tortugas, Satellite, Bausch, Iota, and Mirum. Patton has no disclosures.

Metabolic dysfunction-associated steatotic liver disease (MASLD) has surpassed hepatitis C virus (HCV) infection as the leading cause of cirrhosis among veterans, according to a recently published retrospective analysis. This trend suggests a major shift in the causes of chronic liver disease due to effective HCV therapy and the continued rise of obesity and diabetes.

The analysis also found an increase in overall cirrhosis among veterans despite a massive dropoff in HCV. The data also hint that alcohol-related cases are on the rise.

Among new cirrhosis cases in the US Department of Veterans Affairs (VA) tracked annually from 2014 to 2023, the percentage due to HCV alone fell from 36.1% to 8.7%, while cases linked to MASLD rose from 26.8% to 41.0%, Pedro Ochoa-Allemant, MD, MSCE, a clinical fellow in advanced/transplant hepatology at the University of Pennsylvania, et al, reported in the American Journal of Gastroenterology.

Cases due to alcohol use rose from 12.5% to 22.5%; those linked to metabolic dysfunction and alcohol use combined increased from 8.1% to 16.6%.

“This shift represents a major public health challenge,” Ochoa-Allemant told Federal Practitioner, noting that metabolic- and alcohol-related forms of cirrhosis require long-term care, unlike HCV, which has a cure.

“For this reason, we should move towards better strategies for early identification, risk stratification, and prevention, particularly in primary care where most patients are seen,” he said.

New Nomenclature, Rising Cases

Ochoa-Allemant et al launched the study to better understand the etiology of cirrhosis in light of the lack of new population-based research using recently revised steatotic liver disease nomenclature. In 2023, liver specialists removed “nonalcoholic fatty liver disease” and “nonalcoholic steatohepatitis” from the taxonomy, dismissing them as “exclusionary, negative” terms that “used potentially stigmatizing language.”

The study analyzed the Veterans Outcomes and Costs Associated with Liver Disease cohort, which includes > 1300 Veterans Health Administration (VHA) facilities.

In 2014, 0.84% of 5.7 million veterans who were actively treated at the VHA had cirrhosis. The prevalence grew to 1.29% of 6.0 million veterans in 2023, reflecting a direct increase in overall cases.

Hepatitis C Declines, Obesity Rises

Ochoa-Allemant attributed the changing picture of cirrhosis to available antiviral cures for HCV and the rising burden of obesity and diabetes in the general population.

“This shift means that prevention of cirrhosis is no longer primarily about treating HCV infection, but it now requires our focus on managing cardiometabolic risk factors and increased alcohol use,” he said.

He also noted that the study reported information on new cases of cirrhosis vs deaths that suggests MASLD rates are stabilizing while cases related to alcohol continue to rise.

A March 2026 study in The Lancet Gastroenterology & Hepatology reported similar trends. The analysis of 41,100 US adults with cirrhosis from 1988 to 2023 identified a significant increase in the prevalence of MASLD among those with steatotic liver disease (12.69% to 28.16%)

Alcohol-Related Cases May Be Undercounted

Elliot B. Tapper, MD, research professor of hepatology and associate professor of internal medicine at the University of Michigan Medical School, told Federal Practitioner that the findings are “striking, but not entirely unexpected given the obesity and diabetes epidemics.”

Tapper is familiar with the study but did not participate in it, added that the impact of alcohol may be even larger due to misclassification. The figures regarding alcohol-related cases “should probably be interpreted as a floor rather than a ceiling,” he said in an interview.

Moving forward, Tapper said “multidisciplinary collaboration with endocrinology, addiction medicine, and primary care is no longer optional. I would go further. Hepatologists cannot defer management to others.”

New Therapies for Metabolic-Related Liver Disease

Heather M. Patton, MD, chief of the Gastrointestinal Section at VA San Diego Healthcare System and clinical professor of medicine at the University of California at San Diego, told Federal Practitioner that “it is essential to ensure that patients with chronic HCV infection and advanced fibrosis continue to receive appropriate care following HCV cure, inclusive of liver cancer screening."

As for cases related to metabolic syndrome, Patton – who also is familiar with the study findings but did not take part – highlighted the role of newly approved therapies for metabolic-associated steatohepatitis. Most recently, the US Food and Drug Administration approved the GLP-1 agonist semaglutide for the condition.

The treatments represent “a tremendous opportunity to decrease incident cirrhosis,” Patton said in an interview. She also noted that primary care physicians and endocrinologists should recognize that “metabolic health is a major risk factor for liver disease, and utilizing liver health screening tools such as the FIB-4 score has the opportunity to save lives."

The authors of the new study cited limitations regarding generalizability such as male predominance and higher psychosocial comorbidity. They also noted that the decline in HCV-related cirrhosis probably occurred earlier in the VA system than elsewhere due to “greater identification and access to antiviral therapy.”

They also noted that attribution of cases to alcohol may be underestimated due to self-reporting.

No study funding is reported. Ochoa-Allemant discloses a relationship with the National Institutes of Health. Other authors disclose relationships with the National Institutes of Health, Grifols, National Institute on Aging, and the VA. Tapper discloses relationships with Madrigal, Resolution, Korro, Tortugas, Satellite, Bausch, Iota, and Mirum. Patton has no disclosures.

Metabolic dysfunction-associated steatotic liver disease (MASLD) has surpassed hepatitis C virus (HCV) infection as the leading cause of cirrhosis among veterans, according to a recently published retrospective analysis. This trend suggests a major shift in the causes of chronic liver disease due to effective HCV therapy and the continued rise of obesity and diabetes.

The analysis also found an increase in overall cirrhosis among veterans despite a massive dropoff in HCV. The data also hint that alcohol-related cases are on the rise.

Among new cirrhosis cases in the US Department of Veterans Affairs (VA) tracked annually from 2014 to 2023, the percentage due to HCV alone fell from 36.1% to 8.7%, while cases linked to MASLD rose from 26.8% to 41.0%, Pedro Ochoa-Allemant, MD, MSCE, a clinical fellow in advanced/transplant hepatology at the University of Pennsylvania, et al, reported in the American Journal of Gastroenterology.

Cases due to alcohol use rose from 12.5% to 22.5%; those linked to metabolic dysfunction and alcohol use combined increased from 8.1% to 16.6%.

“This shift represents a major public health challenge,” Ochoa-Allemant told Federal Practitioner, noting that metabolic- and alcohol-related forms of cirrhosis require long-term care, unlike HCV, which has a cure.

“For this reason, we should move towards better strategies for early identification, risk stratification, and prevention, particularly in primary care where most patients are seen,” he said.

New Nomenclature, Rising Cases

Ochoa-Allemant et al launched the study to better understand the etiology of cirrhosis in light of the lack of new population-based research using recently revised steatotic liver disease nomenclature. In 2023, liver specialists removed “nonalcoholic fatty liver disease” and “nonalcoholic steatohepatitis” from the taxonomy, dismissing them as “exclusionary, negative” terms that “used potentially stigmatizing language.”

The study analyzed the Veterans Outcomes and Costs Associated with Liver Disease cohort, which includes > 1300 Veterans Health Administration (VHA) facilities.

In 2014, 0.84% of 5.7 million veterans who were actively treated at the VHA had cirrhosis. The prevalence grew to 1.29% of 6.0 million veterans in 2023, reflecting a direct increase in overall cases.

Hepatitis C Declines, Obesity Rises

Ochoa-Allemant attributed the changing picture of cirrhosis to available antiviral cures for HCV and the rising burden of obesity and diabetes in the general population.

“This shift means that prevention of cirrhosis is no longer primarily about treating HCV infection, but it now requires our focus on managing cardiometabolic risk factors and increased alcohol use,” he said.

He also noted that the study reported information on new cases of cirrhosis vs deaths that suggests MASLD rates are stabilizing while cases related to alcohol continue to rise.

A March 2026 study in The Lancet Gastroenterology & Hepatology reported similar trends. The analysis of 41,100 US adults with cirrhosis from 1988 to 2023 identified a significant increase in the prevalence of MASLD among those with steatotic liver disease (12.69% to 28.16%)

Alcohol-Related Cases May Be Undercounted

Elliot B. Tapper, MD, research professor of hepatology and associate professor of internal medicine at the University of Michigan Medical School, told Federal Practitioner that the findings are “striking, but not entirely unexpected given the obesity and diabetes epidemics.”

Tapper is familiar with the study but did not participate in it, added that the impact of alcohol may be even larger due to misclassification. The figures regarding alcohol-related cases “should probably be interpreted as a floor rather than a ceiling,” he said in an interview.

Moving forward, Tapper said “multidisciplinary collaboration with endocrinology, addiction medicine, and primary care is no longer optional. I would go further. Hepatologists cannot defer management to others.”

New Therapies for Metabolic-Related Liver Disease

Heather M. Patton, MD, chief of the Gastrointestinal Section at VA San Diego Healthcare System and clinical professor of medicine at the University of California at San Diego, told Federal Practitioner that “it is essential to ensure that patients with chronic HCV infection and advanced fibrosis continue to receive appropriate care following HCV cure, inclusive of liver cancer screening."

As for cases related to metabolic syndrome, Patton – who also is familiar with the study findings but did not take part – highlighted the role of newly approved therapies for metabolic-associated steatohepatitis. Most recently, the US Food and Drug Administration approved the GLP-1 agonist semaglutide for the condition.

The treatments represent “a tremendous opportunity to decrease incident cirrhosis,” Patton said in an interview. She also noted that primary care physicians and endocrinologists should recognize that “metabolic health is a major risk factor for liver disease, and utilizing liver health screening tools such as the FIB-4 score has the opportunity to save lives."

The authors of the new study cited limitations regarding generalizability such as male predominance and higher psychosocial comorbidity. They also noted that the decline in HCV-related cirrhosis probably occurred earlier in the VA system than elsewhere due to “greater identification and access to antiviral therapy.”

They also noted that attribution of cases to alcohol may be underestimated due to self-reporting.

No study funding is reported. Ochoa-Allemant discloses a relationship with the National Institutes of Health. Other authors disclose relationships with the National Institutes of Health, Grifols, National Institute on Aging, and the VA. Tapper discloses relationships with Madrigal, Resolution, Korro, Tortugas, Satellite, Bausch, Iota, and Mirum. Patton has no disclosures.

SAN FRANCISCO – The treatment of early-stage diffuse large B-cell lymphoma (DLBCL) is evolving after decades of failed attempts to improve on the standard treatment of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), a hematologist-oncologist said at the Association of Veterans Affairs (VA) Hematology/Oncology regional meeting on lymphoma on March 21.

A combination therapy known as pola-R-CHP is now the preferred option for many patients but has limited additional benefit, said Solomon A. Graf, MD, of the University of Washington and VA Puget Sound Health Care System. Pola-R-CHP is a modified regimen of R-CHOP that replaced vincristine in R-CHOP with polatuzumab vedotin.

The keys to treatment, Graf said, include consideration of disease variations that can affect therapy efficacy and understanding the special needs of older patients.

Understanding DLBCL

DLBCL is the most common non-Hodgkin lymphoma in the US with about 30,000 new cases per year; the median age at diagnosis is 67 years, Graf said.

“The overall incidence of DLBCL has been relatively stable over the last decades,” he said. “But gratifyingly, the rate of death from this disease has steadily been declining since about the turn of the century.”

Pola-R-CHP: A New Standard, Significant Limitations

From 2002-2022, “many attempts to improve on first-line DLBCL therapy did not pan out,” Graf said, as more than a dozen large phase 3 trials failed to dethrone R-CHOP as the standard. Most of the trials attempted to add an agent to R-CHOP but showed no additional benefit.

Then, in 2021, the landmark POLARIX study was published. The double-blind, randomized trial on the new regime showed a progression-free survival benefit (PFS) vs R-CHOP (76.7% vs 70.2% at 2 years, respectively). Safety profiles were similar between the 2 combination therapies.

However, overall survival (OS) did not differ.

"Pola-R-CHP is now considered a preferred standard, despite no overall survival benefit and despite increased upfront cost,” Graf said. (A 2023 analysis found that pola-R-CHP is more cost-effective than R-CHOP in DLBCL.)

Pola-R-CHP or Not Pola-R-CHP?

Pola-R-CHP is not for all patients with DLBCL. In advanced cases, Graf said, genomic analyses provide important information that helps clinicians understand whether patients will fare better with R-CHOP. Cell-of-origin classifications include germinal center B-cell like (GCB), activated B-cell like (ABC), and unclassifiable.

“If it’s GCB type, there's no clear benefit for Pola-R-CHP,” Graf said. “On the other hand, the ABC subtype does much better when treated with Pola-R-CHP.”

Graf highlighted the recently updated VA Oncology Clinical Pathway for DLBCL, which recommends cell-of-origin testing by the Hans algorithm for certain advanced-stage patients. The guidelines suggest R-CHOP for GCB-type patients and Pola-R-CHP for non–GCB-type patients. However, he cautioned that the Hans algorithm comes with an increased risk of misclassification.

Early-Stage Disease: Radiation or No Radiation?

About 25% to 30% of patients have stage I or II disease, and the landmark 1998 SWOG trial initially suggested that 3 cycles of CHOP plus radiation had superior PFS and OS compared with 8 cycles of CHOP alone, Graf said. This trial was conducted prior to the R-CHOP era. However, follow-up revealed that the benefit vanished over time and the risk of secondary cancers grew. “Both strategies are perfectly viable, but there isn’t as much of a preference anymore,” Graf said.

A pair of recent trials – a 2019 European study and a 2020 US study – support eliminating radiation and lowering the number of cycles of therapy in certain patients, he said.

Managing Older Patients

Patients with DLBCL tend to be older, Graf said, and many have comorbidities and other limitations. A standard course of 6 cycles of therapy may be too much for them, he said. Graf highlighted the Elderly Prognostic Index, a tool created by an Italian group that allows clinicians to predict outcomes based on patient fitness levels.

Graf offered additional guidance for this population:

• Consider corticosteroids in the prephase setting, which can be “very valuable” and improve a patient’s ECOG performance status, “giving you better confidence about proceeding with more standard therapy.”
• Include anthracycline-based therapies such as R-CHOP if appropriate, such as in patients who are focused on living longer, since they “are really crucial to achieving cure in patients with DLBCL.” Graf noted that he has “a low threshold to involve cardiology if there’s anthracycline use and some underlying cardiac comorbidity.”
• Adjust dosage as appropriate: “You can adjust in the middle, be rather flexible and creative about these doses and dosing levels as you get going with your patient and see just what they can tolerate,” he said. “Sometimes you can ramp it up over the course, and sometimes you have to ramp it down to respond to toxicities.”
• Be aware that older patients are at much higher risk of suffering from toxicities due to the vincristine component of R-CHOP. These include neurotoxicities and constipation.

Graf highlighted the phase 3 Polar Bear study, which may offer more insight into therapy options in patients aged ≥ 75 years who are frail or those aged ≥ 80 years. The trial is scheduled to end in early 2027.

Graf discloses relationships with Janssen, TG Therapeutics, BeOne, AstraZeneca, Genentech, Incyte, Eli Lilly, and Pfizer.

SAN FRANCISCO – The treatment of early-stage diffuse large B-cell lymphoma (DLBCL) is evolving after decades of failed attempts to improve on the standard treatment of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), a hematologist-oncologist said at the Association of Veterans Affairs (VA) Hematology/Oncology regional meeting on lymphoma on March 21.

A combination therapy known as pola-R-CHP is now the preferred option for many patients but has limited additional benefit, said Solomon A. Graf, MD, of the University of Washington and VA Puget Sound Health Care System. Pola-R-CHP is a modified regimen of R-CHOP that replaced vincristine in R-CHOP with polatuzumab vedotin.

The keys to treatment, Graf said, include consideration of disease variations that can affect therapy efficacy and understanding the special needs of older patients.

Understanding DLBCL

DLBCL is the most common non-Hodgkin lymphoma in the US with about 30,000 new cases per year; the median age at diagnosis is 67 years, Graf said.

“The overall incidence of DLBCL has been relatively stable over the last decades,” he said. “But gratifyingly, the rate of death from this disease has steadily been declining since about the turn of the century.”

Pola-R-CHP: A New Standard, Significant Limitations

From 2002-2022, “many attempts to improve on first-line DLBCL therapy did not pan out,” Graf said, as more than a dozen large phase 3 trials failed to dethrone R-CHOP as the standard. Most of the trials attempted to add an agent to R-CHOP but showed no additional benefit.

Then, in 2021, the landmark POLARIX study was published. The double-blind, randomized trial on the new regime showed a progression-free survival benefit (PFS) vs R-CHOP (76.7% vs 70.2% at 2 years, respectively). Safety profiles were similar between the 2 combination therapies.

However, overall survival (OS) did not differ.

"Pola-R-CHP is now considered a preferred standard, despite no overall survival benefit and despite increased upfront cost,” Graf said. (A 2023 analysis found that pola-R-CHP is more cost-effective than R-CHOP in DLBCL.)

Pola-R-CHP or Not Pola-R-CHP?

Pola-R-CHP is not for all patients with DLBCL. In advanced cases, Graf said, genomic analyses provide important information that helps clinicians understand whether patients will fare better with R-CHOP. Cell-of-origin classifications include germinal center B-cell like (GCB), activated B-cell like (ABC), and unclassifiable.

“If it’s GCB type, there's no clear benefit for Pola-R-CHP,” Graf said. “On the other hand, the ABC subtype does much better when treated with Pola-R-CHP.”

Graf highlighted the recently updated VA Oncology Clinical Pathway for DLBCL, which recommends cell-of-origin testing by the Hans algorithm for certain advanced-stage patients. The guidelines suggest R-CHOP for GCB-type patients and Pola-R-CHP for non–GCB-type patients. However, he cautioned that the Hans algorithm comes with an increased risk of misclassification.

Early-Stage Disease: Radiation or No Radiation?

About 25% to 30% of patients have stage I or II disease, and the landmark 1998 SWOG trial initially suggested that 3 cycles of CHOP plus radiation had superior PFS and OS compared with 8 cycles of CHOP alone, Graf said. This trial was conducted prior to the R-CHOP era. However, follow-up revealed that the benefit vanished over time and the risk of secondary cancers grew. “Both strategies are perfectly viable, but there isn’t as much of a preference anymore,” Graf said.

A pair of recent trials – a 2019 European study and a 2020 US study – support eliminating radiation and lowering the number of cycles of therapy in certain patients, he said.

Managing Older Patients

Patients with DLBCL tend to be older, Graf said, and many have comorbidities and other limitations. A standard course of 6 cycles of therapy may be too much for them, he said. Graf highlighted the Elderly Prognostic Index, a tool created by an Italian group that allows clinicians to predict outcomes based on patient fitness levels.

Graf offered additional guidance for this population:

• Consider corticosteroids in the prephase setting, which can be “very valuable” and improve a patient’s ECOG performance status, “giving you better confidence about proceeding with more standard therapy.”
• Include anthracycline-based therapies such as R-CHOP if appropriate, such as in patients who are focused on living longer, since they “are really crucial to achieving cure in patients with DLBCL.” Graf noted that he has “a low threshold to involve cardiology if there’s anthracycline use and some underlying cardiac comorbidity.”
• Adjust dosage as appropriate: “You can adjust in the middle, be rather flexible and creative about these doses and dosing levels as you get going with your patient and see just what they can tolerate,” he said. “Sometimes you can ramp it up over the course, and sometimes you have to ramp it down to respond to toxicities.”
• Be aware that older patients are at much higher risk of suffering from toxicities due to the vincristine component of R-CHOP. These include neurotoxicities and constipation.

Graf highlighted the phase 3 Polar Bear study, which may offer more insight into therapy options in patients aged ≥ 75 years who are frail or those aged ≥ 80 years. The trial is scheduled to end in early 2027.

Graf discloses relationships with Janssen, TG Therapeutics, BeOne, AstraZeneca, Genentech, Incyte, Eli Lilly, and Pfizer.

SAN FRANCISCO – The treatment of early-stage diffuse large B-cell lymphoma (DLBCL) is evolving after decades of failed attempts to improve on the standard treatment of R-CHOP (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone), a hematologist-oncologist said at the Association of Veterans Affairs (VA) Hematology/Oncology regional meeting on lymphoma on March 21.

A combination therapy known as pola-R-CHP is now the preferred option for many patients but has limited additional benefit, said Solomon A. Graf, MD, of the University of Washington and VA Puget Sound Health Care System. Pola-R-CHP is a modified regimen of R-CHOP that replaced vincristine in R-CHOP with polatuzumab vedotin.

The keys to treatment, Graf said, include consideration of disease variations that can affect therapy efficacy and understanding the special needs of older patients.

Understanding DLBCL

DLBCL is the most common non-Hodgkin lymphoma in the US with about 30,000 new cases per year; the median age at diagnosis is 67 years, Graf said.

“The overall incidence of DLBCL has been relatively stable over the last decades,” he said. “But gratifyingly, the rate of death from this disease has steadily been declining since about the turn of the century.”

Pola-R-CHP: A New Standard, Significant Limitations

From 2002-2022, “many attempts to improve on first-line DLBCL therapy did not pan out,” Graf said, as more than a dozen large phase 3 trials failed to dethrone R-CHOP as the standard. Most of the trials attempted to add an agent to R-CHOP but showed no additional benefit.

Then, in 2021, the landmark POLARIX study was published. The double-blind, randomized trial on the new regime showed a progression-free survival benefit (PFS) vs R-CHOP (76.7% vs 70.2% at 2 years, respectively). Safety profiles were similar between the 2 combination therapies.

However, overall survival (OS) did not differ.

"Pola-R-CHP is now considered a preferred standard, despite no overall survival benefit and despite increased upfront cost,” Graf said. (A 2023 analysis found that pola-R-CHP is more cost-effective than R-CHOP in DLBCL.)

Pola-R-CHP or Not Pola-R-CHP?

Pola-R-CHP is not for all patients with DLBCL. In advanced cases, Graf said, genomic analyses provide important information that helps clinicians understand whether patients will fare better with R-CHOP. Cell-of-origin classifications include germinal center B-cell like (GCB), activated B-cell like (ABC), and unclassifiable.

“If it’s GCB type, there's no clear benefit for Pola-R-CHP,” Graf said. “On the other hand, the ABC subtype does much better when treated with Pola-R-CHP.”

Graf highlighted the recently updated VA Oncology Clinical Pathway for DLBCL, which recommends cell-of-origin testing by the Hans algorithm for certain advanced-stage patients. The guidelines suggest R-CHOP for GCB-type patients and Pola-R-CHP for non–GCB-type patients. However, he cautioned that the Hans algorithm comes with an increased risk of misclassification.

Early-Stage Disease: Radiation or No Radiation?

About 25% to 30% of patients have stage I or II disease, and the landmark 1998 SWOG trial initially suggested that 3 cycles of CHOP plus radiation had superior PFS and OS compared with 8 cycles of CHOP alone, Graf said. This trial was conducted prior to the R-CHOP era. However, follow-up revealed that the benefit vanished over time and the risk of secondary cancers grew. “Both strategies are perfectly viable, but there isn’t as much of a preference anymore,” Graf said.

A pair of recent trials – a 2019 European study and a 2020 US study – support eliminating radiation and lowering the number of cycles of therapy in certain patients, he said.

Managing Older Patients

Patients with DLBCL tend to be older, Graf said, and many have comorbidities and other limitations. A standard course of 6 cycles of therapy may be too much for them, he said. Graf highlighted the Elderly Prognostic Index, a tool created by an Italian group that allows clinicians to predict outcomes based on patient fitness levels.

Graf offered additional guidance for this population:

• Consider corticosteroids in the prephase setting, which can be “very valuable” and improve a patient’s ECOG performance status, “giving you better confidence about proceeding with more standard therapy.”
• Include anthracycline-based therapies such as R-CHOP if appropriate, such as in patients who are focused on living longer, since they “are really crucial to achieving cure in patients with DLBCL.” Graf noted that he has “a low threshold to involve cardiology if there’s anthracycline use and some underlying cardiac comorbidity.”
• Adjust dosage as appropriate: “You can adjust in the middle, be rather flexible and creative about these doses and dosing levels as you get going with your patient and see just what they can tolerate,” he said. “Sometimes you can ramp it up over the course, and sometimes you have to ramp it down to respond to toxicities.”
• Be aware that older patients are at much higher risk of suffering from toxicities due to the vincristine component of R-CHOP. These include neurotoxicities and constipation.

Graf highlighted the phase 3 Polar Bear study, which may offer more insight into therapy options in patients aged ≥ 75 years who are frail or those aged ≥ 80 years. The trial is scheduled to end in early 2027.

Graf discloses relationships with Janssen, TG Therapeutics, BeOne, AstraZeneca, Genentech, Incyte, Eli Lilly, and Pfizer.

SAN FRANCISCO – Peripheral T-cell lymphoma (PTCL) accounts for 4% of mature non-Hodgkin lymphoma cases in the US, or only about 4000 cases a year. While the number of patients is small, however, treatment for PTCL is complex due to wide variations in subtypes and survival rates, a hematologist-oncologist said at the March 21 Association of VA Hematology/Oncology (AVAHO) regional meeting on lymphoma.

Weiyun Ai, MD, PhD, a clinical professor of medicine at University of California, San Francisco who specializes in lymphoma, explained that there are multiple subtypes of PTCL based on their location within the body. Ai discussed a 2008 analysis of North American cases of PTCL and natural killer/T-cell lymphoma from 1990-2002, of which:

• 34% were PTCL, not otherwise specified;

• 16% were angioimmunoblastic T-cell lymphoma (AITL);

• 16% were anaplastic large cell lymphoma (ALCL), anaplastic lymphoma kinase (ALK)-positive;

• 7.8% were ALCL, ALK-negative;

• 5.8% were enteropathy-type;

• 5.4% were primary cutaneous ALCL; and

• 5.1% were extranodal natural killer/T-cell lymphoma, nasal type.

The remaining cases were adult T-cell leukemia/lymphoma, hepatosplenic, subcutaneous panniculitis-like, and unclassified. 

International Prognostic Index Predicts Outcomes

“The subtype with the best outcome is ALCL, ALK-positive with a 5-year overall survival rate of 70% followed by ALK-negative ALCL at 50%, and all the other common subtypes at 30%,” Ai said. 

Ai outlined the International Prognostic Index (IPI), a tool to predict clinical outcomes in patients with aggressive non-Hodgkin lymphoma based on risk factors. IPI assigns worse scores to patients aged > 60 years; patients who have higher (worse) performance scores, higher lactate dehydrogenase (LDH) levels, and more extranodal sites; and patients at stages III-IV.

First-Line Therapy: Consider Subtypes and CD30 Levels

Subtypes and CD30 expression levels are important factors in choosing therapy, Ai said, and 2019’s landmark ECHELON-2 study (updated in 2022) defines the standard. 

Newly diagnosed patients who strongly express CD30 (ie, those with both types of ALCL) are recommended to be treated with A+CHP (brentuximab vedotin [BV] plus cyclophosphamide, doxorubicin, and prednisone). 

Combination therapy of cyclophosphamide, doxorubicin, hydroxydaunorubicin, vincristine, and prednisone (CHOP) was the prior standard of care until the ECHELON-2 study, Ai said. 

That trial, which randomized 452 patients with untreated PTCL (CD30 ≥ 10%) to A+CHP or CHOP, found that 5-year progression-free rates were 51.4% vs 43.0%, respectively (hazard ratio [HR], 0.70; 95% CI, 0.53-0.91). Five-year overall survival rates were 70.1% vs. 61.0%, respectively (HR, 0.72; 95% CI, 0.53-0.99).

The threshold CD30 level at which to turn to A+CHP—1%, 5%, or 10%—“is kind of a dealer’s choice,” Ai said. Her own cutoff is 1%.

“If they're < 1%, I tend not to do it,” Ai said. “It's usually much more expensive, as you can imagine.”

If CD30 < 1%, Ai recommends CHOP or, in younger patients, CHOP plus etoposide (CHOEP).

Follow-up treatments include autologous stem cell transplant (ASCT) and observation/maintenance, depending on factors such as subtype, fitness, and remission.

Transplant: Still Relevant

When ECHELON-2 was released, some clinicians wondered if ASCT was still warranted, Ai said. A posthoc exploratory analysis found a 62% reduction in relative risk for progression in patients who underwent transplants after reaching complete remission with A+CHP. 

The findings provide support for transplant, she said. 

For transplant-ineligible patients, a small analysis of BV and CHP followed by BV maintenance showed a progression-free survival curve that appeared to plateau after 18-24 months.

“You don't see this kind of curve very often. I was quite impressed,” Ai said. “If the patient is willing and able, I will give them BV cycles.”

Ai discloses relationships with ADC, AbbVie, Acrotech, Kite, and Kyowa Kirin.

SAN FRANCISCO – Peripheral T-cell lymphoma (PTCL) accounts for 4% of mature non-Hodgkin lymphoma cases in the US, or only about 4000 cases a year. While the number of patients is small, however, treatment for PTCL is complex due to wide variations in subtypes and survival rates, a hematologist-oncologist said at the March 21 Association of VA Hematology/Oncology (AVAHO) regional meeting on lymphoma.

Weiyun Ai, MD, PhD, a clinical professor of medicine at University of California, San Francisco who specializes in lymphoma, explained that there are multiple subtypes of PTCL based on their location within the body. Ai discussed a 2008 analysis of North American cases of PTCL and natural killer/T-cell lymphoma from 1990-2002, of which:

• 34% were PTCL, not otherwise specified;

• 16% were angioimmunoblastic T-cell lymphoma (AITL);

• 16% were anaplastic large cell lymphoma (ALCL), anaplastic lymphoma kinase (ALK)-positive;

• 7.8% were ALCL, ALK-negative;

• 5.8% were enteropathy-type;

• 5.4% were primary cutaneous ALCL; and

• 5.1% were extranodal natural killer/T-cell lymphoma, nasal type.

The remaining cases were adult T-cell leukemia/lymphoma, hepatosplenic, subcutaneous panniculitis-like, and unclassified. 

International Prognostic Index Predicts Outcomes

“The subtype with the best outcome is ALCL, ALK-positive with a 5-year overall survival rate of 70% followed by ALK-negative ALCL at 50%, and all the other common subtypes at 30%,” Ai said. 

Ai outlined the International Prognostic Index (IPI), a tool to predict clinical outcomes in patients with aggressive non-Hodgkin lymphoma based on risk factors. IPI assigns worse scores to patients aged > 60 years; patients who have higher (worse) performance scores, higher lactate dehydrogenase (LDH) levels, and more extranodal sites; and patients at stages III-IV.

First-Line Therapy: Consider Subtypes and CD30 Levels

Subtypes and CD30 expression levels are important factors in choosing therapy, Ai said, and 2019’s landmark ECHELON-2 study (updated in 2022) defines the standard. 

Newly diagnosed patients who strongly express CD30 (ie, those with both types of ALCL) are recommended to be treated with A+CHP (brentuximab vedotin [BV] plus cyclophosphamide, doxorubicin, and prednisone). 

Combination therapy of cyclophosphamide, doxorubicin, hydroxydaunorubicin, vincristine, and prednisone (CHOP) was the prior standard of care until the ECHELON-2 study, Ai said. 

That trial, which randomized 452 patients with untreated PTCL (CD30 ≥ 10%) to A+CHP or CHOP, found that 5-year progression-free rates were 51.4% vs 43.0%, respectively (hazard ratio [HR], 0.70; 95% CI, 0.53-0.91). Five-year overall survival rates were 70.1% vs. 61.0%, respectively (HR, 0.72; 95% CI, 0.53-0.99).

The threshold CD30 level at which to turn to A+CHP—1%, 5%, or 10%—“is kind of a dealer’s choice,” Ai said. Her own cutoff is 1%.

“If they're < 1%, I tend not to do it,” Ai said. “It's usually much more expensive, as you can imagine.”

If CD30 < 1%, Ai recommends CHOP or, in younger patients, CHOP plus etoposide (CHOEP).

Follow-up treatments include autologous stem cell transplant (ASCT) and observation/maintenance, depending on factors such as subtype, fitness, and remission.

Transplant: Still Relevant

When ECHELON-2 was released, some clinicians wondered if ASCT was still warranted, Ai said. A posthoc exploratory analysis found a 62% reduction in relative risk for progression in patients who underwent transplants after reaching complete remission with A+CHP. 

The findings provide support for transplant, she said. 

For transplant-ineligible patients, a small analysis of BV and CHP followed by BV maintenance showed a progression-free survival curve that appeared to plateau after 18-24 months.

“You don't see this kind of curve very often. I was quite impressed,” Ai said. “If the patient is willing and able, I will give them BV cycles.”

Ai discloses relationships with ADC, AbbVie, Acrotech, Kite, and Kyowa Kirin.

SAN FRANCISCO – Peripheral T-cell lymphoma (PTCL) accounts for 4% of mature non-Hodgkin lymphoma cases in the US, or only about 4000 cases a year. While the number of patients is small, however, treatment for PTCL is complex due to wide variations in subtypes and survival rates, a hematologist-oncologist said at the March 21 Association of VA Hematology/Oncology (AVAHO) regional meeting on lymphoma.

Weiyun Ai, MD, PhD, a clinical professor of medicine at University of California, San Francisco who specializes in lymphoma, explained that there are multiple subtypes of PTCL based on their location within the body. Ai discussed a 2008 analysis of North American cases of PTCL and natural killer/T-cell lymphoma from 1990-2002, of which:

• 34% were PTCL, not otherwise specified;

• 16% were angioimmunoblastic T-cell lymphoma (AITL);

• 16% were anaplastic large cell lymphoma (ALCL), anaplastic lymphoma kinase (ALK)-positive;

• 7.8% were ALCL, ALK-negative;

• 5.8% were enteropathy-type;

• 5.4% were primary cutaneous ALCL; and

• 5.1% were extranodal natural killer/T-cell lymphoma, nasal type.

The remaining cases were adult T-cell leukemia/lymphoma, hepatosplenic, subcutaneous panniculitis-like, and unclassified. 

International Prognostic Index Predicts Outcomes

“The subtype with the best outcome is ALCL, ALK-positive with a 5-year overall survival rate of 70% followed by ALK-negative ALCL at 50%, and all the other common subtypes at 30%,” Ai said. 

Ai outlined the International Prognostic Index (IPI), a tool to predict clinical outcomes in patients with aggressive non-Hodgkin lymphoma based on risk factors. IPI assigns worse scores to patients aged > 60 years; patients who have higher (worse) performance scores, higher lactate dehydrogenase (LDH) levels, and more extranodal sites; and patients at stages III-IV.

First-Line Therapy: Consider Subtypes and CD30 Levels

Subtypes and CD30 expression levels are important factors in choosing therapy, Ai said, and 2019’s landmark ECHELON-2 study (updated in 2022) defines the standard. 

Newly diagnosed patients who strongly express CD30 (ie, those with both types of ALCL) are recommended to be treated with A+CHP (brentuximab vedotin [BV] plus cyclophosphamide, doxorubicin, and prednisone). 

Combination therapy of cyclophosphamide, doxorubicin, hydroxydaunorubicin, vincristine, and prednisone (CHOP) was the prior standard of care until the ECHELON-2 study, Ai said. 

That trial, which randomized 452 patients with untreated PTCL (CD30 ≥ 10%) to A+CHP or CHOP, found that 5-year progression-free rates were 51.4% vs 43.0%, respectively (hazard ratio [HR], 0.70; 95% CI, 0.53-0.91). Five-year overall survival rates were 70.1% vs. 61.0%, respectively (HR, 0.72; 95% CI, 0.53-0.99).

The threshold CD30 level at which to turn to A+CHP—1%, 5%, or 10%—“is kind of a dealer’s choice,” Ai said. Her own cutoff is 1%.

“If they're < 1%, I tend not to do it,” Ai said. “It's usually much more expensive, as you can imagine.”

If CD30 < 1%, Ai recommends CHOP or, in younger patients, CHOP plus etoposide (CHOEP).

Follow-up treatments include autologous stem cell transplant (ASCT) and observation/maintenance, depending on factors such as subtype, fitness, and remission.

Transplant: Still Relevant

When ECHELON-2 was released, some clinicians wondered if ASCT was still warranted, Ai said. A posthoc exploratory analysis found a 62% reduction in relative risk for progression in patients who underwent transplants after reaching complete remission with A+CHP. 

The findings provide support for transplant, she said. 

For transplant-ineligible patients, a small analysis of BV and CHP followed by BV maintenance showed a progression-free survival curve that appeared to plateau after 18-24 months.

“You don't see this kind of curve very often. I was quite impressed,” Ai said. “If the patient is willing and able, I will give them BV cycles.”

Ai discloses relationships with ADC, AbbVie, Acrotech, Kite, and Kyowa Kirin.

Anxiety, depression, and suicide rates are elevated for veterans who are survivors of testicular cancer (TC) compared with veterans without cancer, a retrospective analysis finds.

Over 5 years, the cumulative incidence of anxiety and depression was 53.4% in veterans with TC vs 35.0% in matched controls (P < .001; hazard ratio [HR], 1.66), reported Aditya Bagrodia, MD, professor of urology and radiation oncology at the University of California San Diego, et al in Cancer Medicine. The cumulative incidence of suicidality was 5.0% and 0.1%, respectively (P < .001; HR, 22.99).

“More than half of men with testicular cancer contend with these diagnoses,” Bagrodia told Federal Practitioner. “There are risk factors, including chemotherapy, being single or divorced, or unemployed.”

Patients in these groups warrant aggressive screening and intervention, Bagrodia said. TC is the most common cancer in men in the military and the most common malignancy in men aged 18 to 45 years, Bagrodia said: “The vast majority of men who have testicular cancer are curable.”

Patients, however, face an intense burden. 

“One theme that comes up consistently from patients and caregivers is centered around mental health impact, brain fog, anxiety, depression, and difficulty concentrating,” Bagrodia said. “We wanted to dig into this a little bit further. The idea is to shed light on how common these diagnoses are on these young cancer survivors and intervene so we could positively impact their quality of life.”

The study analyzed 2022 patients with TC and 6375 matched controls enrolled at the US Department of Veterans Affairs (VA) from 1990 through 2016. In the cancer cohort, the mean age at diagnosis was 42.46 years, and ages ranged from 18 to 88 years; 89.7% of patients were White, 6.0% were Black, 2.4% were other race, 1.2% were Asian/Pacific Islander, and 0.7% were Native; 6.2% were Hispanic; and 19.9% were diagnosed between 1990 and 1999.

Factors linked to higher rates of anxiety/depression among patients with TC included divorce (HR 1.15, P = .044), unemployment (HR 1.68, P < .001), and receipt of chemotherapy (HR 1.20, P < .001).

The incidence of de novo anxiety/depression was 30.1% for patients with TC vs 16.7% for controls (P < .001), and the incidence of de novo suicidality was 2.4% for patients and 0.1% for controls.

“These are men who are going to beat their cancer and go on to live for decades and decades,” Bagrodia said. “We found that the impact of a diagnosis and chemotherapy can persist beyond the initial time frame.”

It’s not clear, however, why chemotherapy boosts the risk, Bagrodia said. Clinicians who treat patients with TC should let them know that anxiety, depression, and suicidality are common and treatable concerns.

“We've got some wonderful support services, therapy, and medications that can help out with those diagnoses,” Bagrodia said.

The study authors noted limitations such as the retrospective study design and limited consideration of factors that may affect mental health.

“Additionally, the baseline rates of anxiety, depression, and suicidality are high in the VA population, which may limit ability to apply results to the civilian population,” Bagrodia said.

Genitourinary oncologist Philippe Spiess, MD, of Moffitt Cancer Center in Tampa, praised the study in an interview, saying it provides stronger evidence than previous research. 

"It's not only about screening but surveillance, because you never know what kind of challenges they have in their lives,” Spiess told Federal Practitioner, emphasizing the need for clinicians to continue to monitor patients. “They're young, they're vulnerable. Don’t assume they're going to get help somewhere else. You need to be that source that facilitates it.”

No funding is reported. Bagrodia and other authors have no disclosures. Spiess has no disclosures. 

Anxiety, depression, and suicide rates are elevated for veterans who are survivors of testicular cancer (TC) compared with veterans without cancer, a retrospective analysis finds.

Over 5 years, the cumulative incidence of anxiety and depression was 53.4% in veterans with TC vs 35.0% in matched controls (P < .001; hazard ratio [HR], 1.66), reported Aditya Bagrodia, MD, professor of urology and radiation oncology at the University of California San Diego, et al in Cancer Medicine. The cumulative incidence of suicidality was 5.0% and 0.1%, respectively (P < .001; HR, 22.99).

“More than half of men with testicular cancer contend with these diagnoses,” Bagrodia told Federal Practitioner. “There are risk factors, including chemotherapy, being single or divorced, or unemployed.”

Patients in these groups warrant aggressive screening and intervention, Bagrodia said. TC is the most common cancer in men in the military and the most common malignancy in men aged 18 to 45 years, Bagrodia said: “The vast majority of men who have testicular cancer are curable.”

Patients, however, face an intense burden. 

“One theme that comes up consistently from patients and caregivers is centered around mental health impact, brain fog, anxiety, depression, and difficulty concentrating,” Bagrodia said. “We wanted to dig into this a little bit further. The idea is to shed light on how common these diagnoses are on these young cancer survivors and intervene so we could positively impact their quality of life.”

The study analyzed 2022 patients with TC and 6375 matched controls enrolled at the US Department of Veterans Affairs (VA) from 1990 through 2016. In the cancer cohort, the mean age at diagnosis was 42.46 years, and ages ranged from 18 to 88 years; 89.7% of patients were White, 6.0% were Black, 2.4% were other race, 1.2% were Asian/Pacific Islander, and 0.7% were Native; 6.2% were Hispanic; and 19.9% were diagnosed between 1990 and 1999.

Factors linked to higher rates of anxiety/depression among patients with TC included divorce (HR 1.15, P = .044), unemployment (HR 1.68, P < .001), and receipt of chemotherapy (HR 1.20, P < .001).

The incidence of de novo anxiety/depression was 30.1% for patients with TC vs 16.7% for controls (P < .001), and the incidence of de novo suicidality was 2.4% for patients and 0.1% for controls.

“These are men who are going to beat their cancer and go on to live for decades and decades,” Bagrodia said. “We found that the impact of a diagnosis and chemotherapy can persist beyond the initial time frame.”

It’s not clear, however, why chemotherapy boosts the risk, Bagrodia said. Clinicians who treat patients with TC should let them know that anxiety, depression, and suicidality are common and treatable concerns.

“We've got some wonderful support services, therapy, and medications that can help out with those diagnoses,” Bagrodia said.

The study authors noted limitations such as the retrospective study design and limited consideration of factors that may affect mental health.

“Additionally, the baseline rates of anxiety, depression, and suicidality are high in the VA population, which may limit ability to apply results to the civilian population,” Bagrodia said.

Genitourinary oncologist Philippe Spiess, MD, of Moffitt Cancer Center in Tampa, praised the study in an interview, saying it provides stronger evidence than previous research. 

"It's not only about screening but surveillance, because you never know what kind of challenges they have in their lives,” Spiess told Federal Practitioner, emphasizing the need for clinicians to continue to monitor patients. “They're young, they're vulnerable. Don’t assume they're going to get help somewhere else. You need to be that source that facilitates it.”

No funding is reported. Bagrodia and other authors have no disclosures. Spiess has no disclosures. 

Anxiety, depression, and suicide rates are elevated for veterans who are survivors of testicular cancer (TC) compared with veterans without cancer, a retrospective analysis finds.

Over 5 years, the cumulative incidence of anxiety and depression was 53.4% in veterans with TC vs 35.0% in matched controls (P < .001; hazard ratio [HR], 1.66), reported Aditya Bagrodia, MD, professor of urology and radiation oncology at the University of California San Diego, et al in Cancer Medicine. The cumulative incidence of suicidality was 5.0% and 0.1%, respectively (P < .001; HR, 22.99).

“More than half of men with testicular cancer contend with these diagnoses,” Bagrodia told Federal Practitioner. “There are risk factors, including chemotherapy, being single or divorced, or unemployed.”

Patients in these groups warrant aggressive screening and intervention, Bagrodia said. TC is the most common cancer in men in the military and the most common malignancy in men aged 18 to 45 years, Bagrodia said: “The vast majority of men who have testicular cancer are curable.”

Patients, however, face an intense burden. 

“One theme that comes up consistently from patients and caregivers is centered around mental health impact, brain fog, anxiety, depression, and difficulty concentrating,” Bagrodia said. “We wanted to dig into this a little bit further. The idea is to shed light on how common these diagnoses are on these young cancer survivors and intervene so we could positively impact their quality of life.”

The study analyzed 2022 patients with TC and 6375 matched controls enrolled at the US Department of Veterans Affairs (VA) from 1990 through 2016. In the cancer cohort, the mean age at diagnosis was 42.46 years, and ages ranged from 18 to 88 years; 89.7% of patients were White, 6.0% were Black, 2.4% were other race, 1.2% were Asian/Pacific Islander, and 0.7% were Native; 6.2% were Hispanic; and 19.9% were diagnosed between 1990 and 1999.

Factors linked to higher rates of anxiety/depression among patients with TC included divorce (HR 1.15, P = .044), unemployment (HR 1.68, P < .001), and receipt of chemotherapy (HR 1.20, P < .001).

The incidence of de novo anxiety/depression was 30.1% for patients with TC vs 16.7% for controls (P < .001), and the incidence of de novo suicidality was 2.4% for patients and 0.1% for controls.

“These are men who are going to beat their cancer and go on to live for decades and decades,” Bagrodia said. “We found that the impact of a diagnosis and chemotherapy can persist beyond the initial time frame.”

It’s not clear, however, why chemotherapy boosts the risk, Bagrodia said. Clinicians who treat patients with TC should let them know that anxiety, depression, and suicidality are common and treatable concerns.

“We've got some wonderful support services, therapy, and medications that can help out with those diagnoses,” Bagrodia said.

The study authors noted limitations such as the retrospective study design and limited consideration of factors that may affect mental health.

“Additionally, the baseline rates of anxiety, depression, and suicidality are high in the VA population, which may limit ability to apply results to the civilian population,” Bagrodia said.

Genitourinary oncologist Philippe Spiess, MD, of Moffitt Cancer Center in Tampa, praised the study in an interview, saying it provides stronger evidence than previous research. 

"It's not only about screening but surveillance, because you never know what kind of challenges they have in their lives,” Spiess told Federal Practitioner, emphasizing the need for clinicians to continue to monitor patients. “They're young, they're vulnerable. Don’t assume they're going to get help somewhere else. You need to be that source that facilitates it.”

No funding is reported. Bagrodia and other authors have no disclosures. Spiess has no disclosures. 

A pilot program appeared to more than double the rate of germline genetic testing among veterans with metastatic prostate cancer (mPC) by using remote communication rather than relying on clinicians for in-person outreach to patients. 

Of 1952 veterans with mPC, 681 (34.9%) provided consent and 459 (23.5%) completed testing, exceeding the usual 10% to 12% of patients who undergo testing, reported Bruce Montgomery, MD, et al in Cancer.

Although testing is recommended for all patients with mPC to guide therapy and alert relatives who may be at risk, 23.5% is still an impressive number, Montgomery, an oncologist with Veterans Affairs (VA) Puget Sound Health Care System in Seattle told Federal Practitioner: “With a letter and very little money and very little real time from clinicians, we could get testing done at 3 times the rate happening out there in the big wide world,” he said. “For 2000 patients, we needed one research coordinator and a small part of a genetic counselor's time.”

According to the study, germline genetic testing—which examines inherited DNA—is now recommended for all men with mPC by the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the American Urological Association. Germline genetic testing differs from somatic testing, which seeks genetic changes in the tumors themselves.

In the VA and community at large, the percentage of men with mPC who undergo germline genetic testing is low, Montgomery said. Research suggests < 40% of patients undergo somatic testing.

Germline genetic testing only costs about 10% compared with somatic testing, Montgomery said, and can be conducted at any time. In about 10% of mPC cases, the testing provides insight into the best treatment, he said.

Montgomery noted another benefit to germline genetic testing: It can raise the alarm about pathogenic variants that could boost cancer risk in family members, allowing them to get screened and take action.

There are many reasons veterans do not get tested, Montgomery said. The process is not automatic because patient consent is needed, and clinicians often fail to ask. In some cases, veterans worry about privacy or whether they will lose service-connected benefits if their cancer is blamed on genetics.

The study focused on 2104 veterans with mPC who had already agreed to take part in the Million Veteran Program, a prospective cohort study examining genetic and nongenetic risk for disease. The genetic analysis from that project did not provide guidance about mPC, so researchers approached the veterans directly.

Patients were enrolled from February 2021 to October 2023. A total of 1952 veterans did not opt out when contacted by mail (median age, 75 years; 63% White, 25% Black; 74% urban and 24% rural). The median age of those who consented and completed testing after phone contact was 74 years; 67% of patients were White and 22% were Black; 78% of patients lived in urban communities and 20% lived in rural communities.

Fifty-nine patients (13%) had pathogenic variants, and 37 of those had variants that indicated treatment with targeted therapies. Of the 37, 14 received targeted therapy, 18 were not at the point where targeted therapy was indicated, and 5 were not treated with targeted therapy for various reasons before they died.

Twelve of the 59 patients with pathogenic variants agreed to let the study team contact their first-degree relatives. Thirty relatives underwent testing, and 10 of them were positive for the variants.

Following completion of the study, researchers examined electronic records for the 59 patients with pathogenic variants and found that 19% did not have documentation of the germline finding in the medical record. The authors cited an “urgent need” to standardize where genetic information is included in the records.

While “it seems like a very small number of patients took up testing,” Montgomery said, the study findings are promising: “If we did the same thing nationally in the VA, there would be 15,000 men with metastatic disease, and we’d be testing 5000 of them with almost no effort.”

In an interview, Susan Vadaparampil, PhD, MPH, associate center director of Community Outreach and Engagement at Moffitt Cancer Center, who studies genetic testing, praised the strengths of the study. Vadaparampil, who did not take part in the research, told Federal Practitioner that the study relies on “an intervention that could likely be incorporated into routine clinical practice, a less resource-intensive model that provides posttest counseling for those who test positive, and support to share results with family members.”

However, she said, “testing uptake was uneven based on participant sociodemographic characteristics. It's important to consider how discussions and resources to facilitate testing may need to be adapted to meet the needs of all patients.

“Strategies that facilitate clinicians’ knowledge, comfort, and consistency in discussing testing with all mPC patients are essential,” Vadaparampil added. “Simultaneously using multiple strategies targeted to different levels can further help boost uptake.”

The study was funded by the VA Office of Research and Development, Prostate Cancer Foundation, Pacific Northwest Prostate Cancer SPORE, Institute for Prostate Cancer Research, Congressionally Directed Medical Research Programs (CDMRP), and Put VA Data to Work for Veterans. 

Montgomery discloses relationships with Daiichi Sankyo, INmune Bio, Clovis, Janssen Pharmaceuticals, Johnson and Johnson, and Merck. Some other authors report various disclosures. Vadaparampil has no disclosures.

A pilot program appeared to more than double the rate of germline genetic testing among veterans with metastatic prostate cancer (mPC) by using remote communication rather than relying on clinicians for in-person outreach to patients. 

Of 1952 veterans with mPC, 681 (34.9%) provided consent and 459 (23.5%) completed testing, exceeding the usual 10% to 12% of patients who undergo testing, reported Bruce Montgomery, MD, et al in Cancer.

Although testing is recommended for all patients with mPC to guide therapy and alert relatives who may be at risk, 23.5% is still an impressive number, Montgomery, an oncologist with Veterans Affairs (VA) Puget Sound Health Care System in Seattle told Federal Practitioner: “With a letter and very little money and very little real time from clinicians, we could get testing done at 3 times the rate happening out there in the big wide world,” he said. “For 2000 patients, we needed one research coordinator and a small part of a genetic counselor's time.”

According to the study, germline genetic testing—which examines inherited DNA—is now recommended for all men with mPC by the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the American Urological Association. Germline genetic testing differs from somatic testing, which seeks genetic changes in the tumors themselves.

In the VA and community at large, the percentage of men with mPC who undergo germline genetic testing is low, Montgomery said. Research suggests < 40% of patients undergo somatic testing.

Germline genetic testing only costs about 10% compared with somatic testing, Montgomery said, and can be conducted at any time. In about 10% of mPC cases, the testing provides insight into the best treatment, he said.

Montgomery noted another benefit to germline genetic testing: It can raise the alarm about pathogenic variants that could boost cancer risk in family members, allowing them to get screened and take action.

There are many reasons veterans do not get tested, Montgomery said. The process is not automatic because patient consent is needed, and clinicians often fail to ask. In some cases, veterans worry about privacy or whether they will lose service-connected benefits if their cancer is blamed on genetics.

The study focused on 2104 veterans with mPC who had already agreed to take part in the Million Veteran Program, a prospective cohort study examining genetic and nongenetic risk for disease. The genetic analysis from that project did not provide guidance about mPC, so researchers approached the veterans directly.

Patients were enrolled from February 2021 to October 2023. A total of 1952 veterans did not opt out when contacted by mail (median age, 75 years; 63% White, 25% Black; 74% urban and 24% rural). The median age of those who consented and completed testing after phone contact was 74 years; 67% of patients were White and 22% were Black; 78% of patients lived in urban communities and 20% lived in rural communities.

Fifty-nine patients (13%) had pathogenic variants, and 37 of those had variants that indicated treatment with targeted therapies. Of the 37, 14 received targeted therapy, 18 were not at the point where targeted therapy was indicated, and 5 were not treated with targeted therapy for various reasons before they died.

Twelve of the 59 patients with pathogenic variants agreed to let the study team contact their first-degree relatives. Thirty relatives underwent testing, and 10 of them were positive for the variants.

Following completion of the study, researchers examined electronic records for the 59 patients with pathogenic variants and found that 19% did not have documentation of the germline finding in the medical record. The authors cited an “urgent need” to standardize where genetic information is included in the records.

While “it seems like a very small number of patients took up testing,” Montgomery said, the study findings are promising: “If we did the same thing nationally in the VA, there would be 15,000 men with metastatic disease, and we’d be testing 5000 of them with almost no effort.”

In an interview, Susan Vadaparampil, PhD, MPH, associate center director of Community Outreach and Engagement at Moffitt Cancer Center, who studies genetic testing, praised the strengths of the study. Vadaparampil, who did not take part in the research, told Federal Practitioner that the study relies on “an intervention that could likely be incorporated into routine clinical practice, a less resource-intensive model that provides posttest counseling for those who test positive, and support to share results with family members.”

However, she said, “testing uptake was uneven based on participant sociodemographic characteristics. It's important to consider how discussions and resources to facilitate testing may need to be adapted to meet the needs of all patients.

“Strategies that facilitate clinicians’ knowledge, comfort, and consistency in discussing testing with all mPC patients are essential,” Vadaparampil added. “Simultaneously using multiple strategies targeted to different levels can further help boost uptake.”

The study was funded by the VA Office of Research and Development, Prostate Cancer Foundation, Pacific Northwest Prostate Cancer SPORE, Institute for Prostate Cancer Research, Congressionally Directed Medical Research Programs (CDMRP), and Put VA Data to Work for Veterans. 

Montgomery discloses relationships with Daiichi Sankyo, INmune Bio, Clovis, Janssen Pharmaceuticals, Johnson and Johnson, and Merck. Some other authors report various disclosures. Vadaparampil has no disclosures.

A pilot program appeared to more than double the rate of germline genetic testing among veterans with metastatic prostate cancer (mPC) by using remote communication rather than relying on clinicians for in-person outreach to patients. 

Of 1952 veterans with mPC, 681 (34.9%) provided consent and 459 (23.5%) completed testing, exceeding the usual 10% to 12% of patients who undergo testing, reported Bruce Montgomery, MD, et al in Cancer.

Although testing is recommended for all patients with mPC to guide therapy and alert relatives who may be at risk, 23.5% is still an impressive number, Montgomery, an oncologist with Veterans Affairs (VA) Puget Sound Health Care System in Seattle told Federal Practitioner: “With a letter and very little money and very little real time from clinicians, we could get testing done at 3 times the rate happening out there in the big wide world,” he said. “For 2000 patients, we needed one research coordinator and a small part of a genetic counselor's time.”

According to the study, germline genetic testing—which examines inherited DNA—is now recommended for all men with mPC by the National Comprehensive Cancer Network, the American Society of Clinical Oncology, and the American Urological Association. Germline genetic testing differs from somatic testing, which seeks genetic changes in the tumors themselves.

In the VA and community at large, the percentage of men with mPC who undergo germline genetic testing is low, Montgomery said. Research suggests < 40% of patients undergo somatic testing.

Germline genetic testing only costs about 10% compared with somatic testing, Montgomery said, and can be conducted at any time. In about 10% of mPC cases, the testing provides insight into the best treatment, he said.

Montgomery noted another benefit to germline genetic testing: It can raise the alarm about pathogenic variants that could boost cancer risk in family members, allowing them to get screened and take action.

There are many reasons veterans do not get tested, Montgomery said. The process is not automatic because patient consent is needed, and clinicians often fail to ask. In some cases, veterans worry about privacy or whether they will lose service-connected benefits if their cancer is blamed on genetics.

The study focused on 2104 veterans with mPC who had already agreed to take part in the Million Veteran Program, a prospective cohort study examining genetic and nongenetic risk for disease. The genetic analysis from that project did not provide guidance about mPC, so researchers approached the veterans directly.

Patients were enrolled from February 2021 to October 2023. A total of 1952 veterans did not opt out when contacted by mail (median age, 75 years; 63% White, 25% Black; 74% urban and 24% rural). The median age of those who consented and completed testing after phone contact was 74 years; 67% of patients were White and 22% were Black; 78% of patients lived in urban communities and 20% lived in rural communities.

Fifty-nine patients (13%) had pathogenic variants, and 37 of those had variants that indicated treatment with targeted therapies. Of the 37, 14 received targeted therapy, 18 were not at the point where targeted therapy was indicated, and 5 were not treated with targeted therapy for various reasons before they died.

Twelve of the 59 patients with pathogenic variants agreed to let the study team contact their first-degree relatives. Thirty relatives underwent testing, and 10 of them were positive for the variants.

Following completion of the study, researchers examined electronic records for the 59 patients with pathogenic variants and found that 19% did not have documentation of the germline finding in the medical record. The authors cited an “urgent need” to standardize where genetic information is included in the records.

While “it seems like a very small number of patients took up testing,” Montgomery said, the study findings are promising: “If we did the same thing nationally in the VA, there would be 15,000 men with metastatic disease, and we’d be testing 5000 of them with almost no effort.”

In an interview, Susan Vadaparampil, PhD, MPH, associate center director of Community Outreach and Engagement at Moffitt Cancer Center, who studies genetic testing, praised the strengths of the study. Vadaparampil, who did not take part in the research, told Federal Practitioner that the study relies on “an intervention that could likely be incorporated into routine clinical practice, a less resource-intensive model that provides posttest counseling for those who test positive, and support to share results with family members.”

However, she said, “testing uptake was uneven based on participant sociodemographic characteristics. It's important to consider how discussions and resources to facilitate testing may need to be adapted to meet the needs of all patients.

“Strategies that facilitate clinicians’ knowledge, comfort, and consistency in discussing testing with all mPC patients are essential,” Vadaparampil added. “Simultaneously using multiple strategies targeted to different levels can further help boost uptake.”

The study was funded by the VA Office of Research and Development, Prostate Cancer Foundation, Pacific Northwest Prostate Cancer SPORE, Institute for Prostate Cancer Research, Congressionally Directed Medical Research Programs (CDMRP), and Put VA Data to Work for Veterans. 

Montgomery discloses relationships with Daiichi Sankyo, INmune Bio, Clovis, Janssen Pharmaceuticals, Johnson and Johnson, and Merck. Some other authors report various disclosures. Vadaparampil has no disclosures.